1999 Blackwell Science, Inc.

Evolving Models of Human Health Toward

an Ecosystem Context

J.A. VanLeeuwen,* D. Waltner-Toews, T. Abernathy, and B. Smit

*Department of Health Management, University of Prince Edward Island,
Charlottetown, PEI, Canada; Department of Population Medicine, Ontario Veterinary
College, University of Guelph, Guelph, Ontario, Canada;
Central West Health Planning Information Network, Hamilton, Ontario, Canada

ABSTRACT

Current models or frameworks used to represent and/or
conduct research on determinants of human health
have lagged behind in adopting emerging concepts of
ecosystems: multiple spatial and temporal scales; nested
hierarchies of socioeconomic and biophysical environ-
ments; inherent complexity of interrelationships among
environmental components and influences; external en-
vironmental influences; and feedback loops between en-
vironments, providing self-organizational capacity and
functional emergent properties. This article provides a
concise description of a number of human health mod-
els and their relevance to an ecosystem health context.
A new model of human health is described, the Butter-
fly Model of Health, that draws on the strengths of
previous health models, but more fully incorporates sa-
lient characteristics of ecosystems. In the new model,
health is considered to be a societally defined, social,
economic, and biological resource for self-renewal and
meeting goals. This capacity is dependent on an equita-
ble balance between socioeconomic and biophysical en-
vironmental pressures. Within the model, the health of
the individual or population (the body of the butterfly),
enveloped by biological and behavioral filters, is affected
by both biophysical and socioeconomic holarchic envi-
ronments (the wings), which are influenced by each other
through the actions of individuals. Health is present when
the two wings of the butterfly are equitably balanced
within and between their respective dimensions, with nei-
ther dominating and putting undo pressure on the other.
The model is sufficiently flexible to conceptualize links
with community and ecosystem models in a variety of
contexts.

INTRODUCTION

Ecosystems have gained widespread acceptance as a
conceptual construct of the world in which we live
in today, both academically and publicly (Goodall
1999; Chadwick

et al.

1999). They have been de-
scribed as having a number of salient characteris-
tics. Ecosystems exist at multiple spatial and tempo-
ral scales and therefore can be thought of as being
arranged within nested hierarchies, with each level
of the hierarchy having emergent functional prop-
erties that are a result of the complex interactions
of the many internal and external structural com-
ponents and functions to the ecosystem. An exam-
ple of such an ecological hierarchy based in agricul-
ture includes the following: field, farm, land use
district, watershed, ecological region, ecological
zone, and biosphere (Allen & Starr 1982). Al-
though ecosystems may change over time, they re-
main self-organizing to maintain the balance of eco-
system structures and functions. That is not to say
that they are organisms, but that they are more
than just the sum of their parts (Rapport

et al.

1985). One method by which they self-organize is
through positive and negative feedback loops that
regulate the many species interactions, including
humans and their complex socioeconomic and
biophysical environments (VanLeeuwen

et al.

1998;
Waltner-Toews 1996).
Ecosystem health has been introduced as a par-
adigm for dealing with the interconnectedness of
many global problems and complexities of manag-

Address correspondence to: John VanLeeuwen, Department
of Health Management, University of Prince Edward Island,
Charlottetown, PEI, Canada, C1A 4P3; E-mail jvanleeuwen
@upei.ca.
VanLeeuwen et al.: Human Health in an Ecosystem Context

205

ing and caring for our world (Rapport 1989; Cos-
tanza 1992; Rapport 1995; Waltner-Toews 1996;
Rapport

et al.

1998a,b). Ecosystem health is a logi-
cal extension of the health paradigm (and its ac-
companying language, values, testing, and pro-
cedures) beyond individuals (human or animal
health) and populations of the same species in
one place (public or herd health), to populations
of different species in one place, or in many places
(Rapport 1989). In a world where social and eco-
logical interactions are increasing in both inten-
sity and spatial scope, a model of human health in
an ecosystem context provides a more realistic
model of the determinants of human health.
The purposes of this article are to briefly dis-
cuss a number of models of human health and
how they relate to concepts of ecosystem health,
and to describe a new model of human health in
an ecosystem context which draws on the strengths
of previous models of health, while incorporating
the salient characteristics of ecosystems mentioned
above.

MODELS OF HUMAN HEALTH

There have been many descriptive models of hu-
man health proposed and utilized, some of which
have been reviewed by Dever (1991). With in-
creasing knowledge and changing characteristics
of disease, there has been considerable evolution
in our understanding of the notion of health and
its determinants. In this section, we document
this evolution and evaluate the models in terms of
their relevance to ecosystem health. Table 1 pro-
vides a summary of some of the stepping stones
along this path.

THE ECOLOGICAL MODEL

In the late 19th century, at a time when the infec-
tious causal components of many diseases were be-
ing discovered (e.g., tuberculosis, polio, plague),
Robert Kochs Germ Theory led to one of the
first recorded descriptive models of human health,
the Ecological Model (Figure 1), also called the
health triad (Thrusfield 1995). In this model,
there is a dynamic equilibrium between three ele-
ments: the host, the environment, and the agent. A
change in any one of the three may upset the bal-
ance between the host and agent in favor of one or
the other, resulting in more or less exposure and
disease, and conversely, less or more health, re-
spectively.
The model contains a number of assumptions:
all agents cause only one disease; all diseases have
only one causal agent, an infectious agent; and all
exposed individuals become diseased. However,
current patterns of disease do not always corre-
spond to the model assumptions. Today, some
agents are thought to cause more than one disease,
many diseases have multiple causes (Levins

et al.

TABLE 1

Relevance of previous human health models to ecosystem characteristics

Health model
Nested
hierarchy
SE
environment
BP
environment
Complex
interactions
Self
organizing
Multiple
species
Ecologic Y
Socioecologic Y/N Y/N Y Y
Wellness Y Y/N
Holistic Y Y
Health promotion Y Y/N
Mandala Y Y Y
Community health Y Y
Health determinants Y Y Y

Ecologic, The Ecologic Model; Socioecologic, The Socio-Ecological Model (Morris 1975); Wellness, The Illness-Wellness Continuum (Travis 1977);
Holistic, The Environment of Health Model (Blum 1974); Health Promotion, A Framework for Health Promotion (Epp 1986); Mandala, The Mandala
of Health (Hancock & Perkins 1986); Community Health, A Model of Health and the Community Ecosystem (Hancock 1993); Health Determinants,
The Health Determinants Model of Health (Evans & Stoddart 1990).
206

Ecosystem Health Vol. 5 No. 3 September 1999

1994), many diseases are noninfectious, and many
exposed individuals remain healthy.
Although the assumptions of the model do not
apply to all diseases, agents, or circumstances, the
model continues to have relevance to conceptual-
izing what constitutes health, introducing the idea
that health is a dynamic equilibrium and balance
between the host, agent, and environment, a con-
cept that is related to ecosystem theories around
interconnectedness and the balance of nature.
The model, in a simplified manner, describes what
influences health in the form of the three very
broad categories of influences: host, agent, and en-
vironment.

THE SOCIOECOLOGICAL MODEL

In 1975 Morris described a model similar to the Eco-
logical Model or Health Triad, but addressing its
major shortfalls. In the model, the agent is re-
placed with multiple personal behavioral influ-
ences, thereby changing the model from one disease
caused by one infectious agent to a multifactorial
cause and effect model for both infectious and non-
infectious disease (Figure 2). The model also subdi-
vides host (genetic and experiential) and environ-
mental (physical and social) influences.
This model assumes that behavioral influences
have a greater impact on disease than the physical
environment. Disease is dependent on where and
how one chooses to live. For example, someone
who chooses to live in an urban setting will have in-
creased contact with other humans and therefore
more opportunity for contracting contagious dis-
eases compared with a hermit who chooses to live
in the middle of the forest and is therefore more
likely to contract zoonotic diseases. Even environ-
mental diseases from nonpoint exposure of con-
taminants do not affect some people who take steps
to minimize their exposure, while possibly taking a
tremendous toll on the rest of the population. Radi-
ation poisoning from atomic bombs or nuclear re-
actors, although devastating to nearly everything in
their wake, would have minimal effects on those
who chose to build radiation-proof shelters.
Although the model still concentrates on dis-
ease instead of health, the specification of the host
and environmental influences as well as the intro-
duction of personal behaviors, are valuable contri-
butions, considering the large influence that per-
sonal choices can have on human health. However,
this model was not designed to address issues of eco-
system health and therefore is insufficient for de-
scribing human health in an ecosystem health con-
text.

THE WELLNESS MODEL

In 1977 Travis developed the Illness-Wellness Con-
tinuum Model (Figure 3) to describe influences
that can move one more optimally along a health
continuum. This model directly challenges the
World Health Organization (WHO 1948) defini-
tion of health as a state of complete physical, men-
tal, and social well-being, a virtually unattainable
state. The model portrays what constitutes human
health within ecosystems through the introduction
of the notion that health is not an end-state but
rather a continuum, ranging from death through
poor health, beyond a point of no physical illness,
to feelings of awareness, education, growth, and a
high level of wellness.
Although not specified in the model, physical
activity, nutrition, stress management, and self-
responsibility are mentioned as important com-
ponents of lifestyle influences that affect health.
However, in the model, there is no mention of
how ones socioeconomic and biophysical envi-
ronments influence health. Therefore, although
the idea of a health continuum is useful, the model
is incomplete as a basis for ecosystem health.

THE HOLISTIC MODEL

During the 1970s there was a conceptual shift to-
ward more holistic models. Blum (1974), Dever
(1976), and Lalonde (1974) developed models
that include four central influences on human
FIGURE 1. The Ecological Model.
FIGURE 2. The Socioecological Model reprinted from
Uses of Epidemiology 3rd Ed. By J.N. Morris, p. 177,
with permission of Churchill Livingstone Inc., 1975.
VanLeeuwen et al.: Human Health in an Ecosystem Context

207

health: environment, lifestyle, human biology, and
system of health care. The models also combine
the best health practices from both Eastern and
Western civilizations.
Of the three, Blums model (Figure 4) is most
applicable to assessing the health of human popu-
lations in an ecosystem context, suggesting that
what affects the four major influences of health
(above) are five background influences: factors of
population, culture, mental health, natural re-
sources, and ecological balance. How much each
of the four influences contributes to human health
depends on the combination of these five items.
In his model, Blum alters the size of the four
arrows according to his perception of their relative
contribution to health of the human population.
However, the arrow sizes would be different for re-
gions and countries where health care services are
nominal (e.g., most African nations where disease
is primarily related to their environment) (Swantz
1994), or where human behavior, to a large extent,
dictates the health of that population (e.g., Can-
ada, where lifestyle influences are important, lead-
ing to heart and lung disease). Both Lalonde and
Dever assumed equal weighting of the four inputs
for health to occur, but do not make any assump-
tions as to how they perceive current levels of influ-
ence in any specific situations. All three of the ho-
listic authors portray health or well-being as an
ultimate state of complete physical, mental, and so-
cial well-being, rather than a continuum of health.
Blums holistic model promotes the Health
Education/Disease Prevention approach whereby
initiatives to educate high-risk groups of people
on the influences of health should result in ap-
propriate health choices. However, mass educa-
tional approaches are mainly effective among
middle and upper-income populations, leaving
those in greatest need both unreached and unaf-
fected (Green & Richard 1993). The model intro-
duces the notion that what constitutes health can
be subdivided into three parts: psychological, so-
cial, and physical. The author describes health
not in terms of disease but of a persons growth
toward harmony and balance.
We suggest that Blums Environment of Health
Model provides much guidance for describing what
influences human health. However, due to its so-
cioeconomic focus and lack of detail with respect
to the biophysical processes affecting health, this
model also proves inadequate for describing hu-
man health in an ecosystem health context.

A FRAMEWORK FOR
HEALTH PROMOTION

In 1986 the World Health Organization (WHO)
produced the Ottawa Charter on Health Promo-
tion (WHO 1986). In the document, health was
viewed very broadly, which was reflected in WHOs
1984 description of health as:
FIGURE 4. The Environment of Health Model. Source:
Reprinted from Planning for Health: Developmental Ap-
plication of Social Change Theory by H.L. Blum, p. 3,
with permission of Human Sciences Press, 1974.
FIGURE 3. The Illness-Wellness Continuum re-
printed from Wellness for Helping Professionals
by J.W. Travis, with permission of Wellness Asso-
ciates, 1977.
208

Ecosystem Health Vol. 5 No. 3 September 1999

. . . the extent to which an individual or group
is able, on the one hand, to realize aspirations
and satisfy needs; and on the other hand, to
change or cope with the environment. Health is
therefore seen as a resource for everyday life,
not the objective of living; it is a positive concept
emphasizing social and personal resources, as
well as physical capacity.

The Health Promotion initiative was very in-
fluential in developing a focus on

both

individual
(lifestyle) and structural (mostly socioeconomic)
health rather than disease (Lalonde 1974). Epp
(1986) outlined a Health Promotion Framework
to achieve health for all by the year 2000. In this
framework he presented how the government of
Canada planned to improve and enhance capac-
ity-building at the individual level with respect to
ones health, rather than building services that
can be incapacitating or can foster dependency.
Central to the Canadian governments plans were
three tiers of activities: health challenges, health
promotion mechanisms, and implementation strat-
egies, as shown in Figure 5.
As a result another paradigm emerged, pro-
posing a systems approach to health rather than a
biomedical model. The systems approach recog-
nizes that the increasing, context-specific com-
plexity and number of influences that affect hu-
man health cannot be adequately resolved one at
a time. In order to improve health, structural im-
provement in the overall living environment, with
its many interrelated subsystems, is also needed.
Just preventing specific influences in high-risk
groups has limited success since the living envi-
ronment of the rest of society is neglected (WHO
1986). A systems approach to health promotion
was given five action areas to develop:
1. building public policies that support health;
2. creating supportive environments;
3. strengthening community action;
4. developing personal skills; and
5. reorienting health services (WHO 1986).
The Health Promotion approach is compared
with the previous Health Education/Disease Pre-
vention approach in Tables 2 and 3. Essentially,
the Health Promotion model of health developed
concepts of what socioeconomic strategies, mecha-
nisms, and challenges are needed to improve
health toward the goal of achieving health for all,
which indirectly describes what influences human
health, albeit from a socioeconomic perspective. In
terms of what constitutes health, the model consid-
ers health a personal, social, and physical resource
for meeting human goals and needs.
Both of these developments about what consti-
tutes and what influences human health are di-
rectly applicable to describing human health within
an ecosystem health context, but due to the lack of
detail on biophysical environmental factors, the
model, by itself, is insufficient for describing human
health in an ecosystem health context.

THE MANDALA OF HEALTH

Working within the newly established health pro-
motion paradigm, Hancock and Perkins (1985)
developed the Mandala of Health, a mandala be-
ing a circular design of concentric geometric
forms symbolizing the universe. The model of the
FIGURE 5. A Framework for Health Promotion.
Reprinted from Canadian Journal of Public
Health 77, 402, with permission of Canadian
Public Health Association, 1986.
VanLeeuwen et al.: Human Health in an Ecosystem Context

209

human ecosystem is conceptualizing and explain-
ing the modern day approach to public health . . .
to health science students as well as the general
public. At the center of the model, similar to the
holistic model, individual health is considered to
have three constituent parts: mind, body, and spirit
(Figure 6). The influences on health are repre-
sented by three circles of nested systems around
the individual: the family, the community and hu-
man-made environment, and finally the culture or
biosphere, in that order. The rings are meant to be
both three-dimensional, implying multilevel and
multifaceted, and dynamic in size and shape, de-
pending on the temporal and spatial context.
The authors specify four subgroups of health
influences within the family and community cir-
cles of influence which are similar to some of the
previous models discussed: personal behavior (life-
style), human biology, and two types of environ-
ments, physical and psychosocioeconomic (PSE).
In addition to the four determinants, the health of
the individual and family is dictated by their life-
style choices (their behavior within their PSE envi-
ronment), their work (the interaction between

TABLE 2

Differences between health promotion programs versus disease prevention programs

Health promotion programs Disease prevention programs
Health concept Positive and multidimensional Negative and one-dimensional:
absence of disease
Health models Holistic Deterministic
Population focus Total population High-risk groups
Program types Diverse and complementary Often focused and unconnected
Program approaches Participatory facilitation and empowerment
rejects professional dominance
Top-down education and persuasion
Program goals Improve physical and socioeconomic
environment
Improve individual and group choices
Program participants Health and other organizations, civic groups,
governments, public
Health professionals and recipients

Source: adapted from Stachtchenko & Jenicek 1990; Rose 1985; Labonte 1981; 1991.

TABLE 3

Differences between health promotion research versus disease prevention research

Health promotion research
Disease prevention
research
Types of relationships investigated Webs of causes and webs of effects Simple cause-effect
Object of research or evaluation Ongoing process of decision-making Endpoint effect
Level of research focus Individual, political, environmental, and
organizational levels
Individual level usually
Methodology Qualitative and quantitative Quantitative usually

Source: adapted from Stachtchenko & Jenicek 1990; Rose 1985.
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Ecosystem Health Vol. 5 No. 3 September 1999

their physical and PSE environment), and how their
consumption patterns of health care affect their
body (Hancock & Perkins 1986).
Hancock and Perkins did not overstate the
importance of health care services the way Blum
did, choosing to include it as a secondary influ-
ence on personal behavior and human biology,
influences on health which are given equal im-
portance to the psychosocioeconomic and physi-
cal environments in the model. It would, how-
ever, seem more appropriate for the personal
behavior and human biology influences to be
closely linked with the body, mind, and spirit of
the individual since they are largely interdepen-
dent (Evans

et al.

1994a).
With regard to modeling human health in eco-
systems, the Mandala of Health is the first model
to represent a nested hierarchy of influences on
individual healththat being the family, the com-
munity, and the larger culture and biosphere
thereby recognizing these three scales as having
emergent properties. The model reiterates previ-
ous interpretations of what constitutes health by
its subdivision of individual health into three
parts: mind, body, and spirit. However, the socio-
economic and biophysical environmental struc-
tures and processes that influence health (both
internal and external to the ecosystem) are not
given much attention, and there still are a number
of important ecosystem characteristics not repre-
sented in the model. Therefore the Mandala of
Health is incomplete for the purposes of situating
human health in an ecosystem health context.

A COMMUNITY ECOSYSTEM MODEL

Hancock (1993) proposed a model of health that
integrates community health and sustainable de-
velopment of communities (Figure 7). This model
suggests that sustainable development of commu-
nities is essential for sustaining human health. This
community-oriented model is meant to supple-
ment the Mandala of Health model of individual
health discussed earlier.
In the Community Ecosystem Model, commu-
nity health is found at the intersection of three cir-
cles: the community, the environment, and the
economy. Healthy community ecosystems should
have six qualities within their environmental, eco-
nomic, and community dimensions. They should
be convivial, liveable, sustainable, viable, and ade-
quately prosperous with equitable wealth distribu-
tion. Hancock suggests that these six qualities
could be used as principles of development policy
in land use planning in a holistic manner. They
could also be used as scales or indicators of healthy
community ecosystems.
The contribution of the Community Ecosys-
tem Model to modeling human health in ecosys-
tems is its identification of what constitutes health
at the community level: the three qualities of each
of the community, the environment, and the econ-
omy, how they relate to each other, and their im-
FIGURE 6. The Mandala of HealthModel of the Hu-
man Ecosystem. Reprinted from Health Promotion 1, 99,
by T. Hancock, with permission of Oxford University
Press, 1986.
FIGURE 7. A Model of Health and the Community Eco-
system. Reprinted from Health Promotion 8, 44, by T.
Hancock, with permission of Oxford University Press,
1993.
VanLeeuwen et al.: Human Health in an Ecosystem Context

211

portance for human health and development. Be-
cause of its focus on what constitutes health, the
model only sketches out what influences health at
the community level in the form of the three cir-
cles: the community, the environment, and the
economy.

THE HEALTH DETERMINANTS
MODEL OF HEALTH

In 1990 Evans and Stoddart (1990) developed the
Health Determinants Model of Health, also called
the Feedback Loop of Human Well-Being and Eco-
nomic Costs (Figure 8). The model is centered on
the relationships among disease, health care, and
health and function, with a number of other iden-
tified health influences and arrows surrounding
them to represent the deterministic relationships
believed to occur among them all. The constitu-
ents and identified influences of human health are
similar to those of previously discussed models.
This model reflects a 30-year trend to identify
the direct relationships between human health
and the so-called determinants of health de-
fined as factors, whether they be events, charac-
teristics, or other definable entities, that brings
about change in a health condition, or other de-
fined characteristici.e., causal associations of
health (Last 1988). However, the identification
of direct deterministic causal relationships among
determinants of disease and health is problem-
atic. Determinants of health are not the uncondi-
tional machinery parts that invariably lead to dis-
ease, a reflection of industrial revolution science
according to Descartes (Jones & Moon 1987). In-
stead, they only have a certain probability of re-
sulting in a particular health outcome, and there-
fore a probabilistic interpretation of influences of
health is preferred for specific health influences
(Hancock & Perkins 1985). Furthermore, there
are often many stressors leading to a disease and
many diseases or disease symptoms that can mani-
fest from any particular influence. The intercon-
nections and context-specificity of ecosystems go
beyond what the deterministic biomedical model
can handle or was meant to handle. For example,
toxins in the physical environment can affect the
genetic endowment of subsequent generations,
but this model does not depict any factors affect-
ing genetic endowment.
Nonetheless, the health determinants model
contributes to describing what influences human
health in ecosystems through its explicit introduc-
tion of feedback loop relationships between health
influences and human health. Feedback loops oc-
cur directly and indirectly; health care has direct
effects on level of disease as well as indirect effects
on prosperity, the social environment, and finally
the level of disease.
In summary, none of the above models are ad-
equate for describing human population health in
the context of changing ecological conditions.
Therefore, a model of human health within an eco-
system context seeks to address this deficiency.

A MODEL OF HUMAN HEALTH IN
AN ECOSYSTEM CONTEXT

Our proposed model, the Butterfly Model of
Health, builds upon the strengths of the models
discussed above and incorporates the salient char-
acteristics of ecosystems listed in Table 1. Our
model is generic in that it is meant to have broad
application to the health of individuals, popula-
tions, communities, and ecosystems as discussed
at the end of the section. Table 4 provides a sum-
mary of the key characteristics of the Butterfly
Model of Health.

HUMAN PLACEMENT AND DIVISION

The Butterfly Model of Health (Figure 9) places
humans inside the ecosystem (Bormann 1996) (es-
pecially applicable in ecosystems with extensive hu-
man influence, such as urban ecosystems and agro-
ecosystems), the boundary of which is shown as a
broken line because both natural and human-
FIGURE 8. The Health Determinants Model of Health
reprinted from Social Science and Medicine 31, 1347
1363, with permission of Elsevier Scientific Ltd, Perga-
mon Press, 1990.
212

Ecosystem Health Vol. 5 No. 3 September 1999

made influences move in and out of ecosystems
routinely.
Humans act as intermediaries, individually
and collectively, between the two environments of
the ecosystem: the biophysical (BP) environment
and the socioeconomic (SE) environment. Policies
generated in the SE environment usually have
equally important impacts on the BP environment,
and vice versa. For example, if economic decisions
are made to allow further use of prime agricultural
land for industrial development, the economic
benefits of such actions must be weighed against

TABLE 4

Key characteristics of the Butterfly Model of Health

Characteristics Butterfly Model of Health
Socioeconomic (SE) environment
components
Different human structural elements and functional features
influencing, and being influenced by, human health
Biophysical (BP) environment
components
Different biophysical structural elements and functional features
influencing, and being influenced by, human health
Multiple species Multiple biota categories represented
Nested hierarchy Humans placed inside the BP and SE environments, which are within
larger ecosystems, affected by neighboring and distant BP and SE
external environments
Model structure and complex interactions Arrows and broken lines used to identify relationships, and represent
permeability and indiscrete definitions
Self-organization Positive and negative feedback loops
Location and function of human behavior
and biology
Human population is intimately surrounded by biological and behavioral
filters which are affected by, and influence the impact of, the BP and SE
environments
Model utility To describe the health of individual humans, populations,
communities and ecosystems
Political influence Political institutions present as a SE element
FIGURE 9. Butterfly Model of Health
for an Ecosystem Context.
VanLeeuwen et al.: Human Health in an Ecosystem Context

213

the short- and long-term additional pressures on
forest and wetland utilization to maintain food
production.
In the Butterfly Model, the three constituent
parts of human population health (physical, men-
tal, and spiritual, as in the Mandala of Health)
(Hancock & Perkins 1985) are not drawn as segre-
gated portions of a circle but rather are separated
by a broken line, depicting their profound interde-
pendencies. At the individual level the body influ-
ences, and is influenced by, the mind and spirit.
These connections between mental and spiritual
states and immune status have been documented
empirically and can be explained, even with only
partial knowledge of current neural and hormonal
transmitters (Tizard 1996). At population and
community levels, one can define similar intercon-
nections and fields of influence among physical,
intellectual, and spiritual health (Leighton 1959).

BIOLOGICAL AND BEHAVIORAL FILTERS

Surrounding the human population are two filters
acting in concert to enhance or reduce health.
The first is a biological filter, the innate biochemi-
cal and biophysical abilities of a population to
maintain health and fight disease. The second is a
behavioral filter, the power to control personal be-
havior, lifestyle, and associated environmental ex-
posures within a specific set of opportunities. To-
gether these filters govern the types of exposures
that are encountered, along with the response that
is invoked to the exposure and the degree to which
the exposure can cause damage. Operating well,
these two functions filter out or prevent a wide
variety of diseases and achieve higher levels of
health. Placing them together around the human
population recognizes the growing evidence that
the immune system (biological filter) and the ner-
vous system (behavioral filter) communicate in
such a way that the influences in the social environ-
ment (such as prolonged stress), via its effects on
the nervous system, can affect a variety of biologi-
cal responses (Dantzer & Kelley 1989; Evans &
Stoddart 1990).
With regard to the biological filter, no two
people have the exact same response to an envi-
ronmental stimulus because every human contains
a unique set of genetic material. Even identical
twins, who begin life with identical genomes, begin
drifting apart genetically as the body produces
replacement cells that may contain random muta-
tions from the original genetic material. Of course,
some of the response differences are also a func-
tion of differing social and biophysical interac-
tions. People who attend to their requirements for
physical (food, exercise, and rest), mental (creative
and emotional thought), and spiritual (religious
or metaphysical) sustenance allow their biological
(and behavioralsee BP and SE Environments
section below) filter to function to its fullest capac-
ity to reduce the effects of an invading agent, while
those who neglect the needs of their body, mind,
and spirit are more likely to suffer more deleteri-
ous consequences. Some exposures may even af-
fect the degree to which the immune system can
properly function, e.g., human immunodeficiency
virus (HIV). Hence, there are major differences
between individuals in their ability to defend them-
selves against the same disease agent.
Populations also vary with respect to their col-
lective biological filter, due to different BP and
SE/cultural environments that affect the general
diet, exercise habits, spiritual activities, and emo-
tional support systems. As a result, and in con-
junction with differing behavioral filters, different
populations have different rates and patterns of
disease (Evans 1994).
The behavioral filter also varies considerably
in its development and functioning to prevent un-
healthy exposures, depending on the SE environ-
ment (see below) of an individual. A happy but
disciplined rearing environment with an active
support network of friends and family allows the
development of a discriminating behavioral filter
that is less susceptible to peer pressure or stressful
circumstances (Spencer 1981; Evans 1994). The
behavioral filter is primarily a product of the SE en-
vironment and varies with the culture (Australian
aboriginal versus Tibetan Buddhist), country, and
specific SE environment of each individual.
It must be emphasized that the intimate and
prominent position of this personal behavior filter
around the human population is not a throwback
to early health promotion discussions of the 1970s
(Lalonde 1976) that blame the victim for their
health problems and excuse a society that neglects
the influences that lead to the high-risk behavior.
Individual health problems are not simply the re-
sult of free, independent personal decisions made
by individuals to engage in risky behaviors, such
as smoking or unprotected sex. To some extent,
people are able to make decisions about options
on whom to see, what to do, when to go places,
along with where and how to live and what infor-
mation to believe. However, their set of options, or
perceived options, are constrained by the holon
(hierarchical context) within which they are called
214

Ecosystem Health Vol. 5 No. 3 September 1999

upon to make decisions (Checkland & Scholes
1990).
For example, people of lower SE status are less
able to avoid certain environmental exposures
when the only type of housing they can afford is
near a dump site or industrial park. They also are
more likely to intentionally expose themselves to
high levels of certain harmful substances such as
cigarette smoke because their family, friends, and
coworkers are more likely to be smokers, some of
which is related to social class and restricted expec-
tations for employment, education, and living con-
ditions (Ontario Ministry of Health 1991). They
choose to smoke, but that is more likely to be part
of their social norms and reality. Ones behavioral
filter can determine what exposures are encoun-
tered, but how that filter develops and functions
(along with the set of opportunities from which it
can choose) is shaped by aspects and policy regard-
ing the SE environment (Evans

et al.

1994b). As the
African proverb goes, it takes a village to raise a
child.
Disagreements regarding individual responsi-
bility versus social and biological determinism of-
ten stem from a failure to specify hierarchical scale
issues and interactions. Just as cells and organs can
only be understood fully in terms of the body in
which they occur, so individual health cannot be re-
alistically characterized without reference to their
community context, the health of communities
cannot be realistically characterized without refer-
ence to some larger context, and so on (Waltner-
Toews 1995). This is discussed in further detail in
the next subsection.

BIOPHYSICAL AND
SOCIOECONOMIC ENVIRONMENTS

The ecosystem can be broadly categorized into the
biophysical aspects (BP environment) and socio-
economic aspects (SE environment) (Gaudet

et al.

1997). The two environments are depicted as large
circles with broken lines, signifying permeability
and susceptibility to influence from other struc-
tures and processes of the ecosystem itself, neigh-
boring ecosystems, or even distant ecosystems.
The structural elements of the BP environ-
ment are those that are important to biological
life on earth. The basic building blocks of life in
ecosystems include air, water, soil for nutrients,
and energy in the form of sunlight and tempera-
ture (climate), making them essential elements of
the BP environment of ecosystems. The interac-
tions between these basic building blocks resulted
in the formation of the three basic life forms on
earthmicrobes, plants, and animalsthe final
three elements of the BP environment. Together,
the elements of the BP environment in ecosystems
form the ecological support system upon which all
life is dependent.
What is it about these BP elements that influ-
ences human health and enables the human pop-
ulation to achieve good health? According to
Maslows (1970) hierarchy of human needs, the
BP environment provides basic survival needs.
One needs to breath reasonably clean air and
consume sufficient fluids and nutritious food that
do not contain toxic levels of substances. These
needs reflect what Cairns and Pratt (1995) and
Daily (1997) refer to as ecosystem services.
Therefore, the nonsocioeconomic (primar-
ily) functional features that are of interest to hu-
man health regarding the structural elements of
the BP environment would include air quality and
quantity, water quality and quantity, and food
quality and quantity. Human health would also be
affected by how well the ecosystem meets aes-
thetic needs, because health also has mental and
spiritual aspects to it.
The SE environment surrounding an individ-
ual or population also has a number of principal
elements (people and the built environment) and
features (functions) that have repeatedly been
shown to have a major influence on human
health (Frank 1995), either directly or through
their effects on what we have dubbed the biologi-
cal and behavioral filters. These effects may be
muted somewhat by the current ability of the be-
havioral filter as formed by historical SE and BP
environmental effects. Although called the SE en-
vironment, each of the listed elements and fea-
tures in the model has its respective spiritual,
emotional, psychological, sociological, and eco-
nomic aspects.
Within the SE environment of the Butterfly
Model of Health, four influences comprise an in-
dividuals primary peer group of influence: homes
and families, neighbors and friends, workplaces
and coworkers, and voluntary organizations. Of
these, the first and most dominant influence on
health is the home and family. In particular, it is
the first few years of home life which are the most
formative (Spencer 1981). Most adults spend
around 8 hours a day for 30 or 50 years in formal
or informal employment, making coworkers and
the workplace another huge cumulative influence
on population health. Of course, neighbors and
friends are the people we, by geography or by
VanLeeuwen et al.: Human Health in an Ecosystem Context

215

choice, spend much time with, and therefore are a
socioeconomic influence on population health.
Voluntary organizations, such as religious, recre-
ational, and/or interest groups, provide structure
and process for interactions between people
(Berger & Luckmann 1967), and therefore are
also a large part of ones SE environment. To-
gether, these four influences of ones SE environ-
ment form the lions share of the direct SE impact
on population health.
There are three other major elements in the
SE environment: political institutions, social sup-
port networks, and the health care systems (Evans

et
al.

1994a). A number of neighborhoods cooperate
to form political institutions for decision-making re-
garding social support, health services, and policy.
Beyond ones peer group, these SE elements have a
large influence on human health. Political institu-
tions can allocate funds to bolster social support
where it is lacking through a variety of means, in-
cluding financial, physical, cultural, psychological,
emotional, and/or spiritual support programs. Of
these programs, the health care system is ultimately
responsible for tending to the health care needs of
its people, both therapeutically and prophylacti-
cally. These SE aspects vary considerably among
countries and regions, depending on their culture,
prosperity, and political focus.
What is it about these SE elements that influ-
ence human health? Many researchers support
the notion that the early childhood development
period is extremely important in anyones life,
particularly the first year or two of life (Spencer
1981). Proper nurturing with ample food, infor-
mation stimuli, and values education are crucial
to the development of ones self-esteem and abil-
ity to learn and make decisions without undue re-
liance on the opinions of others within ones peer
group (Evans

et al.

1994a).
As children grow into adults they learn to have
control and responsibility over more and more of
their lives. However, that feeling of control de-
pends on the degree to which other people (fam-
ily, friends and/or coworkers) in ones SE environ-
ment allow control over ones life. Lower feelings
of control over ones life (empowerment), at work
and/or at home have been shown to be strongly as-
sociated with human health, disease, and death
(Marmot & Theorell 1988; Rook 1984).
Another important SE feature that influences
human health is the strength of social support one
has, be it informal (including neighbors, friends,
and relatives) or formal (including counselors,
clergy, and psychiatrists) (Lin & Dean 1984). Dur-
ing major psychosocioeconomic crises in ones life,
such as death of family members, failure of a loved
one to succeed in one of lifes main areas (school,
work, marriage, parenting, etc.), access to and
quality social support has a tremendous effect on
the amount of stress that is felt, how that stress is
handled, and ultimately how much impact the cri-
ses have on ones health (Dantzer & Kelley 1989),
particularly with respect to cardiovascular disease
(Frank 1995). Hertzman

et al.

(1994) point out
that, especially in more industrialized countries,
these psychosocioeconomic crises are more fre-
quent and burdensome than most diseases on the
lives and health of individuals. Therefore, the im-
portance of social support is larger than the impact
of health care services for the majority of people.
When and where the social support is less avail-
able, health care services increase in importance.
Community attachment and a sense of belong-
ing is another important influence on human
health, particularly spiritual, emotional, mental,
and social health, achieved through participation
in community life both in a formal work setting as
well as in an informal setting, such as with volun-
tary organizations, be they religious, recreational,
or interest groups. Participation in community life
may provide people with financial gain and/or a
sense of self and contributing to society, whether
that be in the production of a widget or providing
some service for which there is a demand. More
personal contacts are also made which can increase
ones social support network, indirectly influenc-
ing health (Spencer 1981).
Humans have a unique role to play in the eco-
system, deciding, according to current societal
values, the fate of the many elements and features
of the ecosystem and thus the fate of the ecosys-
tem itself. This unique role occurs both in a direct
way at the individual level through interactions
with the ecosystem, as well as in an indirect man-
ner through the establishment of public policy.
Regarding relationships between the SE and
BP environments and other components of the
model, large double-headed arrows run between
the BP and SE environments, through individuals,
thereby emphasizing 1) the bidirectional move-
ment and feedback loops of energy, nutrients, and
impacts, and 2) the fact that these effects are mani-
fested through individuals by their behavioral and
biological filters. The double-headed arrows do
not penetrate the broken lines of the individual.
This shows that individuals may have the option of
avoiding a particular environmental influence if
they have the capacity to do so. The arrows pene-
216

Ecosystem Health Vol. 5 No. 3 September 1999

trate the broken line borders of the environments
to show their permeable nature to human influ-
ences. Arrows linking individual environmental
components have been omitted for two reasons: to
represent their profound interdependencies, and
to indicate that these complex interactions are de-
pendent on the SE and BP environmental context
of the ecosystem, as discussed earlier.

EXTERNAL BIOPHYSICAL AND
SOCIOECONOMIC ENVIRONMENTS

Lying outside the boundaries of any ecosystem are
the BP and SE environments of neighboring ecosys-
tems, environments that can influence the internal
BP and SE environments of a particular ecosystem.
Water and air pollution, for example, freely move
between ecosystems, creating problems in neigh-
boring ecosystems. Similarly, there is considerable
social and economic activity between neighboring
and distant ecosystems. External BP and SE envi-
ronments can have a dramatic influence on the BP
and SE environment of ecosystems and therefore
should be represented as major categories of influ-
ences affecting human health in ecosystems, and
ecosystem health.
External BP and SE environments can also rep-
resent influences occurring at a hemispheric or glo-
bal scale. Global warming and the ozone hole have
effects on the climate of the BP environments of
many ecosystems, potentially altering habitats and
the population dynamics between many compo-
nents within habitats. Similarly, international policy
can have an immense direct impact on the internal
SE environment of an ecosystem. For example, the
General Agreement on Tariffs and Trade (GATT),
along with the World Trade Organization (WTO),
affects commerce around the world, reducing re-
strictions on trade and effectively lowering com-
modity prices. As a result livelihood capabilities are
affected, which in turn have demonstrable effects
on ecosystem health at both individual and com-
munity scales (Winson 1992, 1996).
Two-way arrows between the external BP and
SE environments of neighboring ecosystems and
the internal BP and SE environments of an ecosys-
tem recognize the interaction and feedback be-
tween ecosystems. Furthermore, the internal BP
and SE environments of one ecosystem are the ex-
ternal BP and SE environmental influences on
other ecosystems. Of course, because of the intricate
interconnections between the BP and SE environ-
ments of an ecosystem, external BP environments
would not only directly influence the internal BP
environment of an ecosystem, but also indirectly in-
fluence the internal SE environment of an ecosys-
tem as members of the ecosystem adapt to the
changing internal BP environment. The same argu-
ment applies for external SE environments.
Due to the nested hierarchical nature of eco-
systems, what is considered a neighboring exter-
nal influence at one scale may be part of the inter-
nal environment at a higher scale. Because of this
concept, it is important to always state to which
scale one is referring. Global influences, such as
global warming, the ozone hole, or the WTO,
would be external to all but the global ecosystem.

INDIVIDUAL, COMMUNITY, AND
ECOSYSTEM HEALTH LINKAGES

The Butterfly Model of Health describes what con-
stitutes and what influences health in ecosystems.
Because ecosystems are hierarchical, the identified
structural elements and functional features would
apply when looking at human health at any one of
the nested hierarchies found in ecosystems, be it at
the community level, ecodistrict level, watershed
level, or larger regional level such as a province or
country. The elements and features would be quite
similar, regardless of the spatial or temporal scale
of focus.
Communities and populations are more than
just aggregations of individual people. They also
include the many elements and features of interac-
tion between people (psychological, social, eco-
nomic, political, and cultural), and between peo-
ple and the natural environment that can only be
measured at that higher scale. As such they require
a more complex and multiscalar measurement of
health than for individuals or human population
health. The following example, using the Butterfly
Model of Health, illustrates this.
The health of individuals depends on the
health and balance of the BP and SE environments
of the ecosystem around them. Perhaps James Rob-
ertson (1978) described it best in his SHE soci-
ety: sane (in balance with oneself), humane (in
balance with other people), and ecological (in bal-
ance with nature). However, an individual can
maintain an adequate level of health within an un-
healthy community if they have taken extra efforts
to maintain the health of their immediate sur-
roundings. That individual may live in a luxurious
neighborhood with security guards, have on-site air
and water purification systems installed, and lobby
to maintain large correctional centers to incarcer-
ate those people labeled criminals. At the individ-
VanLeeuwen et al.: Human Health in an Ecosystem Context

217

ual level, such people may be considered healthy
in most respects. Physically, they may be living as
long or longer, and with an equal or greater qual-
ity of life, than the average person in the larger
community or nation. Socially and politically, they
may be functioning, interacting, and participating
in the maintenance of the structure and process of
their particular circle of friends and acquaintan-
ces. However, the larger community, within which
this enclosed neighborhood is nested, may be very
unhealthy due to natural resource degradation
and devastation, and a wide disparity in income
distribution leading to social and political unrest
and economic havoc. Examples of where healthy
(privileged) individuals are living within unhealthy
communities can be found in virtually any country.
However the long-term viability of such systems are
questionable.
After one includes more and more individuals
and families into ones view, one flips into a new
field of vision where community health offers a dif-
ferent and perhaps clearer perspective. Once the
entire community becomes visible, those compo-
nents only measurable at the community level can
then be measured (political institutions, health
and social support services), permitting a clearer
picture of why and how the interactions between
people, and between people and the natural envi-
ronment, occur.
The Butterfly Model of Health can apply to
human populations aggregated according to politi-
cal boundaries, such as communities, counties,
provinces, etc., or according to ecological bound-
aries, such as subwatersheds, watersheds, ecodis-
tricts, or ecosystems. It could therefore be said that
ecosystem health relies on aggregated individual
health, aggregated community health, and the
health and balance of ecosystem level SE and BP
environments.
In fact, determination of health and balance
between SE and BP environment influences may be
more appropriate with ecological aggregations than
political aggregations since there are visual differ-
ences between the BP environments of different ec-
osystems, with these differences often carrying im-
portant differences in SE opportunities and the SE
environment. Local industries, particularly those re-
lated to agriculture, often reflect the BP landscape
in which they are located. For example, the Niagara
Escarpment of Ontario demarcates a boundary be-
tween two ecosystems with dramatically different
soil types, vegetation, SE activities, and farming sys-
tems. Similarly, the Haldimand-Norfolk Sand Plain
in Ontario has very different BP and SE environ-
ments from that of the surrounding ecosystems.
Conversely, one can travel across county or provin-
cial borders with little or no immediate change in
landscape or people. Perhaps analysis of health
would be more appropriately conducted using eco-
logical boundaries and aggregations of individuals
(bioregionalism reference).

CONCLUSIONS

The Butterfly Model of Health has been presented
as a descriptive model for representing and study-
ing human health in ecosystems. The model incor-
porates many structural elements and functional
features of what constitutes and what influences
health. It builds upon the strengths of other mod-
els, such as balance from the Kochs Ecological
Model; what constitutes health from the Mandala
of Health (Hancock & Perkins 1986); what influ-
ences health from the Community Ecosystem
Model (Hancock 1993); and feedback loops from
the Health Determinants Model (Evans & Stoddart
1990). However, it also includes many salient char-
acteristics of ecosystems, including nested spatial
hierarchies of important categories of elements
and features of internal and external SE and BP
environments (built upon those of the Mandala);
multiple species; functional emergent properties
depicted in the environmental features; the com-
plex structural and functional interrelationships
among the elements and features; and feedback
loops between environments, providing self-orga-
nizational capacity.
Certainly the Butterfly Model of Health does
not completely capture all aspects of human
health within ecosystem health. For example, the
model cannot resolve tradeoffs between what is
good for humans versus what is good for other
ecosystem species. However, the model does de-
scribe dimensions and determinants of human
health and ecosystem health and their interrelation-
ships. When properly integrated, these relationships
will enhance our understanding of human health
and ecosystem health, and their interdependency.

ACKNOWLEDGMENTS

I would like to thank the following organizations
and people for their financial, technical, and/or re-
source assistance: the Eco-Research Program of the
Canadian Tricouncil for a doctoral fellowship and
research funding through the Ecosystem Health
218

Ecosystem Health Vol. 5 No. 3 September 1999

Project; fellow Ecosystem Health Project research-
ers for stimulating discussions; and the Department
of Population Medicine, Ontario Veterinary Col-
lege and University of Guelph for awards received
during the pursuit of my Ph.D. in epidemiology.

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