In 1988, 25 reports were submitted to Health and Welfare Canada in order to assist in defining priorities for health promotion research in Canada.  The full report from which this article is summarized is entitled “Health Environments for Canadians”.

Physical and social environments play an important role in people’s health and well-being.  While this has been known for many years and is well documented, it is not generally reflected in Canada’s health care delivery systems for in the design of our physical settings and social programs and institutions.  

In virtually every physical setting in Canada – in homes, schools and the workplace, and in public places, whether built or natural – there are major health and safety issues that need to be addressed.  Moreover, many people in Canada are trapped in social conditions that are unhealthy.  Poverty and unemployment, for example, are major contributors to ill health.  Too often individuals are kept confined to these unhealthy environments by overt or subtle forms of discrimination.  

The fact is that Canadians share many environments which ignore the true range of the physical and cultural differences between them.  Although some of our more specialized environments do take heed of our physical differences, they often overlook the rest of our human characteristics and needs.  Thus, while they may be safe and accessible, they may also be psychologically or socially unhealthy.  A new vision is needed, one in which Canadians can make environmental choices and exert greater individual control over their surroundings, both physical and social.

How can we succeed in creating better environmental designs, eliminating prejudices and incorporating what we know about environmental health into our health care systems?

What else do we need to know?

WHAT WE KNOW
The following is a brief synthesis of the main conclusions drawn from our review of the literature, and from ideas obtained through various research contacts.

Our physical environment can affect our health.  For many people in Canada, dangers in the physical environment contribute significantly to the risk of injury, ill health or death.  In virtually every Canadian setting the physical environment contains some health or safety risks.

Indoor air pollution, caused by numerous chemical emissions, is a significant component of the overall risk.  The sources of such emissions include industrial processes, building materials, furnishings, combustion devices, maintenance products, pest control substances, personal care or pleasure products, and human metabolism.

Likewise, the trace-level contamination of food, drinking water and outdoor air with a wide array of pollutants of varying toxicities, presents a general chemicals stress to which virtually everyone in Canada is subject.

Social and economic conditions can also affect people’s health.  Unemployment, poverty and financial stress, work pressures, family problems, prejudice and victimization, isolation, and lack of control over their lives can all have an adverse effect on people’s physical and mental health.  Conditions once considered as merely unfortunate can in fact be highly stressful, and now appear to be more costly to health than has been commonly acknowledged.  

There is a wide range of vulnerability in the population.  Each individual is unique in his or her response to factors in the physical environment.  There are those who can go about their lives experiencing little or no effect from the immediate physical environment; but there are others whose day-to-day functioning is severely impaired by one or more specific environmental factors.  Any given individual may have a unique array of sensitivities – it is possible to be quite insensitive to one factor yet highly sensitive to another.

There appear to be limits to people’s ability to adapt to changing environmental conditions.  Some people seem to be unable – whether temporarily or otherwise – to adapt to changing conditions, particularly to an increased pollution load.  An individual who has sufficient control to limit the amount of adaptation required at any one time, and to shape the surroundings to accommodate his or her inherent nature (rather than the other way around) is someone who can be said to have a healthy environment and lifestyles.  

Environmental health issues are different for each person.  People of different ages, genders, family or household types, races, cultures, levels of health, degrees of mobility, sexual orientations and lifestyles, all encounter variations of general environmental health issues which are unique to their particular situation.  Each different physical setting and each different social and economic condition brings with it new viewpoints and priorities in environmental health.  Understanding this diversity of issues is an important key to achieving health for all.

Another finding is that many of the environments in which we live – including, for example, public spaces, offices and schools – do not accommodate the full range of human characteristics.  Take people who are handicapped, less mobile than others, or chemically hypersensitive.  All too often we have ignored the fact that if environments are made accessible to them everyone else stands to benefit – physically, from health and safety features, and socially, from their presence.  While some of the “special environments” we have created perhaps do a good job of these individuals, they frequently ignore their other human characteristics, and isolate them from the wider society.  

Over the past decade, the phenomenon of environmental sensitivity has been receiving increased attention.  Sensitized individuals become reactive to a wide variety of low-level air contaminants in their immediate environment.  Once this process has begun, common indoor and outdoor environments appear to exacerbate symptoms, and chemically less-contaminated environments appear to be therapeutic.  There is some indication that the proportion of hypersensitive individuals in the population is increasing.  The World Health Organization has recommended the special environmental requirements for the protection of the affected groups should be assessed.  

One of the most difficult aspects of dealing with hypersensitivity is the prevalence of negative attitudes among the less sensitive population, towards individuals who find themselves highly reactive to physical environmental factors.  In the words of one individual coping with the illness: “the most demoralizing and frustrating experience, is that, while being seriously ill, weak, exhausted, confused, in pain, and isolated, one must also fight spouse, children, extended family, neighbours, friends, community, all levels of government, doctors, hospitals, social services, OHIP, OME, psychiatrists, employers, insurance companies, pension and/or welfare agencies – in fact, the whole world – in order to survive”.

Many seemingly innocent practices present unexpected hazards to people who have become temporarily hypersensitive, including the use of perfumes built into stationery, advertising and periodicals, and the common use of scented cosmetics, body, and clothing care products by both men and women.  Unannounced pesticiding of apartment buildings and offices can render a previously safe location totally intolerable.

The present atmosphere of general ignorance about hypersensitivity diseases, and even about allergy, which has been studied for a longer time, is an unhealthy and a dangerous one for both allergic and hypersensitive individuals.  It leads to feelings of hopelessness at being misunderstood and often to extreme isolation, as friends and families withdraw, not knowing how to deal with the environmental needs of the afflicted person.  Health care environments have often proven to be particularly hazardous to the asthmatic and/or chemically sensitive individual seeking emergency treatment.  For example, many care-givers and hospital workers are unfamiliar with the potential effects on sensitive individuals of volatile chemicals used in hospitals.  

The food and chemically sensitive individual will sometimes have difficulty in maintaining a healthy and supportive social network for himself or herself.  Some will have childhood histories of learning problems and deficits in appropriate social skills, possibly relating to early malfunction or specific physiological systems.  Behaviours commonly exhibited include increased activation, an increased probability of frustration, decreased attention span, perceptual problems, and memory deficits.  Social skills may be required, however, to negotiate environmental changes that represent, to date, the best means of reducing the individuals hyper-reactivity.

The literature also showed that many people in Canada become locked into situations that expose them to unhealthy environments.  For example, certain groups are more subject to environmental hazards than others.  The devaluing or undervaluing of certain groups of people (women bluecollar workers and handicapped people, for example) can produce widespread disparities between their social and physical environmental conditions and those in which other Canadians live.

Prejudice is itself unhealthy.  Victims of prejudice experience the direct physical and emotional effects of an unhealthy social atmosphere; they also suffer the indirect environmental consequences of the discrimination.  It is not uncommon for such individuals to internalize some of society’s attitudes toward them, and to be subject to a spiral of decreasing self-esteem and related problems.  Many people are undervalued ostensibly because of one distinguishing characteristic.  As if this is not bad enough, the rest of their human qualities are also rejected in the process.  

It is becoming increasingly clear that the personal and social support network is an important determinant of health.  People who are isolated appear to be more susceptible than others to ill health.  Moreover, the rest of society remains unaware of their needs and of their value as human beings.  

Health hazards can be reduced if people have more personal control.  Many people in Canada voice a hopelessness about reducing the risks to their health from environmental exposures; they feel they simply do not have enough control over their personal and social surroundings to be able to bring about the changes they would like.  People have to participate in the creation or modification of their physical and social surroundings.  This is quite feasible and would be an important step towards the overall creation of healthier environments.  What is critical is that sufficiently detailed information about the full diversity of people being served be introduced into the design process.  We already have a great deal of knowledge about user participation; we only need to apply it.

Finally, advances in the measurement of pollutants and the ways in which they affect us are revolutionizing the field of environmental health.  We now know that people’s health and performance can be adversely affected by levels of exposure once considered safe.  Moreover, there is concern about the unknown and possible synergistic health effects of different mixtures of trace levels of pollutants.  The scientific selection of healthier environments is being made possible by the emergence of new techniques.
 

WHAT WE NEED TO KNOW
We would find it much easier to determine which environments were healthy and which were not if we could fill a number of gaps in our knowledge.

For example, with few exceptions, we do not know what actual effects many environments have on individual human beings.  The research so far available to help us decide what is healthy and what is not is either largely epidemiological or statistical in nature, or it deals with the effects of environment on animals.  While perhaps helpful in setting general environmental standards and in identifying major hazards, it does not provide us with the level of detail we need to make truly competent decisions about healthy environments for specific people.  Yet every individual in Canada wants to know how he or she is affected by a particular environment; health care professionals need this kind of information too.  Imagine a time when all Canadians could obtain a profile of their own individual adaptability to different types of environments.  

We also need to develop population profiles of environmental sensitivities.  This is because we cannot now say with any degree of accuracy how sensitivity to environmental insults (either physical or social) varies across the population.  Without this information we cannot make competent decisions about design standards for physical, social, or economic environments in Canada.  One urgently needed profile is that of people’s degree of reactivity to common mixtures of indoor air pollutants.  

No true picture of the diversity of human characteristics and situations found among Canadians has ever been painted.  At present, statistics are gathered in certain basic categories (for example, gender, marital status, age, diseases, income, education, employment, and so on) each of which is usually analyzed separately.  But every individual has many different characteristics, and those who make physical, social, and economic design decisions, need to have a richer picture of these characteristics and of their various possible combinations. 

When we categorize people one-dimensionally we tend to stereotype them rather than thinking about them accurately.  How many young, black, single women with an interest in learning more about computers are there in Canada, and how can we help them to create a healthy environment for themselves? How would our approach differ if we knew more about them?

Another thing we need to know is how physical, chemical and social stress affects our bodies and minds.  For example, it is known that low-level chemical exposures can trigger many measurable symptoms in sensitive individuals, yet there is no consensus on the mechanism that is actually at work here.  Research in the field of immunology is teaching us that our bodies can be affected in various ways by all kinds of stress, but more research is needed to unravel the exact details.  

Our experience in helping people to heal the adverse effects of their environment is also very limited.  Clinical work is being conducted with individuals who are hypersensitive to minute chemical exposures, but there is so far no agreement on what therapy – other than reducing their stress load – is appropriate for such individuals.  This is a serious gap in our knowledge, because there are many physical and social factors in present-day Canadian environments that pose considerable health risks.

We also need a far clearer picture of the impact on health of cleaner environments.  In Canada, we no longer have comparison populations that can provide us with a good idea of what people’s health would be like in a far less polluted and stressful environment.  Most Canadians are exposed to complex mixtures of indoor and outdoor contaminants, albeit at trace levels.  

While our lifestyles vary widely, we all live in a complex environment of social and economic stress.  In order to make competent decisions about the relative value of less polluted or less stressful environments, we need good information about how the alternatives would affect us.  Experimental situations will be needed to help us acquire this knowledge.  
 

GOING ABOUT IT
To find out what we need to know in the field of environmental health will require an expansion of technology and the use of research methods that go well beyond the present state of the art.  In exploring the nature and effects of physical and social stressors, we will have to rid ourselves of that sense of hopelessness which presumes – without ever testing the limits of our ingenuity – that nothing can be done.  

It has become important to know, in far more detail than before, how products behave physically and chemically.  Efficient and economical laboratory protocols are required to determine what substances are released into our air and onto our skins by the materials we handle and by the environments in which we live.

We also need well-controlled, scientifically verified procedures whereby we can obtain accurate information on how specific environmental exposures affect particular individuals.  New and promising technology, including the application of such techniques as computerized brainwave analysis, may help to provide us with the means of obtaining such information.

Better protocols are also needed to deal with situations in which people believe their immediate environment is making them ill.  Considerable work has been done in industrial settings involving high level exposures, but cases where exposure levels fall below the accepted standards are often not resolved satisfactorily.  Several things are required: better detective work; an improved understanding of the possible effect of low-level exposures on sensitive individuals; and more direct involvement by the people who are actually affected.

Also, new procedures, facilities and technology are needed to open up the field of “experimental environmental health”.  Sometimes the best way of determining the effect of an environmental stressor is to remove it from the environment, and then measure how people feel.  Individuals thus become their own scientific controls.  Using this approach, along with protocols for measuring the direct effects of environmental stressors, we could determine the precise role of a particular stressor on someone’s health and well-being.  

Living with prejudice and victimization increases the risk to people’s health.  In Canada, we have relied for years on the idea that with each new generation prejudice will somehow naturally decline.  We have used legislation to guard against blatant violations of rights, and placed emphasis on acknowledging and welcoming multiculturalism in Canada.  What is still required, however, is research to determine how we can go about reducing prejudice and getting rid of bias in our current institutional practices.  The key to achieving this is to make far more information available to the public about the full human nature of those individuals who tend to be devalued in our society.

Another focus of our attention must be educating the public about environmental health.  There is no question that the environment plays a far larger role in people’s health than was once believed.  There are many Canadians who, although their health is being adversely affected by the environment, are ignorant of the fact.  Even health professionals often overlook the possibility that the environment may be implicated in someone’s illness.  Because creating a healthy environment is a very individual affair, “health for all” can never be achieved unless everyone understands the role of environment in health. We need to select, test, evaluate and implement strategies that will ensure that the word gets out.

We also need to find ways of giving individual Canadians greater control over their environments.  People have a better chance of maintaining their health and of thriving, physically as well as socially, if they have control over their lives.  Choosing how or where to live, what job to do, what level of education or style of life to pursue is impossible if you are locked in by lack of resources of by other conditions that restrict your life choices.  We need a more creative effort at every level, from the design of buildings to the design of all our social and economic institutions, to ensure that Canadians gain more control over their lives, and thus access to a greater diversity of choice.  
 

BRUCE M. SMALL, P. ENG
is the founder and Director of Small and Associates of Goodwood, Ontario.  He prepared this article in collaboration with his wife and colleague, Barbara J. Small, and Wendy Priesnitz of Wendy Priesnitz and Associates.  Bruce Small can be reached at www.envirodesic.com.