- This work was presented in part at the International Congress on Occupational Health, Singapore, 2000

Tee L. Guidotti

We are conceptualizing the economic development process as it relates to health in traditional, largely indigenous communities in the boreal forest of northern Canada. Our objective was to build a model incorporating issues of environmental quality, health status, and occupational health and safety compatible with and generalizable to developing societies in general. We offer a model focused on human rights (including cultural norms), population/resource balance, and urbanization. The model builds in four stages, incorporating additional terms such as women's role in society, education, labour dynamics, infrastructure, agriculture, and other issues. In the final stage, the health status and risk of individuals is treated separately but linked to levels of health status in the population. The model may be useful in teaching and describing development issues. All societies are developing, in a sense, because currently "developed" societies are going through another painful transition to a new type of economy. As well, there are pockets and vulnerable populations in "developed" countries that are experiencing a more traditional development process. We must come to understand the development process for our own sake in "developed" countries, not only to address issues of nation-building and trade.

This paper is an initial attempt to build a model of economic and social development that includes a role for occupational health

and safety, environmental integrity and the social role of people who have impairments and illnesses. It is by no means a finished product. Rather, it reports on the current status of a work in progress.

In 1995, we embarked on studies of traditional, largely indigenous communities in Canada that are facing rapid economic development because of an expansion of the forest products industry. These communities have limited resources and limited control over decisions affecting them. They resemble developing societies but also present unique problems and issues. Conceptual models for development do not seem generalizable to such communities. We felt the need to incorporate a broader range of outcomes that reflect health status and environmental quality (ref. 1). This led to our interest in more robust models of development.

These communities are north of the major population centres and south of the Arctic. They resemble developing societies in many ways but exist within a "developed" country. (Throughout this paper, we will use the word "developed" in a qualified sense understanding that development is a process without completion.) We have particularly focused on the integrated role of health and environmental quality in the development model and have examined these factors in a conceptual model relevant to industrial development. Our goal was to make this model generalizable to developing societies as well as to less developed communities within a developed country. In so doing, we incorporate concepts from both the "population health model" developed by the Canadian Institute for Advanced Research (ref. 2) and the somewhat older "health fields model", best known in Canada as the Lalonde report (ref. 3). Where we have been critical of the population health model, we have also incorporated aspects of our criticism (ref. 4). This work has come directly out of our project examining the health implications of economic development in relatively isolated and small communities in the boreal forests of Canada (ref. 1).

As well, individual communities in developed societies may have many of the characteristics of developing societies. In Canada, for example, some remote communities, usually northern and usually with a predominantly indigenous population, may have demographic and social characteristics that resemble societies in development transition. One type of community that often features such characteristics are indigenous communities in isolated northern regions where the wage economy is not firmly established. In such communities traditional activities such as hunting and trapping have important economic and cultural significance. Some of these communities are undergoing an economic development in a process not unlike the rapid industrialization of a traditional village society in the developing world.

In the particular situation described for the boreal forest communities, the population/resource imbalance is not between local residents and the carrying capacity of the local ecosystem to provide food. These communities are generally small. Indigenous peoples living in the area survived for centuries on local resources with populations at least as large. Rather, the population/ resource imbalance comes into play when the resources are harvested for the larger, majority economy. The available resources, such as traplines for hunting, may then become inadequate to support traditional activities such as fur trapping that earn cash income for discretionary purchases and that are culturally important. Thus, the model we shall construct preserves the population/ resource imbalance term because of its general importance, but applied to these particular communities it is inexact.

Although the project has primarily concerned communities of a special nature, the basis for this model has also been drawn from recent work on development policies and health (ref. 5, 6) the environment and health (ref. ^7,8) social policies and development (ref. ^9), and the role of women in development and health (ref. ^10). All of this comes together in the work of the World Bank (ref. ^11), which has been a principal resource for these issues and a target for dissent.

In the case of boreal forest communities, education may also mean access to power and influence in order to protect or control access to resources needed by the community for traditional activities and for its own priorities.

There are two transitions inherent in the stages of development that societies appear to follow. Both involve relationships among national development, environmental quality, health, and social change. The first is the passage from traditional economies to industrial economies. The second is the transition between industrial economies and sustainable economies, in which the core economic activities are based to the greatest extent possible on renewable or recyclable resources and the environmental impact of economic activity within the carrying capacity of the ecosystem. As the developed world comes to grips with the reality that it, too, is undergoing development, the experience of the developing world takes on more immediate relevance at home. This second transition may lead us to a sustainable model of development that balances renewable resources with economic demand and that places minimal pressure on non renewable resources and environmental quality. However, before this can be achieved by a traditional society it now seems clear that there must be a successful prior transition to a society with effectively functioning coordinating institutions, access to technology, and access to information. Even in developed countries, there are pockets and communities that have not made this transition.

Economic and social development may destroy as it creates and the issues that development brings to less developed societies reflects the extent of destruction and the new problems created (ref. 9). Governments, especially, count on development to create more solutions than new problems, but in this they are often disappointed. There is a long transition between sustenance and trading economies and traditional societies, on the one hand, and wage-earning, industrial, market economies linked to politically and culturally integrated societies on the other. During the transition much is lost and much must be rebuilt in a structure alien to the original culture.

Such societies are therefore faced with a paradox: to develop economically and to secure a future for their people that is more attractive and humane than the present, they must destroy much of the society on which their system is based and risk the culture of their people in the transition. This paradox is particularly difficult when the community is a cultural or ethnic minority already struggling to preserve its identity in a much larger and more powerful majority culture. The transition from a traditional to an industrial economy is messy, inefficient, dangerous, destabilizing, and sometimes cruel. It involves the destruction or subordination of traditional institutions and cultural norms to support a social and economic structure that is usually much larger, much more institutionalized, and much less sensitive to the needs of the individual at the local level. However, the structure that results may be also more economically stable, less tolerant of minor and debilitating intergroup conflict, and provide somewhat more economic security overall for its members.

Scholars and government officials studying problems of development tend either to emphasize particular infrastructure issues or the interconnectedness of all factors. The result is either a reduction of the problem to isolated units, the interactions of which are not clear, or a generalization of the problem to a total systems approach, in which the web of interactions is overwhelmingly complicated. In this tentative schema, we will emphasize interconnectedness but will try to isolate particular issues to show their interaction.

We begin at the centre with three primary issues that will be building blocks for the model itself. It is easy to dismiss the complexity of these relationships with the belief that "everything is connected to everything else," but while demonstrably true, this belief is also limiting in dismissing the most important aspect of these relationships: They are highly structured, but not in simple ways. Rather, one issue tends to "drive" another and in turn to be driven by others. What direction and to what extent one issue drives another depends on the national context and local history. To understand what drives what is relatively easy. To understand how the system as a whole will respond to a stress or the outcome of the development process is the hard work of a lifetime. The interpretation given below is one point of view, simple enough to begin the process of learning and understanding.

The model is organized to place human rights on the left and social and cultural institutions on the right, and to place population/resources, environmental, and occupational effects on top and individual and cultural effects on the bottom, in concentric rings as the model is developed. (Of course, this is completely artificial and placement is only for graphic convenience.) The central issues as defined in the figure 1, are three: human rights, population/ resources and urbanization. The interplay between these two are critical driving factors. While inextricably linked, the three may also respond to other factors not represented on the diagram and have their own dynamics in each society that give each development situation unique features.

"Human rights" is a "shorthand" term for a broad range of values and concepts of individual worth in a society. At any point in time, a society has certain norms of behaviour with respect to what is and what is not permitted, the appropriate penalties for infractions of this code of behaviour, and expectations for the role of persons in the society. Human rights is not simply a matter of personal political freedom but a complicated set of behaviours and responses, as they affect its individual members, of the political system, the economic system, hierarchy in the society (in an anthropological sense), gender and race relationships, and the specific history of ideas that have been discussed, disputed, and resolved in the past and currently. Human rights is therefore a cluster of values and relationships that reflect the place, limits, and norms of behaviour acting on the life of an individual resident in that society. One set of human rights concerns is of particular importance as a development issue: women's issues.

Women's issues were marginalized or subordinated to population policy in discussion of development until recently. However, the influence of education for women can be substantial even in a male-dominated tribal society because it also creates, among other benefits to society, role models for change, higher expectations for educational attainment within the family, and entrepreneurial opportunities (because women are often the small business persons at the village level). Ulfvarson has disaggregated gender equality from other covarying characteristics and shows a strong but not absolute correlation with economic development¹². He demonstrates that poorer countries have achieved higher levels of equality but that examples of rich countries with poor equality scores are rare. One explanation may be that gender equality is lifting the economic performance of those countries and moving them out of the poorest group. (The example he gives of a poor country with exemplary gender equality is Zimbabwe. In this issue of OHS and Development, Clementine Dehwe presents another opinion).

Figure 1: The "building blocks" of the assembled model.

In indigenous societies that are in a minority within their own state, issues of cultural identification and equity are also present. These communities may not necessarily face legal discrimination but there may be many forms of subtle social and economic discrimination that act indirectly on human rights. This is certainly a great concern in Canada, where legal protection of human rights is complete but the social obstacles remain.

Population and resource issues are familiar and need not be described in great detail here. Fundamentally, the issue is one of an imbalance between the human population and the resources available to sustain it without degrading the environment or exhausting the alternatives to the extent that society is impaired. Discussions on whether and how this imbalance occurs are usually limited by perceptions of scale: is overpopulation the principal problem on a national basis, is the so-called "ecological footprint"¹³ of a population displaced elsewhere in the world, and does the social dislocation and distortion introduced by attempts to control population outweigh the benefit in reducing the total burden that must be carried during development. However, at some level it is clear that such an imbalance must always occur and that when it does it must be an important driving factor in producing adverse social and economic effects of development.

The last key factor placed at the centre of the model is urbanization. By that word is meant the reorganization of society from an essentially modular, or village, structure in which the connections are relatively few, low in capacity, and restricted in scope to a wide network in which the connections are open, high in capacity, and virtually unlimited¹⁴. Urbanization carries with it access, to technology, communications, ideology, political influence, wages, and the increased level of personal and institutional interactions that drive social development. It also carries with it crowding, the risk of cultural alienation, and the forcing of new hierarchies that may impede access to the benefits of urbanization. Urbanization is not necessarily limited to expanding cities. In the countryside and in remote areas served by improved transportation and communications linkages there may be rapid incorporation of urban habits, lifestyles, tastes, and ideas into the local milieu.

An important aspect of urbanization is nutrition, food preference and retail food availability. The well-documented global epidemic of diabetes appears to be a reflection of maladaptive nutritional change resulting from changes in consumer selection driven at least in part by what is distributed for consumption in the urban economy (ref. ^15,16). These three essential factors are used to build an interactive model, beginning with the next set of factors. It seems apparent that the problem of population and resource imbalance is driven to a considerable degree by issues of human rights. These are not exclusively rights to reproduce, although these are critically important as determinants on a social basis. Rather, rights to education, to economic security, and to participation by women have profound but indirect shaping influence on the population structure by increasing the ability of women to make reproductive decisions and of both genders to accept such decisions. Education also provides access to the means of reproductive control and the political empowerment required to ensure that these means are available.

The resource side of the imbalance is affected in part by technology and the efficiency of work in the society, which is in turn affected by urbanization. In the first instance, however, population/resource imbalance would seem to drive urbanization first by creating demographic trends that accelerate the growth of urban centres and that increase the size of secondary communities and make it more likely that residents will themselves behave as urbanized individuals. Thus, for the purposes of the first iteration of the model it will be assumed that human rights first has the strongest effect on population and that population/resource imbalance first has its strongest effect on accelerating urbanization.

The next step builds on this basic set of relationships by incorporating six additional processes. Closely related to human rights are issues of child labour (not an issue in the communities we study) and women’s role in society. Closely related to population/resource imbalance are employment opportunities in the wage economy and a rural labour surplus resulting from decreased mortality in rural areas. Closely related to urbanization is increasing productivity of agriculture due to improved agronomy and improved infrastructure, which generates employment opportunities initially but may displace jobs with increased automation. Further, pressure to increase agricultural production may lend to environmental damage (ref. 16).

The next "ring" of factors builds on these fundamental economic and social relationships and relates them to a set of consequences that have secondary and feedback effects. At the top of the diagram we have introduced two new outcomes. Environmental degradation and occupational health and safety problems are predictable consequences of the urbanization process in the absence of controls or a mature civic culture. Environmental degradation is not exclusively a consequent of development, of course.

Clean water is a critical intervention for health protection and control of contamination by human wastes is the most critical element of all; the problem of sanitation is hardly unique to developing countries, nor is it closely attached to chemical contamination (ref. ^17). Air pollution, however, is more closely tied to the developed process as suggested by the experience in Latin America (ref. ^18). The history of humanity is largely one of interaction with the environment and purposeful environmental change. Until recently, however, there was little obvious connection between health, prosperity, and environmental quality because there was no feedback mechanism for society to perceive it. Health was dealt with in one economic sphere and resource management in another. Occupational health and safety is rarely considered as a separate factor but plays a major role in the risk of injury and illness in the most productive segment of the population during development. It is also based on some of the same behaviours and controls that operate for environmental degradation. Poor performance in occupational health and safety is likely to reflect poor performance generally in environmental protection and management of human resources. Occupational health and safety issues connect directly to productivity and income security and are important determinants of health in an economically critical and productive segment of the population. Involvement in health and the initiative to prevention through safety is sometimes the first step toward a national health care system and is the origin of most social security systems. These issues are often neglected in existing models but their secondary consequences will be described in the next level of the model.

Cultural traditions may be eroded by the urbanization process and by the increasingly productive agricultural sector, which may result in the disintegration of patterns of social organization based on shared work and the regular need for field labour. Education, on the other hand, may either preserve or undermine traditional culture, often doing both simultaneously. (For an indigenous community, incorporation of traditional knowledge and culture into an educational system designed primarily to prepare children for a future in the mainstream economy may risk turning the culture into a museum piece, a static symbol of heritage shut off from the roots of the culture itself.) The effects of education on the role of women and children in society, in particular, appears to be profound. There is no more consistent link between traditional societies and stable modern societies than education.

The most obvious impact of environmental degradation is illustrated by the severe air and water pollution encountered in many of the world's new megacities ^{(ref. 19)}. However environmental degradation is a cluster of issues¹⁹ that reflect potential adverse effects on health, reduction of biodiversity and habitat (trading short-term economic gain for long-term destruction of potentially renewable resources ^{(ref. 20}), depletion of non-renewable resources, limitations on future land use, risks to agricultural productivity and food supply (ref. ²¹⁾, and diminished appear for tourism, trade, and quality of life. The environmental degradation term both limits personal opportunities in the society and future economic options and when very severe may restrict economic productivity. However, environmental degradation acts in subtle ways most of the time. At extremes of pollution, as observed in some of the formerly socialist countries, it may be associated with health effects sufficiently severe to be visible as an economic factor. Most of the time, however, the effect is more insidious, by increasing the risk of adverse outcomes, reducing sustainability, and closing off future options ^{(ref. 19)}.

At this point in the development model it would seem useful to introduce a factor of housing quality, separate from infrastructure. This issue was included in the so-called economic cycle of diseases (ref. ²²). However, the current literature does not appear to describe a clear link with other development problems or with health, except for the extreme situation of homelessness. At this stage, therefore, we have kept it subsumed in the infrastructure term.

With the basic development model now connected to environmental indicators and to occupational health and safety, one may take the final step of incorporating a variety of health-related outcomes. The completed model incorporates population health status (frequency of health problems and the level of health by various indicators related to personal risk and behaviour, for the community as a whole). Access to health is incorporated as part of infrastructure development and urbanization but drives population health status only indirectly, by influencing personal health outcomes in the individual case. These outcomes may result in a largely socially defined role of illness, disability, and invalidism; whether a given condition is recognized as disabling or not is often culturally determined. This is a departure from most models, which would interpret population health measures as reflecting the aggregate of personal health characteristics in the population. In this model, the measures of population health status are assumed to represent the risk of ill-health for the majority of people and the current state of ill-health for a minority of sick people at any one time who need access to health care. The total illness burden on society is translated into a population health level by the process by which society defines illness and chooses to accept or to act to prevent a burden of illness.

If a society is adapted to a high frequency of endemic disease and cannot change the situation, it may still be functional and health indicators may be relatively favourable despite the high personal risk of disease. It could be argued that until the recent decline in mortality from cardiovascular disease, this was the situation in much of North America and western Europe. High frequencies of death from myocardial infarction and stroke were part of life for many people but on a population basis the indicators of health and longevity appeared favourable.

Table 1 presents a set of general measures that are generally agreed to be necessary if development and environmental quality are to be compatible. They represent a set of actions that represent not an ideal, but that are necessary individually and in the aggregate for the limitations of this model to be overcome.

No model of development can be comprehensive - there are too many factors and too many uncertainties and conditions do vary from place to place. However, models are used for a particular purpose and reflect the purpose for which they were designed. This model was developed for teaching and research about development issues that eventually influence human and ecosystem health. It lacks important factors that may be critical to the formulation of policies affecting development, such as capital formation and investment, trade, housing and community development, and migration ^{(ref. 14)}. These are less critical to our current purpose but would need to be considered in any extension of this model to a larger scale.

Development is no longer a problem faced exclusively by the developing world. Developed countries such as Canada are in the midst of another development transition that is profoundly restructuring society in the conversion from an industrial to a "post-industrial", information-driven economy. Because of Canada’s traditional economic base in primary resources and its limited manufacturing sector compared to other development countries, the latter transition is acutely threatening to this country.

Development problems and development theory are no longer the exclusive issue of the developing world because in an era of post-industrial transition all economies are developing. The significance of development studies to developed societies is no longer primarily a matter of international assistance and trade. The study of development as a process carries lessons for their own social and community development as well. At present, the outlines of this next level of development are still unclear.

TABLE 1

However, it seems likely that the combination of new materials, reliance on information technologies for growth, and the current climate of growth despite resource constraints may bring us one step closer to true sustainable development.²³ This has many economic and social ramifications²⁴ and it provides a material level that other societies may be able to "jump" to with assistance in the form of technology transfer. However, the current set of obstacles and needs must be dealt with now whatever the future promise.

The problems of the two developmental transitions are different but the essential lesson is the same. The development process is complex and difficult and there is much to learn from sharing the experience of societies at all levels of development. We cannot overcome the limitations to development until we understand them.

This work was supported by the Network of Centres of Excellence in Sustainable Forest Management under the SocioEconomic Sustainability Theme. We thank Dr. Lilian Douglas of the Faculty of Nursing at the University of Alberta for her interest and encouragement.

Tee L. Guidotti
School of Public Health and Health Services
The George Washington University
2300 K St., NW, Ste. 201,
Washington DC 20037, USA
Tel:+202 994-1765 or -1734
Fax:+202 994-0011
E-mail:eohtlg@gwumc.edu

1) Guidotti TL, Teschke K, Wein E, Soskolne C. A framework for studying human and ecosystem health in the boreal forest. Ecosystem Health, 1996, in press.

2) Evans RG, Barer ML, Marmor TR. Why Are Some People Healthy and Other Not? Determinants of Health of Populations. New York, Aldine de Gruyter, 1994.

3) Lalonde M. A New Perspective on theHealth of Canadians. Ottawa, Government of Canada, 1974.

4) Guidotti TL. "Why Are Some People Healthy and Others Not?" - A critique of the population health model. Annals of the Royal College of Physicians of Canada, 1996, in press.

5) Cooper Weil DE, Alicbusan AP, Wilson JF, Reich MR, Bradley DJ. The Impact of Development Policies on Health: AReview of the Literature. Geneva, World Health Organization, 1990.

6) Sagan LA. The Health of Nations. New
York, Basic Books, 1987.

7) Gastal A. The environment and its effects on health. Washington DC, Pan American Health Organization, Human Resources Development Series No. 95, 1992, pp. 39-46.

8) Yassi A, de Kok TMCM, Guidotti TL, Kjellström T. Basic Environmental Health. Geneva, World Health Organization, 1996, in preparation.

9) Lesemann F. Economic policies and social policies. International Health: A North South Debate. Washington DC, Pan American Health Organization, Human Resources Development Series No. 95, 1992, pp. 29-38.

10) Sims J, Weinger M. Women, Health and Environment: A Teacher's Guide. Geneva, World Health Organization GEENET, 1994.

11) World Development Report 1993: Investing in Health. Washington DC, International Bank for Reconstruction and Development (The World Bank) and Oxford University Press, 1993.

12) Ulfvarson U. Indicators of human development: gender and power. OSH&Development (Swedish Association for Occupational and Environmental Health and Development), August 1998; (1): 11-16.

13) Wackernagel M, Rees W. Our Ecological Footprint. Gabriola Island BC, New Society Publishers, 1966.

14) Roberts MJ, Tybout JR. Industrial evolution in developing countries. Oxford, Oxford University Press — World Bank, 1996.

15) King H, Rewers, WHO ad hoc Diabetes Reporting Group. Diabetes in adults in now a Third World problem. Bull WHO 1991; 69(6): 643-648.

16) Guidotti TL, Teschke K, Wein E, Soskolne CL. An agenda for studying human and ecosystem health effects in the boreal forest. Ecosystem Health 1997;3(1):11-26.

17) Esrey SA. Water, waste and well-being: a multicountry study. Am J Epidemial 1996; 193(8): 608-623.

18) Onursal B, Gautam SP. Vehicular Air Pollution: Experiences from Seven Latin American Centers. World Bank Technical Paper No. 373.

19) Bartelmus P. Environment, Growth and Development: The Concepts and Strategies of Sustainability. London, Routledge, 1994.

20) Von Amsberg J. Economic parameters of deforestation. World Bank Econ Rev 1998; 12(1): 133-153.

21) López R. The Tragedy of the Commons in Côte d’Ivoire agriculture; empirical evidence and implications for evaluating trade policies. World Bank Econ Rev 1998; 12(1); pp.105-31.

22) Elgstrand K. Occupational safety and health in developing countries. Am J Ind Med 1985; 8:91-93.

23) World Commission on Environmental and Population. Our Common Future. Oxford, Oxford University Press, 1987.

24) Guidotti TL. The environment, risk, and health: notes toward a new conceptual framework. Medicine and Global Survival 1995; 2:235-242.