The mandala of health: a model of the Trevor Hancock, MB,BS, MHSc Associate Medical Officer of Health Department of Public Health City of Toronto Toronto, Ontario Canada human ecosystem 'N RECENT years a major transforma- tion in the understanding of health and disease has taken place. The emphasis has shifted from a simplistic, reductionist cause-and-effect view of the medical model to a complex, holistic, interactive, hierarchic systems view known as an. ecologic model. That shift may be so profound as to constitute a paradigm shift or a change in the collective mind set and world view regarding what the rules are and what is possible.” An ecologic model of human health is consistent with the broad field of human ecology, which is “the study of the inter- actions of man and human society with the environment. It is concerned with the philosophy and quality of life in relation to the development of biological and geolog- ical resources, of urban and rural settle- ments, of industry and technology and of education and culture.”’" To paraphrase Pierre Dansereau,? human ecology is the study of the issues that lie at the intersection of environment FCH, 1985, 813), 1-10 ©1985 Aspen Systems CorporationFAMILY & COMMUNITY HEALTH/NOVEMBER 1985 and culture. Public health lies within the broad field of human ecology.* A public health model of the human ecosystem, such as the one that follows, helps greatly to clarify the interaction of culture with environment within the context of the holistic, interactive, and hierarchic nature of health, THE MANDALA OF PUBLIC HEALTH The mandala of public health (Fig 1) was developed by the Department of Public Health, City of Toronto, to concep- tualize and explain public health at a time when the Department was undergoing reorganization and revising its role and Personal Benaviour Fig. 1. A model of the mandala of health, Source: Cute Community Litestye Human-Made Enviconment Biosphere priorities.*? The tool is useful in teaching health science students and the general public, as well as in raising a number of contemporary public health issues. In the mandala, a circular symbol of the universe, the individual—comprising body, mind, and spirit—is seen as the center or focus but is seldom viewed in isolation. Rather, he or she exists within a family that plays a vital role in estab- lishing health values, attitudes, and habits and continuously influences the health of its members. In buffering people and sheltering them from the effects of the community and the culture, the family acts as perhaps the most important mediating structure between persons and social institutions.* Psycho-Socio- ‘Economie, Envircrment Department of Public Health, City of Toronto.Four factors affect the health of indi- viduals and of the family. These factors are based on the health-field concept originally described in the Lalonde report.” These factors as modified for the purposes of the mandala of health are 1. human biology: the genetic traits and predispositions; the compe- tence of the immune system; and the biochemical, physiologic, and anatomic state of the person and the family; 2. personal behavior: dietary habits, including smoking and drinking; driving habits, including use of seat- belts; general risk-taking and pre- ventive behaviors, 3. psychosocial environment: socio- economic status, peer pressure, exposure to advertising, social sup- port systems, and related factors; and 4. physical environment: adequacy of housing and the physical state of the work place and the immediate environment. The model emphasizes that life style is not the same as personal behavior but rather is personal behavior as influenced, modified, and constrained by a lifelong socialization process, as well as by the psychosocial environment, including fami- ly, community, cultural values, and stand- ards. One's life style, then, is chosen from a fairly narrow range of options. The medical care system exists within a community of which it is a part and to which it is accountable; this system is concerned almost exclusively with human biology and personal behavior. Hence, medical care tends to be a less important ‘A MODEL OF THE HUMAN ECOSYSTEM determinant of health than many of the other elements in the model Work (or its absence) is an important determinant of health. Both physical and mental health are influenced by the physi- cal state of the work site and the psycho- social aspects of work, including the work role, social relations, and the quality of work life. Each community has its own values, standards, support systems, and net- works and is therefore a major influence on health. Additionally, the community and human-made environment exist within a broader frame of reference that includes the biosphere and a Western, democratic, technologic, science-based, Judeo-Christian culture. Cultural values, attitudes, and teliefs influence health, how people perceive health, and how they react to illness; however, the bio- sphere, of which the person is but one small and interdependent part, is the ultimate determinant of health. KEY ISSUES ILLUSTRATED BY THE MANDALA The mandala can be viewed as a model of the human health ecosystem. Such a view of health is compatible with a sys- tems hierarchy of health”? and is a holistic model of health. Holistic models of health such as the mandala differ from holistic medicine. The latter refers to an ex- panded medical model that recognizes that health involves body, mind, and spir- it; this model often fails to recognize the influence of family, community, society, and the planet. Holistic medicine often assumes an individualistic and even vic- tim-blaming approach, thereby failing to