EDITORIALS Recognizing Resilience
In 2012, a year after a devastating tornado hit the town of Joplin, Missouri, leaving 161 people dead and leveling Joplin High School and St. John’s Hospital, President Obama addressed the graduating seniors: There are a lot of stories here in Joplin of unthinkable courage and resilience. . . . [People in Joplin] learned that we have the power to grow from these experiences. We can define our lives not by what happens to us, but by how we respond.1
There are indeed countless stories from Joplin of neighbors helping neighbors, of volunteers arriving by the busloads to lend their hands in rebuilding, and of thousands of trees being planted by community volunteers in an effort to restore and improve the city’s tree canopy. Tragically, social resilience is especially manifest after major disturbances in locales that Tidball and Kransy termed red zones (i.e., places characterized as intense, hostile, or dangerous, including those in postdisaster situations caused by natural occurrences, acts of terrorism or war, or longerterm socio-economic degradation).2 In the aftermath of a disturbance, ordinary people can accomplish heroic acts. How can social resilience be recognized in its myriad forms, especially when it leads to recovery for traumatized people and devastated places?
RECIPROCITY Through more than 40 years of research, much of it supported by the US Forest Service’s research funding, social scientists have explored connections between environmental and human health. Continued cross-disciplinary research
April 2014, Vol 104, No. 4 | American Journal of Public Health
This photograph of the Hull Street Community Garden in Ocean Hill, Brooklyn, NY, is printed with the permission of GrowNYC, “a hands-on nonprofit which improves New York City’s quality of life through environmental programs that transform communities block by block and empower all New Yorkers to secure a clean and healthy environment for future generations” (see http://www.grownyc.org/about). Photograph by Lars Chellberg. identified profound relationships between natural, suburban, and workplace settings and addressing mental fatigue, as access to green space are correlated with significant improvements in mental states.3 Recent research exploring implications from the individual to the societal scales underscores the essential role that trees and natural resources play in creating healthy places for people to live, including relationships between green spaces and enhanced school performance, reduced crime rates, and greater neighborhood livability.4---7 As volunteers and community groups become actively involved in the stewardship of natural resources, their communities exhibit even further gains, including increased civic engagement, neighborhood efficacy, and ecological literacy.8--10 Thus, the present research challenge is to move beyond valuing natural
resources as solely physical green spaces and ask instead: how can urban greening, as a human act, be recognized and managed as a critical component of social resilience? At the New York City Urban Field Station, where Forest Service and New York City Parks researchers bring together a network of scientists and urban land managers, social scientists are using environmental stewardship as a lens through which to better understand the collective ability to strengthen social cohesion, build capacity, and respond to rapidly changing—and often disturbed—environments.
ACUTE AND CHRONIC DISTURBANCE In Spring 2002, just months after the 9/11 terrorist attacks, social scientists from the US Forest Service embarked on
Editorials | 581
EDITORIALS
a journey to learn more about how communities were channeling the vital power of trees and greening as mechanisms for remembrance and recovery.11 Over the ensuing decade, nearly 700 hundred living memorials were documented; these were green spaces cultivated from a shared intention to leave a legacy and a reminder of the lives that were lost in the 9/11 attacks. These memorials sprang up in towns and municipalities surrounding the crash sites, in areas with high concentrations of family members and friends of the victims, and in places with seemingly no other connection to the sites or the victims beyond the realization that it could have happened in their town or to their loved one. The creators of the living memorials were grieving, and through the process of digging in the soil, they were searching for ways to recover their passion for life and community and to honor what had been lost to them. The emergence of the 9/11 living memorials may be viewed as part of a social-ecological process of disturbance and resilience, part of a restorative cycle. They represent community acts tied to traditional mourning rituals and beliefs. These spaces became places of profound social meaning and expression of collective efficacy as people responded to this tragic event with a desire to create, beautify, plant, and trust. Decades before the events of 9/11, a similar pattern emerged in response to a different type of disturbance. Those who were living in New York City; Chicago, Illinois; or Los Angeles, California, in the 1970s may recall first-hand how their communities suffered through a chronic decline in local economies. The fiscal crisis at that time took a devastating toll on urban
582 | Editorials
infrastructure and residents felt the acute impacts of declining neighborhood resources for police, firefighters, sanitation, housing, and parks. Thousands of residents, often those living in the most devastated places, responded by converting garbage-strewn, vacant lots into thriving community gardens and social spaces.12 At the time, these gardens were not recognized and celebrated as evidence of social resilience. Indeed, certain elected officials actively fought against the preservation of these spaces, once development values regained a foothold in previously abandoned urban areas. How might we recognize resilience when it occurs, especially when it is present in an unfamiliar or unexpected form? Preliminary findings from a New York City Urban Field Station social assessment of local waterfront parkland (an investigation in response to the brutal destruction wrought by Hurricane Sandy in October 2012) speak to subtle dimensions in processes of recovery from both extraordinary and everyday stresses. Community members considered their parks to be a refuge that provided them with a buffer when the physical qualities of the city threatened to overwhelm their senses—the noise, traffic, and development—and from social and emotional realities, too. One adolescent reported that a park offered relief from peer pressure and allowed him to stay out of trouble; countless others alluded to stress in their lives and cited local green space as a haven from their worries. Still other residents were engaged in active stewardship of neighborhood parks by planting trees, cleaning up debris, or starting new gardens. Many of those encountered are part of dedicated groups of friends and neighbors who care deeply about their waterfront communities.
These public landscapes are intimately tied to their collective sense of well-being. These encounters provide evidence that social infrastructure is built not of bricks, mortar, and dirt, but rather from the social actions and practices that restore relationships between and among people and the places they hold dear. The materiality of nature, as represented by a handful of vegetable seeds or a group of volunteers planting saplings, provides both a catalyst and a context for dynamic social experiences that have supported thousands of New Yorkers in need of personal, social, economic, and physical recovery. In this era of global climate change, landscapes and natural resources are increasingly valued as buffers that protect human populations against untoward effects—great forests keep atmospheric carbon in check and coastal wetlands soften storm surges that threaten nearby communities. But these biophysical processes and characteristics are just one dimension of their worth. In the face of social, political, economic, emotional, and psychological stressors, green spaces also provide safeguards of a very different kind. The social cohesion that emerges from stewardship activities buffers communities against stresses induced by such experiences.
CULTIVATING MEANING In seeking to synthesize research on the environment and human health, then, nature is cherished not merely as a buffer or a service, but as an integral part of social systems, that is, social infrastructure. The potential for resilience not only resides in physical design and form, but within social relationships. As communities strive
to provide highly efficient green infrastructure that is designed to be resilient to future storms and rising tides, they would do well to also examine and nurture the social meaning in these shared places. The provision of nonprogrammed space in communities creates opportunities for emergent forms of behaviors that reflect a sense of the sacred. These places, which invite access and participation, encourage creativity and interactivity, and require restoration and tending, also afford communities the opportunity to express, support, and—following hard times—heal and inspire. These places are critical not only to the daily lives of community members, but also to the collective spirit of human society. Local community-based organizations such as environmental groups, fair housing coalitions, and community health providers, serve as bridging and bonding entities with the capacity to respond effectively in times of crisis. These groups exert a powerful impact following disturbances because they have learned to adapt to address multiple vulnerabilities in their communities. How might we sustain this form of community work, while expanding frameworks to address social vulnerabilities in the face of both acute and chronic stressors? One strategy is to prepare for disturbances by harnessing the persistent, trusted, and networked relationships of community-based organizations. Social resilience depends upon the ability to cultivate connectedness and encourage human innovation day-in and day-out. While technology and the built form are often revered, it is the human capacity to absorb shocks, self-organize, learn, and adapt that is also worthy of awe. Human beings own the capacity to create: acts of kindness and love,
American Journal of Public Health | April 2014, Vol 104, No. 4
EDITORIALS
organizations that foster respect, communities that attend to emergent and chronic needs, and societies that value social justice. As the life of South African antiapartheid leader Nelson Rolihlahla Mandela (July 18, 1918---December 5, 2013) so eloquently demonstrated, acting out of concern for others brings us closer to a world where well-being and opportunity are shared by all. j Erika S. Svendsen, PhD Gillian Baine, MEM Mary E. Northridge, PhD, MPH Lindsay K. Campbell, PhD Sara S. Metcalf, PhD
NY. Sara S. Metcalf is with the Department of Geography, University at Buffalo, The State University of New York, Buffalo. Correspondence should be send to Erika S. Svendsen, USDA Forest Service, Northern Research Station, 290 Broadway, 26th Floor, New York, NY 10007 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted December 18, 2013. doi:10.2105/AJPH.2013.301848
References
Contributors
3. Kaplan R, Kaplan S. The Experience of Nature: A Psychological Perspective. New York, NY: Cambridge University Press; 1989.
All authors were involved in the conceptualization of this argument. Erika Svendsen led the writing, and her co-authors contributed ideas for enhancement and desired edits. All authors take public responsibility for its content.
Acknowledgments About the Authors Erika S. Svendsen, Gillian Baine and Lindsay K. Campbell are with the USDA Forest Service, Northern Research Station, New York City Urban Field Station, New York, NY. Mary E. Northridge is with the Department of Epidemiology and Health Promotion, New York University College of Dentistry, New York,
Resurrecting “International” and “Public” in Global Health: Has the Pendulum Swung Too Far?
The authors were inspired in the research and writing of this Editorial by a joint venture research agreement from the USDA Forest Service, Northern Research Station to the New York University College of Dentistry (12-JV-11242309-095, Integrating Grey and Green Infrastructure to Improve Health and Well-Being for Urban Populations).
The fashionable term “global health” seeks to convey that health issues are universal and transcend national boundaries. The term’s focus on problem identification within the problem--solution framework undermines critical thinking about solutions at the national and community levels. Public health is ultimately about responding: promoting, protecting, and enhancing the health of populations, especially that of the poorest and most vulnerable populations. The global health system plays an important role in setting standards and noble goals, but action is ultimately taken at national and community levels. Political boundaries confer authority (and responsibility) to uphold the well-being of a population. While recognizing a world of increased interaction and exposures, it is essential to remain grounded in the practicalities of
April 2014, Vol 104, No. 4 | American Journal of Public Health
1. Obama B. Commencement Address. Joplin High School Commencement. Joplin, MO. May 21, 2012. Available at: http:// www.stltoday.com/news/local/metro/ transcript-of-president-obama-s-speech-tojoplin-high-school/article_aeeb8f8e-a41011e1-b2c6-001a4bcf6878.html. Accessed January 23, 2014. 2. Tidball KG, Krasny ME, eds. Greening in the Red Zone: Disaster, Resilience and Community Greening. New York, NY: Springer; 2014.
4. Matsuoka RH. Student performance and high school landscapes: examining the links. Landsc Urban Plan. 2010;97: 273---282. 5. Kuo FE, Sullivan WC. Environment and crime in the inner city: does vegetation reduce crime? Environ Behav. 2001;33(3): 343---367. 6. Troy A, Grove JM, O’Neill-Dunne J. The relationship between tree canopy and crime rates across an urban-rural gradient in the greater Baltimore region. Landsc Urban Plan. 2012;106:262--270.
the “international” aspect of public health. Over the past decade or so, we have observed a trend away from the term “international public health” and a movement toward the term “global health.” In a Lancet commentary, Koplan et al. distinguished between “international health,” “public health,” and “global health.”1 Multiple authors responded,2---4 but, to our knowledge, none focused on how this semantic shift concentrates on only half of the problemsolution framework (i.e., problem identification and assessment) and neglects the solution aspect of the framework and the central role that nation states play in responding with solutions. While the term “global health” seeks to convey that health issues are universal, that health issues transcend national boundaries, and that diseases can and often
7. Campbell LK, Wiesen A eds. Restorative Commons: Creating Health and Well-Being through Urban Landscapes. Gen. Tech. Rep. NRS-P-39. Newtown Square, PA: US Department of Agriculture, Forest Service, Northern Research Station; 2009. 8. Fisher DR, Campbell L, Svendsen ES. The organisational structure of urban environmental stewardship. Env Polit. 2012;21(1):26---48. 9. Connolly JJ, Svendsen ES, Fisher DR, Campbell LK. Organizing urban ecosystem services through environmental stewardship governance in New York City. Landsc Urban Plan. 2013;109:76---84. 10. Falxa-Raymond N, Svendsen E, Campbell LK. From job training to green jobs: a case study for a young adult employment program centered on environmental restoration in New York City, USA. Urban For Urban Green. 2013;12:287-- 295. 11. Svendsen ES, Campbell LK. Living memorials: understanding the social meanings of community-based memorials to September 11, 2001. Environ Behav. 2010;42:318---334. 12. Lawson L. City Bountiful: A Century of Community Gardening in America. Berkeley, CA: University of California Press; 2005.
do spread quickly (and often without respect for political boundaries), the term implies more of a focus on the problem than on what must be done about the problem. The term “global health” may be appropriate when referring to health issues, which are increasingly global in nature, but semantics must not cause us to lose our focus on how to address these problems. The word “public” by definition means “of or concerning the people as a whole.”5 While communities or nations comprise individuals, individuals do not exist in isolation; they are part of a larger, interconnected whole. This larger whole (or population) is the focus of public health. There is tremendous heterogeneity across populations in terms of contextual risk factors driving health outcomes, and the nation state may be
Editorials | 583
EDITORIALS
a useful unit of comparison with political, economic, and cultural commonalities relative to other countries, even though there are often disparities within nations. “Global health” as a term on its own, however, does not allow for population-level analyses, whether at the national or community levels. “Public” also means “being in service of a community or a nation.”5 This definition implies a governmental role, and the responsibility of a government is to serve and protect its people, including the health of its people. While public health is certainly not the exclusive domain of government, the importance of the governmental role and the responsibility of governments to protect and enhance their public’s health cannot be ignored. Public health is also ultimately about the approach of responding to health problems. It is about promoting, protecting, and enhancing the health of groups and populations with an emphasis on preventing illness and injury in the first place (i.e., primary prevention). And, public health is about being responsible to all within the population, especially to its poorest and most vulnerable members. The Institute of Medicine’s frequently cited definition of “public health” refers to “what we, as a society, do collectively to ensure the conditions in which people can be healthy.”6 Often, in order for this response to health problems to truly affect the population as a whole, government must be involved to set policies and standards; regulate and enforce those policies and standards; monitor health status and risk factors; and even provide services to the population. The core functions of public health— assessment, policy development, and assurance6—are ultimately
584 | Editorials
the responsibility of government, thus a public responsibility. In fact, the Institute of Medicine’s report stresses the importance of a strong governmental public health infrastructure to ensure and protect the health and wellbeing of the population.7 While the United Nations (UN) and other multilateral organizations such as the World Bank represent an important role for coordinated, global action, the implementation of any global action relies on the willingness and cooperation of member states. The UN was established in 1945 (original membership of 51 nations) with one of its primary purposes being “to help nations work together to improve the lives of poor people, to conquer hunger, disease and illiteracy, and to encourage respect for each other’s rights and freedoms.”8 The UN holds an important leadership role setting a global vision, facilitating collaborations, and providing the support to move toward that global vision. Ultimately, however, the enactment of any global vision depends on national governments. It is national governments who decide whether to become signatories to conventions, whether to implement and enforce conventions to which they are signatories, and whether to follow proposed norms and standards. It is national governments who enact policies and decide whether to participate in or cooperate with health monitoring and surveillance. The World Health Organization, established in 1948 as the primary health agency of the UN, is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and
monitoring and assessing health trends.9 However, to act on these trends, national governments must decide to buy into such agendas and be willing to invest resources in such implementation. International political borders matter tremendously in public health because those borders determine authority over policies, interventions, and implementation. Many health issues are in fact global in nature and do not respect national borders, but the response may be either considerably constrained or enabled by these political boundaries. Take for example the recent poor air quality in Singapore caused by Indonesian pollution. Because of weather patterns, forest fires in Indonesia resulted in Singapore recording its poorest air quality since 1997, which then prompted the country to issue health alerts.10 Outdoor air pollution is clearly a global health issue. The governments of Singapore and Malaysia (another country also affected by Indonesian air pollution annually) can do little to reduce air pollution as a risk for respiratory illnesses within their populations without cooperation from the Indonesian government, which is ultimately responsible for regulating air quality and pollution originating from within its own borders. Thus, the approach to addressing the global health issue of poor outdoor air quality requires an international public health response. Our ability to protect the respiratory health of those living in Singapore, Malaysia, and surrounding countries is very much constrained by geopolitical boundaries. Another example of a global health issue hampered by the public health response of national governments is the issue of young
women and girls who are the victims of sex-trafficking and who are thus at increased risk of HIV/ AIDS and interpersonal violence. Sex-trafficking is a particularly important issue in the South Asian region (although certainly not exclusively there), and it is an important risk factor in the spread of HIV/AIDS. One study estimated the HIV prevalence among sextrafficked Nepalese women and girls repatriated from India to be approximately 38%,11 markedly higher than Nepal’s overall estimated prevalence of 161 per 100 000.12 Thousands of Nepali women and girls are trafficked every year to work in the brothels of large Indian cities. While international and local nongovernmental organizations often provide much of the support and care services for women and girls rescued from trafficking,13 national governments are responsible for enacting and enforcing legislation against such as trafficking. It is also the national governments who have the authority to negotiate and enter into regional agreements, such as the South Asia Association for Regional Cooperation, in which the member states of Nepal, India, Pakistan, Bangladesh, Bhutan, Sri Lanka, and Maldives signed the Convention on Prevention and Combating the Trafficking in Women and Children for Prostitution in 2002.13 We cannot hope to succeed in tackling sex-trafficking as a human rights issue and as a risk factor for interpersonal violence and HIV/ AIDS without recognizing the important role of political boundaries and the authority (and responsibility) they confer. The global health framework also aims to minimize the dichotomy between higher- and lowerincome countries and to recognize the commonality of health issues.
American Journal of Public Health | April 2014, Vol 104, No. 4
EDITORIALS
Public health as a discipline places particular emphasis on improving the health of the poorest and most vulnerable segments of the population. From this perspective, it makes sense that international public health would focus more heavily—but certainly not exclusively—on improving the health conditions in lower-income countries, and, in particular, for women, children, and marginalized populations within lower-income countries, as they constitute some of the poorest and most vulnerable populations worldwide. It is also true that many lower-income countries still face significant burden from health conditions nearly eliminated from higher-income countries, such as certain lifethreatening micronutrient deficiencies, maternal mortality and childbirth injuries, and infectious diseases like leishmania. These countries are also experiencing an increase in health conditions such as cardiovascular disease and cancer historically associated more with higher-income countries. Finally, the term “international public health” technically refers to what other societies outside one’s home country are doing to prevent disease and protect health among their populations. To learn effectively from others and conduct cross-cultural comparisons, all public health students should develop a solid reference point around which to process their knowledge and experience with health systems elsewhere. Ideally, students will gain an in-depth fundamental understanding and familiarity with one high-quality health system, as defined by health indicators and equitable access to services, to serve as their reference point. Students also need to become well versed in the general, theoretical structures of multiple types of health systems,
so that they can conduct comparative analyses across systems. This familiarity with a reference-point health system is essential for comparison when studying about or working in other countries. Such knowledge also promotes the exchange of ideas related to policies and interventions as one works with populations, programs, and policies in countries other than one’s home country. With a firm grounding in one reference setting, the potential for idea flow, both from the country of study to other countries and vice versa, increases. More and more, public health experts in the United States and other high-income countries are looking outside their borders for ideas on how to solve the challenges facing their populations. With the tide of criticism surrounding the term “international public health” comes a somewhat blind following in the use of “global health.” Even within our universities, we apply the name widely to departments, centers, and institutes with little regard for its nuances. In our view, the term “global health” does not adequately convey the real need for public health prevention and solution-oriented international work. While there is a distinct and vital role for the global health perspective within the UN system and for the characterization of trans-border health issues, ultimately solutions will be found and enacted at the national and community levels. We cannot and should not lose sight of international public health. j Anne Sebert Kuhlmann, PhD, MPH Lora Iannotti, PhD, MA
About the Authors Anne Sebert Kuhlmann and Lora Iannotti are with the George Warren Brown School of Social Work, Washington University, St Louis, MO. Lora Iannotti is also with the
April 2014, Vol 104, No. 4 | American Journal of Public Health
Institute for Public Health, Washington University. Correspondence should be sent to Anne Sebert Kuhlmann, Washington University in St Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted September 19, 2013. doi:10.2105/AJPH.2013.301701
Contributors Both authors conceptualized and wrote this editorial.
References 1. Koplan JP, Bond TC, Merson MH, et al. Towards a common definition of global health. Lancet. 2009;373(9679): 1993---1995. 2. Beaglehole R, Bonita R. What is global health? Global Health Action. 2010;3:5142. 3. Bozorgmehr K. Rethinking the “global” in global health: a dialectic approach. Global Health. 2010;6:19. 4. Fried LP, Bentley ME, Buekens P, et al. Global health is public health. Lancet. 2010;375(9714):535---537. 5. Merriam-Webster. Dictionary: public. Available at: http://www.merriamwebster.com/dictionary/public. Accessed August 2, 2013 6. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1998. 7. Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, DC: The National Academies Press; 2002. 8. United Nations. UN at a glance. Available at: http://www.un.org/en/aboutun/ index.shtml. Accessed August 2, 2013 9. World Health Organization. About WHO. Available at: http://www.who.int/ about/en. Accessed August 2, 2013. 10. Associated Press. Singapore air pollution hits record high. The Guardian. June 21, 2013. Available at: http://www. theguardian.com/world/2013/jun/21/ singapore-air-pollution-record-high. Accessed August 2, 2013. 11. Silverman JG, Decker MR, Gupta J, Maheshwari A, Willis BM, Raj A. HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women. JAMA. 2007;298(5):536---542. 12. World Health Organization. Nepal: health profile. Available at: http://www. who.int/gho/countries/npl.pdf. Accessed August 2, 2013 13. Kaufman MR, Crawford M. Sex trafficking in Nepal: a review of intervention and prevention programs. Violence Against Women. 2011;17(5):651---665.
Editorials | 585
In 2012, a year after a devastating tornado hit the town of Joplin, Missouri, leaving 161 people dead and leveling Joplin High School and St. John’s Hospital, President Obama addressed the graduating seniors: There are a lot of stories here in Joplin of unthinkable courage and resilience. . . . [People in Joplin] learned that we have the power to grow from these experiences. We can define our lives not by what happens to us, but by how we respond.1
There are indeed countless stories from Joplin of neighbors helping neighbors, of volunteers arriving by the busloads to lend their hands in rebuilding, and of thousands of trees being planted by community volunteers in an effort to restore and improve the city’s tree canopy. Tragically, social resilience is especially manifest after major disturbances in locales that Tidball and Kransy termed red zones (i.e., places characterized as intense, hostile, or dangerous, including those in postdisaster situations caused by natural occurrences, acts of terrorism or war, or longerterm socio-economic degradation).2 In the aftermath of a disturbance, ordinary people can accomplish heroic acts. How can social resilience be recognized in its myriad forms, especially when it leads to recovery for traumatized people and devastated places?
RECIPROCITY Through more than 40 years of research, much of it supported by the US Forest Service’s research funding, social scientists have explored connections between environmental and human health. Continued cross-disciplinary research
April 2014, Vol 104, No. 4 | American Journal of Public Health
This photograph of the Hull Street Community Garden in Ocean Hill, Brooklyn, NY, is printed with the permission of GrowNYC, “a hands-on nonprofit which improves New York City’s quality of life through environmental programs that transform communities block by block and empower all New Yorkers to secure a clean and healthy environment for future generations” (see http://www.grownyc.org/about). Photograph by Lars Chellberg. identified profound relationships between natural, suburban, and workplace settings and addressing mental fatigue, as access to green space are correlated with significant improvements in mental states.3 Recent research exploring implications from the individual to the societal scales underscores the essential role that trees and natural resources play in creating healthy places for people to live, including relationships between green spaces and enhanced school performance, reduced crime rates, and greater neighborhood livability.4---7 As volunteers and community groups become actively involved in the stewardship of natural resources, their communities exhibit even further gains, including increased civic engagement, neighborhood efficacy, and ecological literacy.8--10 Thus, the present research challenge is to move beyond valuing natural
resources as solely physical green spaces and ask instead: how can urban greening, as a human act, be recognized and managed as a critical component of social resilience? At the New York City Urban Field Station, where Forest Service and New York City Parks researchers bring together a network of scientists and urban land managers, social scientists are using environmental stewardship as a lens through which to better understand the collective ability to strengthen social cohesion, build capacity, and respond to rapidly changing—and often disturbed—environments.
ACUTE AND CHRONIC DISTURBANCE In Spring 2002, just months after the 9/11 terrorist attacks, social scientists from the US Forest Service embarked on
Editorials | 581
EDITORIALS
a journey to learn more about how communities were channeling the vital power of trees and greening as mechanisms for remembrance and recovery.11 Over the ensuing decade, nearly 700 hundred living memorials were documented; these were green spaces cultivated from a shared intention to leave a legacy and a reminder of the lives that were lost in the 9/11 attacks. These memorials sprang up in towns and municipalities surrounding the crash sites, in areas with high concentrations of family members and friends of the victims, and in places with seemingly no other connection to the sites or the victims beyond the realization that it could have happened in their town or to their loved one. The creators of the living memorials were grieving, and through the process of digging in the soil, they were searching for ways to recover their passion for life and community and to honor what had been lost to them. The emergence of the 9/11 living memorials may be viewed as part of a social-ecological process of disturbance and resilience, part of a restorative cycle. They represent community acts tied to traditional mourning rituals and beliefs. These spaces became places of profound social meaning and expression of collective efficacy as people responded to this tragic event with a desire to create, beautify, plant, and trust. Decades before the events of 9/11, a similar pattern emerged in response to a different type of disturbance. Those who were living in New York City; Chicago, Illinois; or Los Angeles, California, in the 1970s may recall first-hand how their communities suffered through a chronic decline in local economies. The fiscal crisis at that time took a devastating toll on urban
582 | Editorials
infrastructure and residents felt the acute impacts of declining neighborhood resources for police, firefighters, sanitation, housing, and parks. Thousands of residents, often those living in the most devastated places, responded by converting garbage-strewn, vacant lots into thriving community gardens and social spaces.12 At the time, these gardens were not recognized and celebrated as evidence of social resilience. Indeed, certain elected officials actively fought against the preservation of these spaces, once development values regained a foothold in previously abandoned urban areas. How might we recognize resilience when it occurs, especially when it is present in an unfamiliar or unexpected form? Preliminary findings from a New York City Urban Field Station social assessment of local waterfront parkland (an investigation in response to the brutal destruction wrought by Hurricane Sandy in October 2012) speak to subtle dimensions in processes of recovery from both extraordinary and everyday stresses. Community members considered their parks to be a refuge that provided them with a buffer when the physical qualities of the city threatened to overwhelm their senses—the noise, traffic, and development—and from social and emotional realities, too. One adolescent reported that a park offered relief from peer pressure and allowed him to stay out of trouble; countless others alluded to stress in their lives and cited local green space as a haven from their worries. Still other residents were engaged in active stewardship of neighborhood parks by planting trees, cleaning up debris, or starting new gardens. Many of those encountered are part of dedicated groups of friends and neighbors who care deeply about their waterfront communities.
These public landscapes are intimately tied to their collective sense of well-being. These encounters provide evidence that social infrastructure is built not of bricks, mortar, and dirt, but rather from the social actions and practices that restore relationships between and among people and the places they hold dear. The materiality of nature, as represented by a handful of vegetable seeds or a group of volunteers planting saplings, provides both a catalyst and a context for dynamic social experiences that have supported thousands of New Yorkers in need of personal, social, economic, and physical recovery. In this era of global climate change, landscapes and natural resources are increasingly valued as buffers that protect human populations against untoward effects—great forests keep atmospheric carbon in check and coastal wetlands soften storm surges that threaten nearby communities. But these biophysical processes and characteristics are just one dimension of their worth. In the face of social, political, economic, emotional, and psychological stressors, green spaces also provide safeguards of a very different kind. The social cohesion that emerges from stewardship activities buffers communities against stresses induced by such experiences.
CULTIVATING MEANING In seeking to synthesize research on the environment and human health, then, nature is cherished not merely as a buffer or a service, but as an integral part of social systems, that is, social infrastructure. The potential for resilience not only resides in physical design and form, but within social relationships. As communities strive
to provide highly efficient green infrastructure that is designed to be resilient to future storms and rising tides, they would do well to also examine and nurture the social meaning in these shared places. The provision of nonprogrammed space in communities creates opportunities for emergent forms of behaviors that reflect a sense of the sacred. These places, which invite access and participation, encourage creativity and interactivity, and require restoration and tending, also afford communities the opportunity to express, support, and—following hard times—heal and inspire. These places are critical not only to the daily lives of community members, but also to the collective spirit of human society. Local community-based organizations such as environmental groups, fair housing coalitions, and community health providers, serve as bridging and bonding entities with the capacity to respond effectively in times of crisis. These groups exert a powerful impact following disturbances because they have learned to adapt to address multiple vulnerabilities in their communities. How might we sustain this form of community work, while expanding frameworks to address social vulnerabilities in the face of both acute and chronic stressors? One strategy is to prepare for disturbances by harnessing the persistent, trusted, and networked relationships of community-based organizations. Social resilience depends upon the ability to cultivate connectedness and encourage human innovation day-in and day-out. While technology and the built form are often revered, it is the human capacity to absorb shocks, self-organize, learn, and adapt that is also worthy of awe. Human beings own the capacity to create: acts of kindness and love,
American Journal of Public Health | April 2014, Vol 104, No. 4
EDITORIALS
organizations that foster respect, communities that attend to emergent and chronic needs, and societies that value social justice. As the life of South African antiapartheid leader Nelson Rolihlahla Mandela (July 18, 1918---December 5, 2013) so eloquently demonstrated, acting out of concern for others brings us closer to a world where well-being and opportunity are shared by all. j Erika S. Svendsen, PhD Gillian Baine, MEM Mary E. Northridge, PhD, MPH Lindsay K. Campbell, PhD Sara S. Metcalf, PhD
NY. Sara S. Metcalf is with the Department of Geography, University at Buffalo, The State University of New York, Buffalo. Correspondence should be send to Erika S. Svendsen, USDA Forest Service, Northern Research Station, 290 Broadway, 26th Floor, New York, NY 10007 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted December 18, 2013. doi:10.2105/AJPH.2013.301848
References
Contributors
3. Kaplan R, Kaplan S. The Experience of Nature: A Psychological Perspective. New York, NY: Cambridge University Press; 1989.
All authors were involved in the conceptualization of this argument. Erika Svendsen led the writing, and her co-authors contributed ideas for enhancement and desired edits. All authors take public responsibility for its content.
Acknowledgments About the Authors Erika S. Svendsen, Gillian Baine and Lindsay K. Campbell are with the USDA Forest Service, Northern Research Station, New York City Urban Field Station, New York, NY. Mary E. Northridge is with the Department of Epidemiology and Health Promotion, New York University College of Dentistry, New York,
Resurrecting “International” and “Public” in Global Health: Has the Pendulum Swung Too Far?
The authors were inspired in the research and writing of this Editorial by a joint venture research agreement from the USDA Forest Service, Northern Research Station to the New York University College of Dentistry (12-JV-11242309-095, Integrating Grey and Green Infrastructure to Improve Health and Well-Being for Urban Populations).
The fashionable term “global health” seeks to convey that health issues are universal and transcend national boundaries. The term’s focus on problem identification within the problem--solution framework undermines critical thinking about solutions at the national and community levels. Public health is ultimately about responding: promoting, protecting, and enhancing the health of populations, especially that of the poorest and most vulnerable populations. The global health system plays an important role in setting standards and noble goals, but action is ultimately taken at national and community levels. Political boundaries confer authority (and responsibility) to uphold the well-being of a population. While recognizing a world of increased interaction and exposures, it is essential to remain grounded in the practicalities of
April 2014, Vol 104, No. 4 | American Journal of Public Health
1. Obama B. Commencement Address. Joplin High School Commencement. Joplin, MO. May 21, 2012. Available at: http:// www.stltoday.com/news/local/metro/ transcript-of-president-obama-s-speech-tojoplin-high-school/article_aeeb8f8e-a41011e1-b2c6-001a4bcf6878.html. Accessed January 23, 2014. 2. Tidball KG, Krasny ME, eds. Greening in the Red Zone: Disaster, Resilience and Community Greening. New York, NY: Springer; 2014.
4. Matsuoka RH. Student performance and high school landscapes: examining the links. Landsc Urban Plan. 2010;97: 273---282. 5. Kuo FE, Sullivan WC. Environment and crime in the inner city: does vegetation reduce crime? Environ Behav. 2001;33(3): 343---367. 6. Troy A, Grove JM, O’Neill-Dunne J. The relationship between tree canopy and crime rates across an urban-rural gradient in the greater Baltimore region. Landsc Urban Plan. 2012;106:262--270.
the “international” aspect of public health. Over the past decade or so, we have observed a trend away from the term “international public health” and a movement toward the term “global health.” In a Lancet commentary, Koplan et al. distinguished between “international health,” “public health,” and “global health.”1 Multiple authors responded,2---4 but, to our knowledge, none focused on how this semantic shift concentrates on only half of the problemsolution framework (i.e., problem identification and assessment) and neglects the solution aspect of the framework and the central role that nation states play in responding with solutions. While the term “global health” seeks to convey that health issues are universal, that health issues transcend national boundaries, and that diseases can and often
7. Campbell LK, Wiesen A eds. Restorative Commons: Creating Health and Well-Being through Urban Landscapes. Gen. Tech. Rep. NRS-P-39. Newtown Square, PA: US Department of Agriculture, Forest Service, Northern Research Station; 2009. 8. Fisher DR, Campbell L, Svendsen ES. The organisational structure of urban environmental stewardship. Env Polit. 2012;21(1):26---48. 9. Connolly JJ, Svendsen ES, Fisher DR, Campbell LK. Organizing urban ecosystem services through environmental stewardship governance in New York City. Landsc Urban Plan. 2013;109:76---84. 10. Falxa-Raymond N, Svendsen E, Campbell LK. From job training to green jobs: a case study for a young adult employment program centered on environmental restoration in New York City, USA. Urban For Urban Green. 2013;12:287-- 295. 11. Svendsen ES, Campbell LK. Living memorials: understanding the social meanings of community-based memorials to September 11, 2001. Environ Behav. 2010;42:318---334. 12. Lawson L. City Bountiful: A Century of Community Gardening in America. Berkeley, CA: University of California Press; 2005.
do spread quickly (and often without respect for political boundaries), the term implies more of a focus on the problem than on what must be done about the problem. The term “global health” may be appropriate when referring to health issues, which are increasingly global in nature, but semantics must not cause us to lose our focus on how to address these problems. The word “public” by definition means “of or concerning the people as a whole.”5 While communities or nations comprise individuals, individuals do not exist in isolation; they are part of a larger, interconnected whole. This larger whole (or population) is the focus of public health. There is tremendous heterogeneity across populations in terms of contextual risk factors driving health outcomes, and the nation state may be
Editorials | 583
EDITORIALS
a useful unit of comparison with political, economic, and cultural commonalities relative to other countries, even though there are often disparities within nations. “Global health” as a term on its own, however, does not allow for population-level analyses, whether at the national or community levels. “Public” also means “being in service of a community or a nation.”5 This definition implies a governmental role, and the responsibility of a government is to serve and protect its people, including the health of its people. While public health is certainly not the exclusive domain of government, the importance of the governmental role and the responsibility of governments to protect and enhance their public’s health cannot be ignored. Public health is also ultimately about the approach of responding to health problems. It is about promoting, protecting, and enhancing the health of groups and populations with an emphasis on preventing illness and injury in the first place (i.e., primary prevention). And, public health is about being responsible to all within the population, especially to its poorest and most vulnerable members. The Institute of Medicine’s frequently cited definition of “public health” refers to “what we, as a society, do collectively to ensure the conditions in which people can be healthy.”6 Often, in order for this response to health problems to truly affect the population as a whole, government must be involved to set policies and standards; regulate and enforce those policies and standards; monitor health status and risk factors; and even provide services to the population. The core functions of public health— assessment, policy development, and assurance6—are ultimately
584 | Editorials
the responsibility of government, thus a public responsibility. In fact, the Institute of Medicine’s report stresses the importance of a strong governmental public health infrastructure to ensure and protect the health and wellbeing of the population.7 While the United Nations (UN) and other multilateral organizations such as the World Bank represent an important role for coordinated, global action, the implementation of any global action relies on the willingness and cooperation of member states. The UN was established in 1945 (original membership of 51 nations) with one of its primary purposes being “to help nations work together to improve the lives of poor people, to conquer hunger, disease and illiteracy, and to encourage respect for each other’s rights and freedoms.”8 The UN holds an important leadership role setting a global vision, facilitating collaborations, and providing the support to move toward that global vision. Ultimately, however, the enactment of any global vision depends on national governments. It is national governments who decide whether to become signatories to conventions, whether to implement and enforce conventions to which they are signatories, and whether to follow proposed norms and standards. It is national governments who enact policies and decide whether to participate in or cooperate with health monitoring and surveillance. The World Health Organization, established in 1948 as the primary health agency of the UN, is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence-based policy options, providing technical support to countries, and
monitoring and assessing health trends.9 However, to act on these trends, national governments must decide to buy into such agendas and be willing to invest resources in such implementation. International political borders matter tremendously in public health because those borders determine authority over policies, interventions, and implementation. Many health issues are in fact global in nature and do not respect national borders, but the response may be either considerably constrained or enabled by these political boundaries. Take for example the recent poor air quality in Singapore caused by Indonesian pollution. Because of weather patterns, forest fires in Indonesia resulted in Singapore recording its poorest air quality since 1997, which then prompted the country to issue health alerts.10 Outdoor air pollution is clearly a global health issue. The governments of Singapore and Malaysia (another country also affected by Indonesian air pollution annually) can do little to reduce air pollution as a risk for respiratory illnesses within their populations without cooperation from the Indonesian government, which is ultimately responsible for regulating air quality and pollution originating from within its own borders. Thus, the approach to addressing the global health issue of poor outdoor air quality requires an international public health response. Our ability to protect the respiratory health of those living in Singapore, Malaysia, and surrounding countries is very much constrained by geopolitical boundaries. Another example of a global health issue hampered by the public health response of national governments is the issue of young
women and girls who are the victims of sex-trafficking and who are thus at increased risk of HIV/ AIDS and interpersonal violence. Sex-trafficking is a particularly important issue in the South Asian region (although certainly not exclusively there), and it is an important risk factor in the spread of HIV/AIDS. One study estimated the HIV prevalence among sextrafficked Nepalese women and girls repatriated from India to be approximately 38%,11 markedly higher than Nepal’s overall estimated prevalence of 161 per 100 000.12 Thousands of Nepali women and girls are trafficked every year to work in the brothels of large Indian cities. While international and local nongovernmental organizations often provide much of the support and care services for women and girls rescued from trafficking,13 national governments are responsible for enacting and enforcing legislation against such as trafficking. It is also the national governments who have the authority to negotiate and enter into regional agreements, such as the South Asia Association for Regional Cooperation, in which the member states of Nepal, India, Pakistan, Bangladesh, Bhutan, Sri Lanka, and Maldives signed the Convention on Prevention and Combating the Trafficking in Women and Children for Prostitution in 2002.13 We cannot hope to succeed in tackling sex-trafficking as a human rights issue and as a risk factor for interpersonal violence and HIV/ AIDS without recognizing the important role of political boundaries and the authority (and responsibility) they confer. The global health framework also aims to minimize the dichotomy between higher- and lowerincome countries and to recognize the commonality of health issues.
American Journal of Public Health | April 2014, Vol 104, No. 4
EDITORIALS
Public health as a discipline places particular emphasis on improving the health of the poorest and most vulnerable segments of the population. From this perspective, it makes sense that international public health would focus more heavily—but certainly not exclusively—on improving the health conditions in lower-income countries, and, in particular, for women, children, and marginalized populations within lower-income countries, as they constitute some of the poorest and most vulnerable populations worldwide. It is also true that many lower-income countries still face significant burden from health conditions nearly eliminated from higher-income countries, such as certain lifethreatening micronutrient deficiencies, maternal mortality and childbirth injuries, and infectious diseases like leishmania. These countries are also experiencing an increase in health conditions such as cardiovascular disease and cancer historically associated more with higher-income countries. Finally, the term “international public health” technically refers to what other societies outside one’s home country are doing to prevent disease and protect health among their populations. To learn effectively from others and conduct cross-cultural comparisons, all public health students should develop a solid reference point around which to process their knowledge and experience with health systems elsewhere. Ideally, students will gain an in-depth fundamental understanding and familiarity with one high-quality health system, as defined by health indicators and equitable access to services, to serve as their reference point. Students also need to become well versed in the general, theoretical structures of multiple types of health systems,
so that they can conduct comparative analyses across systems. This familiarity with a reference-point health system is essential for comparison when studying about or working in other countries. Such knowledge also promotes the exchange of ideas related to policies and interventions as one works with populations, programs, and policies in countries other than one’s home country. With a firm grounding in one reference setting, the potential for idea flow, both from the country of study to other countries and vice versa, increases. More and more, public health experts in the United States and other high-income countries are looking outside their borders for ideas on how to solve the challenges facing their populations. With the tide of criticism surrounding the term “international public health” comes a somewhat blind following in the use of “global health.” Even within our universities, we apply the name widely to departments, centers, and institutes with little regard for its nuances. In our view, the term “global health” does not adequately convey the real need for public health prevention and solution-oriented international work. While there is a distinct and vital role for the global health perspective within the UN system and for the characterization of trans-border health issues, ultimately solutions will be found and enacted at the national and community levels. We cannot and should not lose sight of international public health. j Anne Sebert Kuhlmann, PhD, MPH Lora Iannotti, PhD, MA
About the Authors Anne Sebert Kuhlmann and Lora Iannotti are with the George Warren Brown School of Social Work, Washington University, St Louis, MO. Lora Iannotti is also with the
April 2014, Vol 104, No. 4 | American Journal of Public Health
Institute for Public Health, Washington University. Correspondence should be sent to Anne Sebert Kuhlmann, Washington University in St Louis, One Brookings Drive, Campus Box 1196, St. Louis, MO 63130 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This editorial was accepted September 19, 2013. doi:10.2105/AJPH.2013.301701
Contributors Both authors conceptualized and wrote this editorial.
References 1. Koplan JP, Bond TC, Merson MH, et al. Towards a common definition of global health. Lancet. 2009;373(9679): 1993---1995. 2. Beaglehole R, Bonita R. What is global health? Global Health Action. 2010;3:5142. 3. Bozorgmehr K. Rethinking the “global” in global health: a dialectic approach. Global Health. 2010;6:19. 4. Fried LP, Bentley ME, Buekens P, et al. Global health is public health. Lancet. 2010;375(9714):535---537. 5. Merriam-Webster. Dictionary: public. Available at: http://www.merriamwebster.com/dictionary/public. Accessed August 2, 2013 6. Institute of Medicine. The Future of Public Health. Washington, DC: National Academy Press; 1998. 7. Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, DC: The National Academies Press; 2002. 8. United Nations. UN at a glance. Available at: http://www.un.org/en/aboutun/ index.shtml. Accessed August 2, 2013 9. World Health Organization. About WHO. Available at: http://www.who.int/ about/en. Accessed August 2, 2013. 10. Associated Press. Singapore air pollution hits record high. The Guardian. June 21, 2013. Available at: http://www. theguardian.com/world/2013/jun/21/ singapore-air-pollution-record-high. Accessed August 2, 2013. 11. Silverman JG, Decker MR, Gupta J, Maheshwari A, Willis BM, Raj A. HIV prevalence and predictors of infection in sex-trafficked Nepalese girls and women. JAMA. 2007;298(5):536---542. 12. World Health Organization. Nepal: health profile. Available at: http://www. who.int/gho/countries/npl.pdf. Accessed August 2, 2013 13. Kaufman MR, Crawford M. Sex trafficking in Nepal: a review of intervention and prevention programs. Violence Against Women. 2011;17(5):651---665.
Editorials | 585
