.

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 environments; inherent complexity of interrelationships among
environmental components and influences; external environmental influences; and feedback loops between environments, providing self-organizational capacity and
functional emergent properties. This article provides a
concise description of a number of human health models and their relevance to an ecosystem health context.
A new model of human health is described, the Butterfly Model of Health, that draws on the strengths of
previous health models, but more fully incorporates salient 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 equitable balance between socioeconomic and biophysical environmental 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 environments (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 neither 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

ple of such an ecological hierarchy based in agriculture includes the following: field, farm, land use
district, watershed, ecological region, ecological
zone, and biosphere (Allen & Starr 1982). Although ecosystems may change over time, they remain self-organizing to maintain the balance of ecosystem 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 paradigm for dealing with the interconnectedness of
many global problems and complexities of manag-

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 described as having a number of salient characteristics. Ecosystems exist at multiple spatial and temporal scales and therefore can be thought of as being
arranged within nested hierarchies, with each level
of the hierarchy having emergent functional properties that are a result of the complex interactions
of the many internal and external structural components and functions to the ecosystem. An examAddress correspondence to: John VanLeeuwen, Department
of Health Management, University of Prince Edward Island,
Charlottetown, PEI, Canada, C1A 4P3; E-mail jvanleeuwen
@upei.ca.

1999 Blackwell Science, Inc.

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ing and caring for our world (Rapport 1989; Costanza 1992; Rapport 1995; Waltner-Toews 1996;
Rapport et al. 1998a,b). Ecosystem health is a logical extension of the health paradigm (and its accompanying language, values, testing, and procedures) 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 ecological interactions are increasing in both intensity 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 discuss 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.

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 provides a summary of some of the stepping stones
along this path.

THE ECOLOGICAL MODEL

In the late 19th century, at a time when the infectious causal components of many diseases were being 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 elements: the host, the environment, and the agent. A
change in any one of the three may upset the balance 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, respectively.
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 correspond to the model assumptions. Today, some
agents are thought to cause more than one disease,
many diseases have multiple causes (Levins et al.

MODELS OF HUMAN HEALTH

There have been many descriptive models of human health proposed and utilized, some of which
have been reviewed by Dever (1991). With increasing knowledge and changing characteristics
of disease, there has been considerable evolution

TABLE 1
Relevance of previous human health models to ecosystem characteristics

Health model

Ecologic
Socioecologic
Wellness
Holistic
Health promotion
Mandala
Community health
Health determinants

Nested
hierarchy

SE
environment

BP
environment

Complex
interactions

Self
organizing

Y/N
Y
Y
Y
Y
Y
Y

Y/N

Y
Y
Y/N

Multiple
species

Y
Y/N
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).

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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.

FIGURE 1. The Ecological Model.

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 conceptualizing what constitutes health, introducing the idea
that health is a dynamic equilibrium and balance
between the host, agent, and environment, a concept 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 environment.

THE SOCIOECOLOGICAL MODEL

In 1975 Morris described a model similar to the Ecological Model or Health Triad, but addressing its
major shortfalls. In the model, the agent is replaced with multiple personal behavioral influences, thereby changing the model from one disease
caused by one infectious agent to a multifactorial
cause and effect model for both infectious and noninfectious disease (Figure 2). The model also subdivides host (genetic and experiential) and environmental (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 increased contact with other humans and therefore
more opportunity for contracting contagious diseases compared with a hermit who chooses to live
in the middle of the forest and is therefore more
likely to contract zoonotic diseases. Even environmental diseases from nonpoint exposure of contaminants do not affect some people who take steps
to minimize their exposure, while possibly taking a
tremendous toll on the rest of the population. Radiation poisoning from atomic bombs or nuclear reactors, although devastating to nearly everything in
their wake, would have minimal effects on those
who chose to build radiation-proof shelters.
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Although the model still concentrates on disease instead of health, the specification of the host
and environmental influences as well as the introduction of personal behaviors, are valuable contributions, considering the large influence that personal choices can have on human health. However,
this model was not designed to address issues of ecosystem health and therefore is insufficient for describing human health in an ecosystem health context.

THE WELLNESS MODEL

In 1977 Travis developed the Illness-Wellness Continuum 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) definition of health as a state of complete physical, mental, 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 selfresponsibility are mentioned as important components of lifestyle influences that affect health.
However, in the model, there is no mention of
how ones socioeconomic and biophysical environments 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 toward more holistic models. Blum (1974), Dever
(1976), and Lalonde (1974) developed models
that include four central influences on human
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FIGURE 3. The Illness-Wellness Continuum reprinted from Wellness for Helping Professionals
by J.W. Travis, with permission of Wellness Associates, 1977.

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 populations 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 resources, 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 regions 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., Canada, where lifestyle influences are important, leading 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 assumptions as to how they perceive current levels of influence in any specific situations. All three of the holistic authors portray health or well-being as an
ultimate state of complete physical, mental, and social 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 appropriate health choices. However, mass educational approaches are mainly effective among
middle and upper-income populations, leaving
those in greatest need both unreached and unaffected (Green & Richard 1993). The model introduces the notion that what constitutes health can
be subdivided into three parts: psychological, social, 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 socioeconomic focus and lack of detail with respect
to the biophysical processes affecting health, this
model also proves inadequate for describing human health in an ecosystem health context.

A FRAMEWORK FOR
HEALTH PROMOTION
FIGURE 4. The Environment of Health Model. Source:
Reprinted from Planning for Health: Developmental Application of Social Change Theory by H.L. Blum, p. 3,
with permission of Human Sciences Press, 1974.

In 1986 the World Health Organization (WHO)

produced the Ottawa Charter on Health Promotion (WHO 1986). In the document, health was
viewed very broadly, which was reflected in WHOs
1984 description of health as:

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. . . 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.

1986). A systems approach to health promotion

was given five action areas to develop:

The Health Promotion initiative was very influential 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 capacity-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 strategies, as shown in Figure 5.
As a result another paradigm emerged, proposing a systems approach to health rather than a
biomedical model. The systems approach recognizes that the increasing, context-specific complexity and number of influences that affect human health cannot be adequately resolved one at
a time. In order to improve health, structural improvement 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 environment of the rest of society is neglected (WHO

The Health Promotion approach is compared

with the previous Health Education/Disease Prevention approach in Tables 2 and 3. Essentially,
the Health Promotion model of health developed
concepts of what socioeconomic strategies, mechanisms, 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 considers health a personal, social, and physical resource
for meeting human goals and needs.
Both of these developments about what constitutes and what influences human health are directly 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.

1.
2.
3.
4.
5.

building public policies that support health;

creating supportive environments;
strengthening community action;
developing personal skills; and
reorienting health services (WHO 1986).

THE MANDALA OF HEALTH

Working within the newly established health promotion paradigm, Hancock and Perkins (1985)
developed the Mandala of Health, a mandala being 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.

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TABLE 2
Differences between health promotion programs versus disease prevention programs
Health promotion programs

Health concept

Positive and multidimensional

Health models
Population focus
Program types
Program approaches

Holistic
Total population
Diverse and complementary
Participatory facilitation and empowerment
rejects professional dominance
Improve physical and socioeconomic
environment
Health and other organizations, civic groups,
governments, public

Program goals
Program participants

Disease prevention programs

Negative and one-dimensional:

absence of disease
Deterministic
High-risk groups
Often focused and unconnected
Top-down education and persuasion
Improve individual and group choices
Health professionals and recipients

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

human ecosystem is conceptualizing and explaining 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 represented by three circles of nested systems around
the individual: the family, the community and human-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, depending on the temporal and spatial context.
The authors specify four subgroups of health
influences within the family and community circles of influence which are similar to some of the
previous models discussed: personal behavior (lifestyle), human biology, and two types of environments, physical and psychosocioeconomic (PSE).
In addition to the four determinants, the health of
the individual and family is dictated by their lifestyle choices (their behavior within their PSE environment), their work (the interaction between

TABLE 3
Differences between health promotion research versus disease prevention research

Health promotion research

Types of relationships investigated

Object of research or evaluation
Level of research focus
Methodology

Webs of causes and webs of effects

Ongoing process of decision-making
Individual, political, environmental, and
organizational levels
Qualitative and quantitative

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

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Disease prevention
research

Simple cause-effect
Endpoint effect
Individual level usually
Quantitative usually

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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

FIGURE 6. The Mandala of HealthModel of the Human Ecosystem. Reprinted from Health Promotion 1, 99,
by T. Hancock, with permission of Oxford University
Press, 1986.

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 influence on personal behavior and human biology,
influences on health which are given equal importance to the psychosocioeconomic and physical environments in the model. It would, however, 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 interdependent (Evans et al. 1994a).
With regard to modeling human health in ecosystems, the Mandala of Health is the first model
to represent a nested hierarchy of influences on
individual healththat being the family, the community, and the larger culture and biosphere
thereby recognizing these three scales as having
emergent properties. The model reiterates previous interpretations of what constitutes health by
its subdivision of individual health into three
parts: mind, body, and spirit. However, the socioeconomic and biophysical environmental structures 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 repreEcosystem Health

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Hancock (1993) proposed a model of health that

integrates community health and sustainable development of communities (Figure 7). This model
suggests that sustainable development of communities is essential for sustaining human health. This
community-oriented model is meant to supplement the Mandala of Health model of individual
health discussed earlier.
In the Community Ecosystem Model, community health is found at the intersection of three circles: the community, the environment, and the
economy. Healthy community ecosystems should
have six qualities within their environmental, economic, and community dimensions. They should
be convivial, liveable, sustainable, viable, and adequately prosperous with equitable wealth distribution. 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 Ecosystem Model to modeling human health in ecosystems is its identification of what constitutes health
at the community level: the three qualities of each
of the community, the environment, and the economy, how they relate to each other, and their im-

FIGURE 7. A Model of Health and the Community Ecosystem. Reprinted from Health Promotion 8, 44, by T.
Hancock, with permission of Oxford University Press,
1993.
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portance for human health and development. Because 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 circles: 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 Economic Costs (Figure 8). The model is centered on
the relationships among disease, health care, and
health and function, with a number of other identified health influences and arrows surrounding
them to represent the deterministic relationships
believed to occur among them all. The constituents 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 defined as factors, whether they be events, characteristics, or other definable entities, that brings
about change in a health condition, or other defined characteristici.e., causal associations of
health (Last 1988). However, the identification
of direct deterministic causal relationships among
determinants of disease and health is problematic. Determinants of health are not the unconditional machinery parts that invariably lead to disease, a reflection of industrial revolution science
according to Descartes (Jones & Moon 1987). In-

stead, they only have a certain probability of resulting in a particular health outcome, and therefore 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 manifest from any particular influence. The interconnections 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 affecting genetic endowment.
Nonetheless, the health determinants model
contributes to describing what influences human
health in ecosystems through its explicit introduction of feedback loop relationships between health
influences and human health. Feedback loops occur 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 adequate for describing human population health in
the context of changing ecological conditions.
Therefore, a model of human health within an ecosystem 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 characteristics of ecosystems listed in Table 1. Our
model is generic in that it is meant to have broad
application to the health of individuals, populations, communities, and ecosystems as discussed
at the end of the section. Table 4 provides a summary of the key characteristics of the Butterfly
Model of Health.

HUMAN PLACEMENT AND DIVISION

FIGURE 8. The Health Determinants Model of Health

reprinted from Social Science and Medicine 31, 1347
1363, with permission of Elsevier Scientific Ltd, Pergamon Press, 1990.

The Butterfly Model of Health (Figure 9) places

humans inside the ecosystem (Bormann 1996) (especially applicable in ecosystems with extensive human influence, such as urban ecosystems and agroecosystems), the boundary of which is shown as a
broken line because both natural and human-

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TABLE 4
Key characteristics of the Butterfly Model of Health
Characteristics

Butterfly Model of Health

Socioeconomic (SE) environment

components
Biophysical (BP) environment
components
Multiple species
Nested hierarchy
Model structure and complex interactions
Self-organization
Location and function of human behavior
and biology
Model utility
Political influence

Different human structural elements and functional features

influencing, and being influenced by, human health
Different biophysical structural elements and functional features
influencing, and being influenced by, human health
Multiple biota categories represented
Humans placed inside the BP and SE environments, which are within
larger ecosystems, affected by neighboring and distant BP and SE
external environments
Arrows and broken lines used to identify relationships, and represent
permeability and indiscrete definitions
Positive and negative feedback loops
Human population is intimately surrounded by biological and behavioral
filters which are affected by, and influence the impact of, the BP and SE
environments
To describe the health of individual humans, populations,
communities and ecosystems
Political institutions present as a SE element

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

FIGURE 9. Butterfly Model of Health

for an Ecosystem Context.
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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, mental, and spiritual, as in the Mandala of Health)
(Hancock & Perkins 1985) are not drawn as segregated portions of a circle but rather are separated
by a broken line, depicting their profound interdependencies. At the individual level the body influences, 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 interconnections 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 biochemical and biophysical abilities of a population to
maintain health and fight disease. The second is a
behavioral filter, the power to control personal behavior, lifestyle, and associated environmental exposures within a specific set of opportunities. Together 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 nervous system (behavioral filter) communicate in
such a way that the influences in the social environment (such as prolonged stress), via its effects on
the nervous system, can affect a variety of biological responses (Dantzer & Kelley 1989; Evans &
Stoddart 1990).
With regard to the biological filter, no two
people have the exact same response to an environmental 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 mutations from the original genetic material. Of course,
some of the response differences are also a func-

tion of differing social and biophysical interactions. 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 capacity 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 deleterious consequences. Some exposures may even affect 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 themselves against the same disease agent.
Populations also vary with respect to their collective biological filter, due to different BP and
SE/cultural environments that affect the general
diet, exercise habits, spiritual activities, and emotional support systems. As a result, and in conjunction 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 unhealthy exposures, depending on the SE environment (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 environment 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 result 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 information to believe. However, their set of options, or
perceived options, are constrained by the holon
(hierarchical context) within which they are called

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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 expectations for employment, education, and living conditions (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 encountered, but how that filter develops and functions
(along with the set of opportunities from which it
can choose) is shaped by aspects and policy regarding the SE environment (Evans et al. 1994b). As the
African proverb goes, it takes a village to raise a
child.
Disagreements regarding individual responsibility versus social and biological determinism often 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 realistically characterized without reference to their
community context, the health of communities
cannot be realistically characterized without reference to some larger context, and so on (WaltnerToews 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 socioeconomic 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 structures and processes of the ecosystem itself, neighboring ecosystems, or even distant ecosystems.
The structural elements of the BP environment 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 temperature (climate), making them essential elements of
the BP environment of ecosystems. The interactions between these basic building blocks resulted
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Vol. 5

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 influences human health and enables the human population 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 (primarily) functional features that are of interest to human 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 aesthetic needs, because health also has mental and
spiritual aspects to it.
The SE environment surrounding an individual 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 biological and behavioral filters. These effects may be
muted somewhat by the current ability of the behavioral filter as formed by historical SE and BP
environmental effects. Although called the SE environment, each of the listed elements and features in the model has its respective spiritual,
emotional, psychological, sociological, and economic aspects.
Within the SE environment of the Butterfly
Model of Health, four influences comprise an individuals 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
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215

choice, spend much time with, and therefore are a

socioeconomic influence on population health.
Voluntary organizations, such as religious, recreational, 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. Together, these four influences of ones SE environment 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 support networks, and the health care systems (Evans et
al. 1994a). A number of neighborhoods cooperate
to form political institutions for decision-making regarding social support, health services, and policy.
Beyond ones peer group, these SE elements have a
large influence on human health. Political institutions can allocate funds to bolster social support
where it is lacking through a variety of means, including 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 prophylactically. 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 influence 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, information stimuli, and values education are crucial
to the development of ones self-esteem and ability to learn and make decisions without undue reliance 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 depends on the degree to which other people (family, friends and/or coworkers) in ones SE environment 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 associated 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 crises 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 frequent and burdensome than most diseases on the
lives and health of individuals. Therefore, the importance 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 available, health care services increase in importance.
Community attachment and a sense of belonging 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 voluntary 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 influencing health (Spencer 1981).
Humans have a unique role to play in the ecosystem, deciding, according to current societal
values, the fate of the many elements and features
of the ecosystem and thus the fate of the ecosystem 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 manner 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 movement and feedback loops of energy, nutrients, and
impacts, and 2) the fact that these effects are manifested 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-

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216

trate the broken line borders of the environments

to show their permeable nature to human influences. Arrows linking individual environmental
components have been omitted for two reasons: to
represent their profound interdependencies, and
to indicate that these complex interactions are dependent 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 ecosystems, 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 neighboring ecosystems. Similarly, there is considerable
social and economic activity between neighboring
and distant ecosystems. External BP and SE environments can have a dramatic influence on the BP
and SE environment of ecosystems and therefore
should be represented as major categories of influences affecting human health in ecosystems, and
ecosystem health.
External BP and SE environments can also represent influences occurring at a hemispheric or global 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 components 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 restrictions on trade and effectively lowering commodity prices. As a result livelihood capabilities are
affected, which in turn have demonstrable effects
on ecosystem health at both individual and community 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 ecosystem recognize the interaction and feedback between ecosystems. Furthermore, the internal BP
and SE environments of one ecosystem are the external BP and SE environmental influences on
other ecosystems. Of course, because of the intricate
interconnections between the BP and SE environments of an ecosystem, external BP environments
would not only directly influence the internal BP
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environment of an ecosystem, but also indirectly influence the internal SE environment of an ecosystem as members of the ecosystem adapt to the
changing internal BP environment. The same argument applies for external SE environments.
Due to the nested hierarchical nature of ecosystems, what is considered a neighboring external influence at one scale may be part of the internal 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 constitutes 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 interaction between people (psychological, social, economic, political, and cultural), and between people 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 Robertson (1978) described it best in his SHE society: sane (in balance with oneself), humane (in
balance with other people), and ecological (in balance with nature). However, an individual can
maintain an adequate level of health within an unhealthy community if they have taken extra efforts
to maintain the health of their immediate surroundings. 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 incarcerate those people labeled criminals. At the individNo. 3

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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 quality 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 acquaintances. 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 different and perhaps clearer perspective. Once the
entire community becomes visible, those components 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 environment, occur.
The Butterfly Model of Health can apply to
human populations aggregated according to political boundaries, such as communities, counties,
provinces, etc., or according to ecological boundaries, such as subwatersheds, watersheds, ecodistricts, 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 differences between the BP environments of different ecosystems, with these differences often carrying important differences in SE opportunities and the SE
environment. Local industries, particularly those related to agriculture, often reflect the BP landscape
in which they are located. For example, the Niagara
Escarpment of Ontario demarcates a boundary between two ecosystems with dramatically different
soil types, vegetation, SE activities, and farming systems. 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 provincial borders with little or no immediate change in
landscape or people. Perhaps analysis of health
would be more appropriately conducted using ecological boundaries and aggregations of individuals
(bioregionalism reference).

CONCLUSIONS
The Butterfly Model of Health has been presented
as a descriptive model for representing and studying human health in ecosystems. The model incorporates many structural elements and functional
features of what constitutes and what influences
health. It builds upon the strengths of other models, such as balance from the Kochs Ecological
Model; what constitutes health from the Mandala
of Health (Hancock & Perkins 1986); what influences 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 characteristics 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 complex structural and functional interrelationships
among the elements and features; and feedback
loops between environments, providing self-organizational 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 describe dimensions and determinants of human
health and ecosystem health and their interrelationships. 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 resource assistance: the Eco-Research Program of the
Canadian Tricouncil for a doctoral fellowship and
research funding through the Ecosystem Health

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218

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

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