Environment, development and health

Human life is now moulded to a large extent by the changes that man has brought about in his external environment and by his attempts at controlling body and soul.
René Dubos (1987, 46)

It is not possible anymore to talk about the environment without referring to health and vice versa (Burger 1990). The environment has become the metaphor for well-being - at least in the industrialized countries suffering from substantial losses of "natural" environments. Densely populated as they are, these countries and their people project the causes of their misery towards the environment. We miss the trees, we fight for each and everyone of them, we want the cows in the meadows and the chicken picking around our houses. Forests, particularly rain-forests, have captured our attention to the limit of psychological competence such that the forests are in danger of becoming the last victims of human kindness after having been already destroyed so extensively.

Environment has become the new buzzword for individual and, particular, sentimental concern. If it was not for the environment, I sometimes think, would there be any other reason to live? Is there any meaning of life without our beloved rain-forests, our frog-highways crossing motorways, our eagles being almost breast-fed if only we could?

The environment has taken possession of our emotions; amongst quite a few of us, it has taken control of their souls. We live in times when the meaning of a tree may easily exceed the meaning of human life. Stranded whales receive better media coverage than unemployed people or battered housewives. We are prepared to take real care of the next plant threatened by extinction, but are rather reluctant when it comes to fellow human beings from a foreign country. One may say: since I know the animals (or plants), I hate humans. As much as there is a fundamentalist environmental concern (environmentalism), there is a fundamentalist concern about health (healthism). Both seem to match, both seem to encourage each other.

It seems reasonable to take a closer look at our relationships regarding the environment and health because, sometimes, we behave "stranger than strange" and we seem to lose contact with the history which we, as humans, have built up during the past centuries. I want to address a few issues I feel of particular interest for those working in the areas of environment and health. In order to do this, I will reflect upon our understanding of environment, development and health as ideological constructs helping us to get along with the ways and means our collectivity is dealing with its social organization. Secondly, I want to take a look at the major political and also social discourse of risks, which predetermine our perceptions of the ecological, social, political, economic, and cultural context of society. Thirdly, I wish to introduce a few sociological considerations in order to clarify the issue of environment and health. I will present some ideas on public health referring to such elusive concepts as health promotion and to those agencies which tell us that the future will look bright if we only adopt their political concepts and squeeze them until their assumed pragmatic juice refreshes our individual and collective lives.

Historically, the term environment is a rather new linguistic buzz-word and refers to different sectors of social reality. We speak of social, personal, cultural, economic, political and, of course, biological and physical environments (Bronfenbrenner 1979, Moos 1976). Environment, to a certain extent, has replaced the terms nature, society and community. Ecology has replaced ideology - so it seems (Sachs 1992, Martinez-Alier 1995).

As a political concept, environment is closely linked to the concept of development. Economic growth and technological progress of all kinds are basic approaches of industrialized societies. It is assumed that the development of a society depends on the improvement of the socio-economic conditions, i.e. on economic growth and the improvement of existing, and the invention of new, technologies to rationalize production processes and services. Research and development are key economic sectors of industrialized societies. The production of knowledge and skills to develop, implement and control technologies lies at the heart of these societies. While traditional societies are based on agriculture, post-traditional societies (Giddens 1991) are based on technology and on those traditional societies which provide them with resources of food, raw materials and inexpensive labor.

Development refers to two different processes which happen simultaneously: the improvement of socio-economic living conditions in industrialized countries and the political, economic, technological and military control of development in traditional societies (Escobar 1995). The development of industrialized countries is based on lower levels of development in other parts of the world. According to classic economics, development has always been linked to economic growth, and subsequently it has been linked to competition rather than to cooperation.

This condition has become even more important now that environmental degradation in industrialized countries due to pollution, over-population and excessive use of natural resources, has brought forward the notion of environmental protection. In the 1960s and 1970s, environment protection referred to the physical and biological conditions of industrialized countries. The environment of post-traditional societies and nation states was threatened and action had to be taken to preserve their geographical space and the quality of the environment. Environmental policies had to be implemented because war to gain new territories of better environmental qualities was impossible. The Cold War era helped stabilize the global political order as far as post-traditional societies are concerned and forced those societies to implement environmental policies in their respective territories.

Since the Cold War, the situation has changed dramatically. The export of environmentally hazardous production lines, the export of toxic waste, and the expansion of the capitalist economy throughout the world has opened huge potentials for post-traditional societies to improve their survival chances by transferring the costs of environmental protection to developing countries at the same time as pretending that socio-economic development in these countries would improve. While the Rio Earth Summit of 1992 sought the reconciliation of environment and development, Wolfgang Sachs assesses its outcome rather sceptically when he states:

It was the developing countries at Rio which insisted on their right to establish socio-economic modes of development similar to those prevailing in developed countries. They clearly stated that they were not prepared to control their socio-economic development according to the needs of the developed countries. As the basic economic pattern of development is capitalism as it had been in the case of the developed countries, it can be assumed that environmental degradation in developing countries will take place more rapidly than before and the global environmental condition will worsen accordingly. Arturo Escobar (1995, 44) comments on the effects of this kind of development:

Escobar`s comments also apply to developed or post-traditional societies. The psycho-social and ecological costs of full-blown industrialized societies are harder to calculate. In terms of individual and collective morbidity and mortality, we are confronted with an amount of disease and suffering hardly known to traditional societies. While they are mostly plagued by communicable diseases, post-traditional societies have developed a new panorama of non-communicable diseases such as cancer, cardiovascular diseases, allergies, etc. All together, the global health situation seems to be horrific, as the World Health Organization (1992, xiii) states:

The sheer number of people affected by the repercussions of development as economic growth and technological rationalization can make us feel helpless in respect of the results of the way of life we are leading. In its 1996 World Health Report, WHO (1996) presents a deteriorating picture of the global health condition particularly emphasizing the recurrence of communicable diseases such as tuberculosis and cholera which seem to spread all over the world affecting developed and developing countries alike. It seems that the situation is getting out of control when

In addition to these health problems, developing countries face a number of social, economic, cultural and political difficulties. Most of these can hardly be dealt with in short-term development programs. Among others, they include:

The economic situation of most developing countries is rather unbalanced; the national budget is low, often due to difficulties in collecting taxes, lack of governmental revenues, and rising foreign debt repayments; falling prices for almost all raw materials offered by these countries; and low average income per capita. On the other hand, energy costs have gone up during the past decades so that industrialization is improving only slowly in many countries. This situation is exacerbated by the lack of vocational training among many people. The lack of an infrastructure needed to improve economic growth prevents foreign investors from coming into the country. Finally, many countries are confronted with unstable political and social conditions.

After humans have engaged in industrialization, nothing has been, or can be the same as before. Traditional societies operated and operate according to natural conditions like seasons, sunrise and sunset, locally determined exchange of goods and services, low tide and high tide. Then, life was determined by natural forces in combination with forces of spiritual necessities. Religion and traditional belief systems predetermined the course of everyday-life. The invention of a temporal structure of societal life is due to the necessity for religious services according to Christian faith. Zerubavel (1981, 1985) has argued that we would not be able to work according to specific time-schedules expressed in seconds, minutes, hours, days, weeks, months, and years without the Catholic Church and its agents.

While the power of the church utilized the human need for security of one form or another, it simultaneously operated on the formation of beliefs and attitudes regarding individual perspectives of life and its meaning regarding spiritual fulfilment. It was the Catholic Church, for example, that had no difficulty in ordering the killing of millions of women considered to be competitors as far as spiritual, mental and physical health was concerned (Heinersohn et al. 1979). The inquisition sought to establish the superiority of the experts' spiritual knowledge over women's knowledge of health and well-being regarding all aspects of health. Several centuries later in 1946, a consortium of experts, foreshadowing the Constitution of the World Health Organization, had difficulty defining health in as comprehensive a way as these women had. The genocide against women in the 15th and 16th century was not only the beginning of male dominance over all aspects of well-being, but it also led to the development of a certain type of philosophy which dominates our thinking even today: mind over matter or, as the French philosopher, René Descartes in the beginning of the 17th century stated: cogito, ergo sum (I think, therefore I am). Subsequently, it created new professions, the most powerful of which are the medical professions which are still with us and which are still determining our world-view to an extent never before accomplished by any other profession.

While health in former times related to the living conditions and ways of life people had developed over the course of time and in the context of natural rhythms, health now became a matter of scientific curiosity. The experts had the religious legitimation to invade the human body, that is, in particular, the female human body, study its physiology, and investigate ways and means of operating on the body in cases of disease and (assumed) necessities. The medical profession established itself as the experts in life and death. They dissociated themselves from the control of the church and created a separate monopoly of knowledge and practice which increasingly competed against the spiritual fatalism of Christian religion by introducing principles of rational pragmatism (Foucault 1994a, 1994b). The conceptual and instrumental development occured simultaneously with the development of industrialized societies. Both sides acted hand in hand: while mass production became the preferred mode of the capitalist economy, the medical profession cleared its broad implementation by gaining control over bacteria and subsequently, communicable diseases which had previously evolved as epidemics in densely populated areas. Industrialization is not possible without sophisticated medical surveillance and monitoring systems being able to detect anomalies in their earliest stages and treat them with massive doses of (bio-) chemical substances. However, the reasons for the successful control of communicable diseases are not the result of medical inventions and treatment, alone. The improvement of water and sanitation, housing conditions, nutrition, education, and workplaces contributed significantly to the establishment of living conditions which have become almost free of life-threatening epidemics until recently.

The risks embedded in the project of modernity were seen by only few academics. The vast majority of the population, including economists and politicians, greeted the socio-economic and technological progress made as a most welcome expression of their capacities and as an improvement of their living conditions. Technology became the key vehicle for social change and was thought to enable even better ways of life in the future. Until the 1970s, it was almost impossible to publicly discuss the serious repercussions of technology on the quality of life of the whole population. The degradation of the environment was seen as a necessary side-effect of the constant improvement of the socio-economic condition - and there was deep confidence that technology would be able to find solutions for the problems it may have created.

With the advent of huge technological complexes of production, safety and security became an increasingly important issue for those who ran those facilities and for those who were employed by them and/or lived close to them. The history of environmental pollution is, of course, longer than our concern with the environment (Douglas & Wildavsky 1984, Landy et al. 1994, Schnaiberg & Gould 1994, Sheehan & Wedeen 1993). Only when pollution had become so prevalent, did we realize what had happened within our cities, towns and villages: industrialization has constantly destroyed the biological fundaments of our lives - and we have played a major part in this process. However, the social and cultural shock which shook developed societies has not changed the course of development significantly. New experts arose and explained that there was no cause for panic since they were able to calculate the risks of technology. Unparalleled in the history of research, risk analysis, risk assessment and similar topics became the fastest growing research areas in the 1980s and 1990s.

The German sociologist, Ulrich Beck (1992), subsequently called developed societies risk societies because their main approach towards development is the calculation, and consequently, the control of risks, that is, they assume they are able to control risk. Seveso, Three Mile Island, Chernobyl and Bhopal are only the well-known technological disasters of the past 20 years. More significant is the daily breakdown of technological systems which were supposed to function for decades without interruption. While risk analysis proves their failure on a day-to-day basis, this has not lead to the conclusion that the basic assumptions of risk analysis may be inappropriate or simply wrong. Real life is more complex and uncertain than mathematical equations are able to swallow.

The sociology of risk tells us, perhaps unintentionally, that all our scientific concepts and methods are much too simple to comprehend the ecological systems we live in and the impact of our technological systems on them. Risk is an abstract category. In real life, we talk of threats and dangers, but this language seems inappropriate when we think of technological progress. However, developed societies have become dangerous indeed. They threaten the global eco-system, and subsequently, they are a significant threat to human life itself. In the next section I will discuss the implications of the concept of risk as far as public health is concerned.

A few years ago, I found an article in a journal called Healthlinks, published by the Health Education Authority of Great Britain. It written by a woman from Glasgow, an industrial center of Scotland. The whole region had been the subject of economic crises and subsequently deteriorating living conditions. In order to change her individual living conditions after having given birth to three children, she got involved in community organization. Her individual health concerns about her children and herself changed to become a question of the distribution of wealth. She wrote:

This may seem to be a rather strong statement of no particular relevance to health promotion as she seems to refer to housing and other subjects supposedly not essential to health. However, Cathy McCormack argues that health promotion should be concerned with living conditions because her living conditions were not on an acceptable level health-wise. Cathy argues that health promotion campaigns which aim at the individual do not make sense if there is not a basic provision of living conditions adequate for human beings. Cathy was concerned about her three children and the conditions she was living in. She thought that those conditions prevented her from being a good mother to her children; and they prevented her children from becoming good and healthy children in the first place.

Health is defined by the World Health Organization (WHO) as physical, mental and social well-being, and as an expression of trust in the present and in the future. Health is a universal and simultaneously a specific indicator for people's experience of the quality of their environment and the embedded quality of social relations they share. One can say, health reflects the relations between people and their living conditions, and thereby looks at both ends of the relations and the processes in between. If these relations lack positive experiences, they lack trust as well and vice versa: that is, they lack trust in oneself, trust in significant others, trust in social support systems, trust in public health policies and, subsequently they lack trust in society as a whole.

Well-being cannot be thought of without referring to trust. If we cannot have trust in ourselves, we feel insecure. If we cannot have trust in the sustainability of the environment, we lose perspective on our lives and the lives of our children and future generations. If we cannot have trust in the government, we feel alienated and excluded from the decision-making regarding our future. Trust is a key category for understanding the construction of societies. Without trust, we would be a conglomeration of individuals, more or less ordered to certain interest groups, pursuing our particular interests in combat against each other about the control of resources.

Ideally, societies provide us with a frame of reference which guides not only individual and collective pursuits of interests, but most important, it sets standards of common weal. Societies are built to enable people to live together despite their different individual interests. Societies do not harmonize, they hardly balance these interests but they provide a framework of values, beliefs, and communicative strategies which binds people together and gives meaning to their action. Of course, this framework is subject to change and, accordingly, all social sectors undergo processes of change. Most importantly, however, trust remains the consistent denominator of societal processes because without trust, these processes would lead to the liquidation of the society as a whole.

The societal development of industrialized countries has led to an almost total destruction of traditional values and belief-systems and the roles and functions of their respective institutions. Economic and technological development have simultaneously destroyed traditional social systems because these traditions have lost their meanings and functions for societal systems based on the individualization of social relations in all social sectors and areas. We have lost traditional systems of rationality and have replaced them with the rationality of technology. We have lost traditional systems of inter-generational families and have replaced them with the two-generation family, although an increasing proportion of the population lives as singles and/or single mothers and fathers. Modern societies have become post-traditional societies in the sense that they have broken with traditions to a large extent.

While the metaphor of the self-made man initially referred to someone who took his economic life in his hand - homo oeconomicus, it has now become an overall ideal of human life in modern societies (Romanyshyn & Whalen 1987). Self-realization and self-sufficiency are the core criteria of success. Human potential has to be developed to the fullest extent by each individual - so we are told not only by the World Health Organization which is concerned about the health status of each person on Planet Earth, but also by educators, psychologists, management trainers, and ecologists; in short by all the modern priests of personhood and well-being. A good individual is the totally developed one! What they are really saying is, a good individual is one which follows our advice.

In post-traditional societies there is no escape from good advice about all aspects of human life. We are subjected to institutions and agencies which provide us with an overload of information and advice resulting frequently in contradictory concepts and measures of alleviating our individual lives. We have to select the appropriate schools and universities, we have to buy the adequate garments and perfumes, we have to train our language and communication skills, we have to eat the right food and watch the politically correct TV channels, we have to put our money in the right trust funds and build ecologically sound homes, and so on. Whatever we do, there is someone "out there" telling us how to do it correctly.

In addition to the governmental bureaucracies which regulate public and private life in terms of law and order, post-traditional societies have developed private and public organizations and agencies to design individual life, guiding it through its course in time, and making sure that no one falls through the net of the consulting industry. Life cannot be lived anymore by ourselves, it is lived according to designs prepared and implemented by public and private agencies. A huge industry has been developed dealing with these issues, mostly covered up by labels such as "Do-it-yourself" or "Self-help".

These labels are not meant seriously, of course. They are euphemisms because they do not really intend to improve our faculties and skills. Self-help does not mean self-determination, and it certainly does not mean self-organization or even empowerment of individuals and groups. What the consulting industry is aiming at is gaining control over individuals and the potential risks they bear for society in terms of development, creativity, solidarity, and empowerment through community organization. "Self-help" has to be understood literally, i.e. just help yourself and do not care about others or worry about the conditions that might have led to the state you are currently in. "Do-it-yourself" only means to fix the things that have been broken by someone else. The focus is on self and not on help. It is the self as a discrete unit that is targeted, not the self as a social human being in relation to other human beings. The consulting industry does not deal with communities or social groups but with numbers of discrete units sometimes packaged to target audiences if the issue needs to be transmitted in a relatively short period of time.

The consulting industry does not let us alone as long as everything turns out fine and we behave according to the advice we are given. We are left alone of course, as soon as something goes wrong. The relations between consultant and client are not characterized by commitment, but by commerce. As soon as we have accepted the advice, i.e. as soon as the advice has become an individual property by making it part of our lives, the responsibilities regarding the effects of acting accordingly are ours. Once we start to jog, the heart failure is ours. It takes time for the consulting industry to find out whether its advice is sound. Until then - whenever that may be, because more and more frequently we are not able to deliver unequivocal research, we have to bear the risks though the consultants initially claimed they knew that we would only improve if we behaved according to plan.

Good advice has always been given to people. Parents, friends, neighbors, colleagues, etc. have always told us to take care of ourselves and avoid falling into this or another trap. Giving advice is an integral part of social relationships because it is an expression of the commitment we feel to significant others. The difference between this type of advice and the advice provided by the consulting industry lies in the quality of the relationships between both sides. Social relationships are characterized by a strong personal responsibility for individual action. Client relations between us and the consultants are characterized by the interests of the consultants to lead us on their paths of life. Social relations are characterized by trust, client relations by efficiency. Social relations have a long-term perspective, client relations are short-term, issue- and outcome-oriented. Social relations are necessary to build communities and societies through solidary action, client relations are designed to fix "problems". Social relations are based in the context of everyday life, client relations are grounded in artificial settings of professional expertise.

In traditional societies, societal and social processes worked through the whole community. In post-traditional societies, these processes are designed by functionaries and experts and are implemented subsequently according to target audiences and target areas, i.e. to segments of the social systems without intending in the first place to give people a say in the development. Post-traditional societies have individualized human life by disembedding the individual from her reference groups and treating her as a discrete unit in relation to her social functions. This has not been a one-way process without any friction and antagonism, and it has never been accomplished according to plan. Individuals cannot be organized and controlled the way post-traditional societies have intended. Despite the prevalence of a consulting industry, individuals have been and will be unpredictable as regards their actions. This is particularly true with regard to all social areas such as education, health, intimate relationships, entertainment, recreational activities or the entire leisure sector.

Post-traditional societies have undergone major changes in terms of economic policies, technological development, international relations (globalization), and environmental degradation. While huge wealth has amassed at home, poverty and hunger have increased abroad in so-called developing countries. While excelling in developing and implementing more and more sophisticated technologies at home, almost barbaric conditions prevail in "developing countries". Post-traditional societies are arbitrary in essence. Their effects on a global as well as a regional and national level are antagonistic, to say the least.

When we take a look at the internal changes of post-traditional societies, we notice rapid processes of destruction of values, beliefs, roles, responsibilities, education, families, etc., and almost simultaneous processes of constructing new ways of dealing with the effects of societal processes on the human level.

From a social-cultural point of view, three processes of conceptual construction in relation to social issues characterize post-traditional societies:

1. Medicalization: Post-traditional societies interpret social issues as social problems which need to be dealt with by professionally trained experts. In order to assign experts to "problem-solving", the "problems" have to be formulated in terms of the experts' knowledge base. For example, social issues like values, family life, education, public health or nutrition are translated into categories of sociology, psychology, social work and medicine. The public discourse about these issues is translated into an experts' discourse addressing the public. In effect, the public discourse is replaced by an experts' discourse taking place in public. The public is reduced to interest groups claiming to represent the public or at least considerable segments of the public.

Expressions of everyday life are interpreted in the light of analytical categories of social and medical sciences. Everyday life itself loses its pragmatic, frequently trivial character and becomes a highly sophisticated issue which needs scientific input to be understood and changed. Human expressions of love, passion, anger, anxiety, enjoyment or lust are decontextualized and deprocessualized into frozen categories of psycho-, medico- and socio-analysis. These analytical categories are used as representations for complex and often complicated psychological, sociological and cultural processes. For example, the term depression is assigned to a variety of decontextualized behaviors thereby leading to the epidemiological statement that depressions are prevalent in post-traditional societies. When defining certain behavior as depressive, we are able to identify the behavior accordingly without needing to question whether the definition is reasonable or valid in the first place. A second example: by the US-catalogue of psychiatric disorders, youth from the age of 10 to 14 years are defined as mentally unstable and psychiatrically ill when they do not obey their parents. Here, the social relationships of the family are translated into psychiatric categories thereby indicating that the family suffers from "problems" and that the "cause of this problem", namely the child, needs professional treatment in order to fit into the set of psychiatric categories of mental health again. Finally, a third example:

The conceptual circle stabilizes the social system as well as the role of experts - and in the end, it tends to make individual and collective behavior consistent with the categories rather than constructing categories to become consistent with behavior. However, this is typical of any process of scientification: the objects of concern are shaped according to categories in order to make them fit with the theories the categories are based upon. As far as health-related issues are concerned, I call this process medicalization of everyday life and I join Peter Conrad when he states:

2. Therapeutization: It is only logical that after the medicalization of social issues, the solution to the defined problems lies in their therapeutization, i.e. in experts' knowledge and skills of problem-solving as regards individual and collective behavior. Again, it is assumed that experts know how to solve social problems because they are trained professionally to understand human thoughts and behavior and to be able to change human thoughts and behavior according to set objectives.

Therapeutization means the scientification of everyday life in terms of psycho-technological treatment potentials, i.e. behavior modification. We have become subjected to experts' insight and techniques regarding our psyche. We are what we are defined for, so it seems. We are no more what we believe we are or we may be able to be. The human potential gets streamlined according to socially preferred and psycho-technologically feasible types of personality development. The social and cultural images and meanings of the human body are but one example.

3. Judicialization: In order to legitimize the role of experts in the process of problem-definition and problem-solving, the problems themselves have to be translated into judicial terms. Legislation of social problems takes place to an extent never seen before. The behavioral control via laws is the key characteristic. The law is a strong control agent of individual and collective behavior in as much as it is perceived as the general behavioral and cognitive guideline of the societal framework of public and private life. Yet, it only presents the formal framework of social relations pressing these relations into judicially manageable mechanisms.

Judicialization refers to the incapability of the political system to open up public discourses on topics of societal relevance. The institution of the political discourse is given up in favor of a judicial one, thereby assuming that the judicial system would be capable to come up with sound regulatory answers to problems that have not yet been discussed in-depth publicly. In the end, the judicial system will have no other option but to refuse the presumptions of the political system and to reject the idea that social problems can be resolved by setting judicial standards of resolution. In the end, we are confronted with a vicious circle which prolongs our insecurity rather than resolving it.

Epidemiology teaches us about the distribution of mortality and morbidity across an entire population. Mortality rates, surprisingly, do not change very much in the course of time. In fact, they almost stay the same. A certain percentage of the population dies every year irrespective of what safety measures are taken. What may change is the distribution of deaths among age groups. With morbidity, the case is only slightly different. We observe changes in patterns of morbidity, but we do not observe significantly higher or lower rates of morbidity over the course of time. Populations seem to suffer and to die rather predicably as soon as they have reached a certain level of socio-economic development. The developed countries of the world, for example, have not suffered from substantial changes in their mortality and morbidity over the past 30-50 years.

This is amazing given the changes in medical technology and the level of public awareness concerning health-hazardous behaviors. What have changed, are certain causes of death as demonstrated in death certificates and certain distributions of so-called premature deaths among particular age groups. The overall epidemiological picture, however, stays almost the same.

There are few issues related to these changes on death certificates. Death certificates have become more precise in the course of time because physicians have more knowledge and skills to determine at least some causes of death. In addition, many deaths are investigated by pathological services. However, since death happens when physiological systems shut down, physicians tend to refer to individual causes of death according to their medico-technological education. That is, many deaths are classified, for example, as caused by cancer or cardiovascular deficiencies. If death certificates were taken seriously, in the end everybody would be classified as dying of cardiovascular arrest, because the heart will stop beating at some point in time. The notion of cancer in a polluted environment does not seem meaningful at all when it only refers to potential individual behavior.

Cancer has become one of the most prominent causes of death related to "individual malbehavior". In a society which promotes such behavior via consumerism and adjacent campaigns of product promotion and which does not take care of occupational health and safety, building codes, environmental protection standards etc., cancer will always be one of the major causes of death among a population which simply grows too old because of these developed living conditions. Cancer is hardly an indicator of "misbehavior" but is an indicator of the level of socio-cultural development of post-traditional societies in addition to the quality and range of pathological investigations.

We are talking about a paradox, maybe even a dilemma: developed societies in uncontrolled ways have gone so far that individual life can be extended to limits never experienced before but simultaneously threatening collective lives in pursuit of their economic prosperity by establishing modes of production, manufacturing, housing codes, environmental pollution and living standards hazardous to the health of the population rather than to the health of particular individuals.

Mortality among age groups demonstrates the inhumane social, cultural and physical environment developed countries have established. In the USA, most deaths of young people under or at 25 years of age are traffic and drug-related and among African-American youth of the same age group, murder ranks number one of the causes. Mortality and morbidity in these cases simply reflect societal developments rather than effects of individual and collective risk-behaviors.

The relation between sick populations and sick individuals has been noted by the late British epidemiologist Geoffrey Rose in his book The Strategy of Preventive Medicine. He brings to focus the key problem of epidemiology by stating:

Geoffrey Rose has been principal investigator of the Whitehall-Study, a long-term epidemiological study of morbidity and mortality of employees of the civil service of the Parliament of England. This is probably the best documented study ever regarding the substance of epidemiological data in relation to the prevention of cardiovascular diseases. The research reports generated from this study can be summed up by as follows:

Health and death do not seem to be a matter of individual choice of certain behaviors over others. There is more to life and death than just the question of what you eat and if you exercise. It is questionable to link particular behaviors to certain death causes. It becomes more questionable, the more we realize that societies are extremely complex systems linked to other societies - and that the environment is a much more basic layer of human development, full of ecological, i.e. systemic qualities not being matched by the societal mechanisms we have developed during the past centuries (Marmot et al. 1987, Wilkinson 1986).

In terms of public health, the understanding of society is a crude one. Health professionals seem to believe societies to be an external frame of individual life and individual life to be external to society. Epidemiological studies and reports on public health rarely reflect the dialectic relations between individual and society, let alone the complexity of the interdependence between societies, between cultures, between social groups, and between individuals.

It is interesting to note that contemporary public health does not have a concept of comparative analysis regarding its subject. Disease and its development is related to individual behavior irrespective of its cultural context. Cardiovascular diseases, for example, are studied in relation to individual behavior classified as risk-factors: smoking, cholesterol level, blood pressure, physical exercise, etc. No suggestion is made that risk-factors may be mathematical clusters of vital social and cultural factors being differently shaped and being of different relevance in different societies and for different people. Risk-factor medicine has become the prevalent concept of public health.

The disease-orientation of public health is not able to comprehend that life follows different, unpredictable paths of direction and meaning. It is only able to understand that life needs to be controlled in terms of questionable physiological parameters and the subsequent necessity of adjusting the body accordingly, without giving an idea how disease may be caused and health may be achieved in culturally sensitive ways. This type of prevailing public health has no idea of the social and cultural connotations of risk, let alone of the individual, collective, interactive and contextual dimensions of personality development.

Environment and health have become nearly interchangeable concepts in post-traditional societies. We are able to observe almost an obsession with them, as if individual changes in ways of life - important for the individual and significant for the culture though they may be - possessed the power to overthrow a system of economic relations that aims at growth in numerical terms rather than at development, enabling society to sustain its specific modes of private and public interaction. From the point of social change, it does not make much difference whether one engages in one or the other arena. Both are weak players in political terms, and both are currently so diverse in concepts and strategies that they do not present a substantial threat to the established political and economic system.

In times of economic crisis, or even transition, which the post-traditional societies are currently confronted with, a completely new frame of mind as regards further development might be appreciated by some. Those in power do not seem to like the idea of substantial change at all. Social movements, the latest hope of some political analysts, still have to prove that they are able to sustain their energy over a long period of time characterized by slow change, conflictuous industrial relations, rising under- and unemployment, and increasing nationalism or even racism. These are not conditions supportive for the changes needed.

As regards scientific ideas on environment and health, I believe that we still depend too often on our old frames of mind. Rationality in the sense of the past centuries has brought us to the point where we are currently. A philosophy which conceptualizes vivid processes as sequences of end-points does not seem to be prepared to comprehend the complexity of ecological systems of which we humans are only one element. Gregory Bateson (1980) in terms of epistemology, and Paul Feyerabend (1993) in terms of methodology presented new ideas which may enable us to face our global problems as expressions of our ways of life rather than as a set of mathematical calculations.

However, beyond all needs for conceptual changes lies an even more difficult task: environment and health are not isolated arenas of political dispute. They are part of a comprehensive system of local, regional, national, and international interdependencies of political and economic power structures. We are not alone anymore, if we have ever been. Whatever happens somewhere on this planet, it will have an impact on our individual and communal living conditions and on the ways how we see the world. We are on our way although nobody knows where the journey will lead us. However, one thing is crystal clear:

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