Explore: The Journal of Science and Healing



Explore: The Journal of Science and Healing

Volume 8, Issue 1 , Pages 59-64, January 2012

The Case for Commons Health Care

Top of Form

• Jamie Harvie, PE

Bottom of Form

Outline

• Lessons from Green Healthcare

• Failing Systems

• Common Drivers

• Agroecology and Healthy Food Systems

• Commons Healthcare

o Commons Healthcare Roadmap

o Commons Healthcare Trusts

o Bioregional and Megaregion Anchor Institutions

o Our Community Commons

• Integrative Health Care and New Healthcare Leadership

o Regenerative Healthcare Design

• Conclusion

• References

• Biography

• Copyright

A “tragedy of the commons” occurs when the self-interest of certain individuals in a group overrides the collective interest of that group, ultimately to the detriment of all. We are all too familiar with examples of how the unnecessary overutilization of healthcare, the race for medical technology and the entrenched medical interests is ultimately bankrupting our entire healthcare system.

Currently we are facing this type of situation in three intersecting areas—healthcare, agriculture, and climate. Moreover, these three spheres are so intricately interconnected to one another that they collectively and strongly affect, either for better or worse, the quality of life for all Americans.

Yet, we have learned from the work by Elinor Ostrom, whose work on commons management was recognized by a Nobel prize,1 and healthcare examples from communities across the country,2 that the tragedy of the commons is not predestined. Moreover, that through a set of community-based rules and conditions, this tragedy can be averted. In light of the dire state of global ecological and financial health, the question becomes whether we have enough time and resources to alter course.

Clearly, we need a new model. The primary purpose of this paper is to offer a new lens on seemingly disparate issues, to accelerate the development of a community-driven, multibenefit framework—“Commons Healthcare”—to solve the problems in our health, food, and climate systems, and to demonstrate that such an approach to public health is imperative.

Lessons from Green Healthcare 

Over the last decade, the environmental community has been working with those in healthcare, with considerable success, to address ecological health issues associated with the design, construction, and operations of healthcare buildings. For example, the sale and purchase of medical equipment containing mercury has been virtually phased out. This trend is now international, with mega cities such as Mexico City, Delhi, and Buenos Aires, as well as countries such as Argentina and the Philippines also eliminating the sale of medical equipment containing mercury.

Increasingly, U.S. healthcare facilities are being designed with the ecological health impacts to individuals, communities, and the planet in mind. This work has been extremely important in shifting healthcare operations toward more environmentally preferable purchasing practices, which has then resulted in a variety of changes in the supply chain. In fact, it is important to emphasize that the greening of healthcare has played an important role in deepening an understanding of the relationship between human health and the environment.

Additionally, the immediacy of environmental and climate problems—note stark warnings from the UN Millennium Assessment and the Intergovernmental Panel on Climate Change—has helped to expand the focus of healthcare/environmental issues from product toxicity, waste reduction, and green design to climate mitigation and adaptation as well.

Yet, these changes have only resulted in limited transformation in funding practices, reimbursement policies, and healthcare-driven primary prevention strategies. In fact, the business of healthcare has for the most part continued “business as usual.”

For example, the healthcare's climate footprint derives primarily from the treatment of an increasingly sick population. Only 20% of a hospitals climate footprint is related to building energy use.3 Yet the majority of mitigation efforts are focused on energy efficiency rather than the increasingly overburdened healthcare system. Even though it would not be in the economic interests of a healthcare administrator working to keep beds filled, a primary prevention strategy that keeps people out of the hospital might be the best healthcare climate mitigation strategy of all.

This is not to suggest, that “green” healthcare is unimportant, or that renewable energy and energy efficient healthcare buildings are unimportant to the future of a prevention-oriented, sustainable healthcare model. All prevention efforts have a role to play. What the green healthcare movement has helped us understand is that even the “greenest” healthcare system cannot be economically or ecologically sustainable if it is not accompanied by a reduced demand for services. Moreover, it also becomes evident that the healthcare community will not change itself, unless the systems in which it is based are also changed.

Failing Systems 

Healthcare now represents 17% of the gross domestic product (GDP) and is on a trajectory that is clearly not sustainable. In addition, although the United States now spends more than 50% more per capita on healthcare than the next most expensive system in the developed world, the health of the U.S. population is demonstrably poorer by most measures.

The most important factor contributing to the growth in health care spending in recent decades has been the emergence, adoption, and widespread diffusion of new medical technologies and services. Although technological innovation can sometimes reduce spending, such advances in medicine and the resulting changes in clinical practice have generally increased spending.

We see similar patterns in agriculture, through the predominance of an industrial agriculture production-driven model. Agricultural trade is now organized in global chains, dominated by a few large transnational players whose interests are driven primarily by their shareholders financial stake. Consequently, we are experiencing a global transformation of how societies grow and access food. Transnational supermarket chains are replacing the local, community-based markets. Thus, food access is not strictly an issue of personal choice, but one of what choices are available and the policies that dictate these choices. This helps explain the emergence of food deserts, areas in both urban cities, and rural communities where there is limited access to fresh fruit and vegetables.

Through this industrial food and agriculture model, ecological health costs have been externalized. In parallel with a treatment-oriented rather than prevention-oriented healthcare system, the treadmill continues. Rather than investing in and supporting a food supply and agriculture model that preserves and regenerates ecological services and social health, the associated ecosystem decline from the use of fertilizer and pesticides and farmer dislocation from land and communities continues unabated.

Common Drivers 

For good reason, the Centers for Disease Control has called obesity the nation's largest public health threat, and organizations such as the World Health Organization has warned about the global tide of chronic disease poised to overwhelm global health systems. WHO Director-General Dr. Margaret Chan said that, “For some countries, it is no exaggeration to describe the situation as an impending disaster; a disaster for health, for society, and most of all for national economies.”4

At the same time, the British Medical Journal warns that climate change could be the largest public health threat of the 21st century. The World Health Organization also warns that health impacts from climate change are predicted to overwhelm healthcare systems.

Our health is linked to our food and agriculture complexes. In turn, the global expansion of agriculture into natural ecosystems has had a significant climate impact,5 through land use changes such as deforestation.

The global contribution of agriculture to green house gas (GHG) emissions, including agriculture related deforestation, has a value of approximately 30%.6, 7 Moreover, food produced and promoted by this system increases the risk of a host of common, nutritionally related chronic disorders, including obesity, diabetes, cardiovascular disease, dementia, and various kinds of cancer, among others. A host of studies demonstrate the risk from unhealthy diets.8, 9, 10, 11, 12, 13

It is clear that healthcare systems will increasingly shoulder the burden of health impacts associated with both our industrial food system and climate change.

Because our current healthcare delivery and industrial food models are in similar feedback loops, driving them toward system failure, business as usual cannot continue for much longer. Hence, it is time to recognize not only the important linkages between food, climate, and healthcare but also the potential for common solutions.

Agroecology and Healthy Food Systems 

In early 2011, the United Nations Human Right Council submitted a report to the United Nations on The Right to Food. The report was based, in large part, on the recommendations of the International Agriculture Assessment on Science, Technology, Knowledge and Development (IAASTD), an initiative funded by the World Bank, and the United Nations' Food and Agriculture Organization and Environmental Program. It recognized that:

Increasing food production to meet future needs, while necessary, is not sufficient. It will not allow significant progress in combating hunger and malnutrition if it is not combined with higher incomes and improved livelihoods for the poorest—particularly small-scale farmers in developing countries. And short-term gains will be offset by long term losses if it leads to further degradation of ecosystems, threatening future ability to maintain current levels of production.

The IAASTD report recognizes the interrelationship between hunger, society, and ecosystem services. Importantly, it proposes agroecology as a viable alternative to our industrial model, which is exacerbating hunger, food insecurity, health disparities, and the destruction of ecological services. Once again, we begin to see potential for the emergence of a commons healthcare solution—the bridging of food systems, communities, and healthcare.

Ultimately, it is communities that will need to take responsibility for bringing these once seemingly disparate issues together, requiring goal setting and metrics to arrive at a commons health care solution. To that end, let us explore what a commons health care framework might look like.

|Current |Future |

|Health care as an institution led service |Health and social care as part of the community |

|Curative and fixing medical care |Early intervention and preventative care |

|Sickness |Health and well being |

|Professional |Personal |

|Isolated and segregated |Integrated and in partnership |

|Buildings |Healing environments |

|Decision making based on today's finances |Integrated value of the future which accounts for the impacts on society and nature |

|Single indicators and out of date measurements |Multiple score cards, and information and in real time |

|Sustainability as an add on |Integrations in culture, practice and training |

|Industrial food production |Agroecology—Local, nutritious food systems |

|Waste and overuse of resources |A balanced use of resources where waste becomes a resource |

|Nobody's business |Everybody's business |

Commons Healthcare 

Several evolving models provide a basis for hope and inspiration. Recently, the National Health System in the United Kingdom published their Route Map for Sustainable Health, which explicitly supports the need for paradigm shift. It describes the shift from a system that is institution led, to one in the community that provides for the future of society and the environment, and is informed and in partnership with patients and communities in a more open decision making system.

Commons Healthcare Roadmap 

Adapted from the Route Map for Sustainable Health (NHS).14

Commons health care also requires changing the current rationale for a healthcare system. In fact, the community-centered philosophy inherent in agroecology and primary prevention approaches reinforce that a new model will necessarily be community informed and directed. No longer can healthcare institutions be rewarded by filling their beds and keeping their labs, operating rooms, and diagnostic and therapeutic machinery humming. The incentives need to change. Moreover, a commons healthcare system would recognize, promote, and preserve health-promoting activities and institutions such as farmers markets, community gardens, better food access, and increased farmland, clean air, and clean water.

The following are some concepts and approaches, that if appropriately articulated, supported, and connected, might help facilitate rapid systems change.

Commons Healthcare Trusts 

One model that holds promise is a proposed Commons Healthcare Trust (CHCT), a community-based trust, which by definition is legally obligated to promote and improve the health of all citizens. A CHCT might develop key metrics from the standpoint of healthcare utilization, primary care physician ratios, in addition to key metrics and indicators of prevention resources. These might include community gardens, average age of farmers, quantity of schools with farm-to-school programs, fast food expenditures per capita, food access, and water access farmland, average age of farmers, etc. The intention behind a CHCT would be transparent metrics that provide communities with an understanding of how and where their community healthcare treatment and prevention resources are being spent and to provide a legal mechanism to allow community-based decision making on prevention allocations.

In Alaska, citizen dividend checks are distributed every year out of the interest payments to an oil royalties deposit account called the Alaska Permanent Fund (APF). The APF is a public trust fund that distributes the commons wealth of its resources to its citizens. The Solar Commons, a recent U.S. Green Building Council Innovation Award winner, uses rights of way to install solar panels. Revenues generated are directed to support low-income housing needs. What if we imagined something similar at the local level, where the benefits went to improve health equity?

Because of the relationship between obesity and sugar-sweetened beverages, many communities have explored the adoption of sugar-sweetened beverage (SSB) taxes. Proceeds from an SSB tax (or a disease fee) could be reallocated to a CHCT, which might be then directed to promote the community objectives of the CHCT, especially because it has been demonstrated that SSB taxes are cost effective at obesity prevention.15 A local ecological service fee applied to genetically engineered food sales (or purchase), or pesticide sales, could be adopted with proceeds directed to the local CHCT. Similarly, fees associated with the marketing/advertising of fast food to kids might also be another mechanism to support a local, nutritious, healthy food system.

Studies indicate that behavior and environment account for roughly 70% of our health outcomes, and medical care only about 10%. Yet 96% of our national health expenditures are focused on medical care, with only 4% dedicated to prevention.16 If we are concerned about the health and future of our communities, we must create institutions that reflect this role. With strong collective will and creativity, we can develop new institutional governance models that generate and implement agricultural and prevention oriented policies, prioritizing the small-scale farm sector, rural livelihoods, food security, nutrition, and a food and agriculture focused policy and practice prevention agenda.

Bioregional and Megaregion Anchor Institutions 

Most hospitals are affiliated within large health systems that cover multiple states and numerous foodsheds. These health systems, in turn, purchase significant amounts of food and medical commodities such as medical equipment through large national buying groups called group purchasing organizations. Although aggregated purchases through system wide and national group purchasing contracts may achieve some economies of scale for health systems, this system of purchases perpetuates food as a commodity.

The role of anchor institutions—large community-based universities and healthcare institutions—and their relationship to their communities and the local food system needs to change. Rather than working independently, these entities need to work collaboratively to utilize their inherent market position and outreach potential to foster an active and vibrant social fabric. Although our current healthcare system promotes competition, we need to develop community-based models that support collaboration. It is increasingly likely that these will be bioregionally or megaregionally based.17 Ideally, we develop food distribution and procurement models that fit the local food shed and as a result reflect the cultural food values of those communities.

Anchor institutions are central the development of commons healthcare at the community level, but to support this agenda, their leadership must recommit resources, attention, and reengage with their community. It will require that our institutions decouple their food procurement from their current model of national contracting and that our educational systems help provide the research and knowledge to support such food system infrastructure development. In some communities this reengagement is already occurring as anchor institutions commit to the development of regional, cooperatively owned and managed food hubs. Health professionals, health and educational leaders are central change agents, especially at the local level, and can influence food, agriculture, and social policies and thereby strengthen community resilience inherent in commons healthcare.

Our Community Commons 

As we begin the 21st century, increasing focus on climate change emissions, water rights, rain forest destruction, overfishing, and other global environmental concerns are reminders about the limits to our biosphere and the value of the ecological services that support human populations. At a global level these services are akin to the “scarcity” value of early grazing rights on “the commons” centuries ago. From the standpoint of human health, these commons are absolutely critical because they support the necessities of life.

In the last decade, water rights in Bolivia were privatized until civil society protests erupted when the poor could no longer afford the cost of drinking water.18 This poses an important question: How can we promote health without access and shared rights to water? Who will determine if the price is fair for a life sustaining force that is naturally derived? Should the control be with private interests that “enclose” the commons and assume ownership?

As climate change accelerates the loss of glacier-fed rivers, as water intensive agriculture competes with drinking water, and as heat waves increase demand on city drinking water supply, communities will be forced to determine who “owns” the water and who determines where and how it is allocated. This conversation must begin sooner rather than later. Some hospitals and communities are promoting access to tap water rather than bottled water, as an alternative to an SSB tax. Yet it is not clear if these initiatives are simply intended to promote water, or to additionally promote publicly owned, rather than commercially owned, water supplies. In July 2011, Italians voted overwhelmingly to overturn laws welcoming water privatization that had been enacted by their government.19 Clearly, these decisions and an understanding of the impact on the “ownership” on our commons is increasingly central to the health of communities.

Equally critical to this conversation is the issue of biotechnology and genetically engineered (GE) foods. Although the proponents of biotechnology frame their industry as central to solving the problem of how we feed the world, we now recognize that perhaps the most vital issue is who actually owns and controls how and what we grow—our food sovereignty. There are numerous examples of farmers who have been sued by biotech companies for growing crops, which had unintentionally been contaminated by patented genetic material through natural processes. Today, only a few private companies control the majority of the world's seeds. Moreover, as the IAASTD report highlighted, the continued reliance on transgenic crops and technological fixes will not reduce persistent hunger and poverty and could exacerbate environmental problems and worsen social inequity. A total of 93% of Americans now believe GE foods should be labeled.20 In the Fall of 2011, a cross-section of public health and healthcare organizations including the American Academy of Environmental Medicine, Illinois Public Health Association, the American Nurses Association, and others have joined with consumer and farming organizations to support a national GE food labeling initiative.20 This is another example of a rising commons healthcare agenda.

As private interests work to control seeds and the right to grow food, other interests are working to own and control land through “land grabs.” A recent report by the Oakland Institute made headline news when it disclosed how tens of thousands of acres of land are being purchased in developing countries across the globe, displacing tens of thousands of people from traditional lands.21

It should be understood that although these land grabs are occurring across the globe, they are also occurring within our urban core. The city of Detroit is undergoing a renaissance through a local urban food movement, which is building community and economic resilience through the conversion of empty lots into gardens and small locally owned urban farms. Yet, there are increasing concerns by food and community activists about corporate farming interests that have reportedly moved to control up to 40% of this land.

Although these land grabs and corporate control of the land may not always be illegal, they raise serious ethical and moral questions. Our health—and our very life—is dependent on the commons associated with ecological services, and unless we want “health” owned and directed by private interests, we have an inherent interest in maintaining them as “commons.”

Both the IAASTD synthesis report and The United Nations Report on Agroecology and the Right to Food implicitly acknowledge the necessity of commons principles. They call for support of community-based agriculture, the need to increase local decision making, and the imperative to change the “rules of the game.”

However, although the reports offer multiple benefit solutions, their recommendations will not be well received by those who currently benefit from the current operating system. For instance, healthcare should act proactively to support commons institutions and the commons to counteract the host of interests that are working to “enclose” their value. Understandably, this will be a tremendous challenge to those adhering to the paradigm that healthcare should focus strictly on disease treatment. Yet, to achieve the multibeneficial goals inherent in a commons health care framework, this transformation will be necessary.

Integrative Health Care and New Healthcare Leadership 

The issues we have been discussing are intrinsically about interrelated systems and the development of, or transformation to, systems that are health promoting at a variety of levels. For this framework to be successful, we need medical and nursing professionals whose training is systems oriented.

Integrative medicine is, by its very nature, holistic through its recognition of the interplay between mind, body, spirit, and community and ecological health. Moreover, integrative medicine has developed a deserved reputation for a focus on prevention and health promoting environments. Research reveals that immediate and significant health benefits and cost savings can be realized throughout our health care system by utilizing three key integrative strategies:22

•Integrative lifestyle change programs for those with chronic disease

•Integrative interventions for people experiencing depression

•Integrative preventive strategies to support wellness in all populations

Although the ecological health benefits of integrative approaches have not yet been fully documented, we can appreciate that these preventive approaches might demonstrate other important benefits— a reduction in climate impacts associated with a reduction in energy intensive medical care, or reductions of pharmaceutical discharge to water ways and other medical waste achieved through lifestyle rather than pharmacological treatment approaches.

Unmistakably, communities and patients will be served by approaches that work to prevent disease, and that recognize the role of health disparities and other social factors in the disease process. An understanding of a patient's social-cultural history, nutritional and community environments is essential. Unhealthy diets contribute to the risk of many diseases and disorders. Medical models that promote dietary interventions and which work to engage and change the social and cultural food environment are paramount. Most healthcare providers understand that changing the food and physical activity environments in neighborhoods and schools is likely to be the most effective way to support obesity-prevention efforts.23

There is an obvious failure when providers remain siloed in their institutional settings. They need support, training, and other skills that integrate the patients and community in ways that have not yet been fully appreciated in healthcare, such as community activism. Inherent in a preventive approach are team-based models of practice that draw on the skill sets, capacities, and knowledge of clinical and nonclinical staff (e.g., physicians, nurses, physician's assistants, social workers, promoters, community health workers).24 In a commons healthcare, these teams will be comprised of systems-minded individuals, working at the intersection of community, environments, and healthcare.

Regenerative Healthcare Design 

Over the last decade, we have witnessed a transformation in the design and construction of healthcare facilities that incorporates sustainable and systems approaches in the design. Yet this is not adequate to meet the challenges of our current climate, food, and healthcare crisis. What we really need is less sick people and fewer hospitals.

Healthcare professionals and designers now recognize the need to advance a commons health care design framework. Although its terminology is still in flux, this work is generally referred to as “regenerative healthcare design,” meaning that the design and construction of hospital and healthcare infrastructure is ecologically neutral—carbon neutral, water balanced, and ultimately ecologically regenerative. Implicit in this approach is the recognition that we must address healthcare and healthcare systems from a community-based approach.

For example, instead of working with two competing hospitals to build two of the greenest hospitals, designers might ask the community if only one is needed. It is not a stretch to imagine how a team of designers, skilled at integrating the multitude of interests necessary to build a single hospital, might bring community health interests together in the same way. Implicit in this conversation is an approach that necessitates shared, rather than competing, interests, and promotes a community conversation rather than a healthcare-directed conversation. Moreover, although we recognize that trauma and treatment will always necessitate treatment and inpatient care, it provokes an even more important awareness that the ultimate community vision is one that requires no hospital.

Such community design might include incorporation of urban agriculture, community gardens and zoning to minimize and eliminate fast food marketing and increase access to healthy, affordable food consistent with the new American Planning Association guide on community and regional food.25 It might include convenient CSA drop offs at healthcare facilities, as well as schools or zoning and other policy support to promote and build food system infrastructure that has been lost over the last 60 years. We might also imagine hospitals and community clinics as facilities that incorporate education and training on food literacy, cooking, and exercise. Healthcare facility design can work to influence community-based design, such that it improves public transportation, walkabilty and bikeabilty for its staff and visitors. Moreover, hospitals and clinics might become community anchors in other health promoting ways. Hospitals often cover a large footprint, and renewable energy systems or water treatment collection could be designed into the buildings such that the excess clean energy and water are provided to the local community. These considerations are all components of a commons healthcare, or regenerative healthcare, design.

Without question, as we are mired in the competitive dialogue between entrenched healthcare interests, regenerative healthcare design might seem somewhat distant. But in a world of limited financial resources, we may soon find communities more than willing to engage in such a conversation. It will be important for the regenerative healthcare design community to articulate a community driven framework, rather than one that is strictly hospital focused. If they do that, it is likely that they will discover an increasingly vocal and supportive network of allied interests.

Conclusion 

Across the globe, food, communities, ecology, and healthcare systems are intricately linked. Moreover, our current healthcare delivery and industrial food model cannot continue with business as usual. We need to work toward a model that reduces inputs, internalizes ecological costs, incorporates the social health aspects of the system, and, from the standpoint of healthy populations, is preventive and regenerative in nature. Moreover, we need to support cost effective medical modalities that are inherently health promoting and a healthcare design community that is reflective of a preventive and ecologically regenerative agenda.

The linkages between food systems, agriculture, climate and health are so important that only by purposefully connecting them can we better understand how to support the future. Many working at the nexus of food systems and healthcare recognize important similarities about these two systems. Both are examples of systems in need of fundamental structural change. Each is increasingly vulnerable and at risk of being unable to deliver as promised in fair and equitable ways to the populations they serve, and in ways that also protect the underlying ecological systems on which they depend. It is increasingly clear that both systems are in need of more than a therapeutic intervention. Each system requires attention to its fundamental design.

References 

1. Accessed October 23, 2011

o View In Article

2. Accessed October 23, 2011

o View In Article

3. NHS England Carbon Emissions Carbon Footprinting Report September 2008 (Updated August 2009) . Accessed October 23, 2011

o View In Article

4. The rise of chronic noncommunicable diseases: an impending disaster . Accessed October 23, 2011

o View In Article

5. Lobell DB , Bala G , Duffy PB . Biogeophysical impacts of cropland management changes on climate . Geophys Res Lett . 2006;33:L06708

o View In Article

6. Harvie J , Mikkelsen L , Shak L . A new health care prevention agenda: sustainable food procurement and agricultural policy . 2009;4:

o View In Article

7. Accessed October 23, 2011.

o View In Article

8. Forman J , Stampfer M , Curhan G . Diet and lifestyle risk factors associated with incident hypertension in women . JAMA . 2009;302:401–411

o View In Article

o CrossRef

9. Willett W , Trichopoulos D . Nutrition and cancer: a summary of the evidence . Cancer Causes Control . 1996;7:178–180

o View In Article

o MEDLINE

o CrossRef

10. Iqbal R , Anand S , Ounpuu S , et al.  Dietary patterns and the risk of acute myocardial infarction in 52 countries: results of the INTERHEART study . Circulation . 2008;118:1929–1937

o View In Article

o CrossRef

11. Costacou T , Mayer-Davis E . Nutrition and prevention of type 2 diabetes . Annu Rev Nutr . 2003;23:147–170

o View In Article

o MEDLINE

o CrossRef

12. US Department of Health and Human Services, Agency for Health Care Research and Quality Medical Expenditure Panel Survery . 2007;

o View In Article

13. Harvie J , Schettler T , Mikkelsen L , Flora C . Common drivers, common solutions . This paper was prepared by a Food Systems and Public Health Conference Work Team funded by the W.K. Kellogg Foundation Accessed October 23, 2011

o View In Article

14. Accessed October, 23, 2011.

o View In Article

15. Sacks G, Veerman JL, Moodie M, Swinbur B. “Traffic-light” nutrition labelling and “junk-food” tax: a modelled comparison of cost-effectiveness for obesity prevention.

o View In Article

16. Doctor support critical in the fight for community prevention in Physician . Accessed October, 23, 2011

o View In Article

17. Accessed October, 23, 2011

o View In Article

18. Accessed October 23, 2011.

o View In Article

19. Toasting a Major Victory for the Water Commons Italian voters overwhelmingly reject water privatization by Wenonah Hauter & Food and Water Europe . Accessed October 23, 2011

o View In Article

20. Accessed October 22, 2011

o View In Article

21. Accessed October 23, 2011

o View In Article

22. The Efficacy and Cost-Effectiveness of Integrative Medicine . Accessed October 23, 2011

o View In Article

23. Boyle M , Lawrence S , Schwarte L , Samuels S , McCarthy WJ . Health care providers' perceived role in changing environments to promote healthy eating and physical activity: baseline findings from health care providers participating in the healthy eating, active communities program . Pediatrics . 2009;123(Suppl 5):S293–S300

o View In Article

o CrossRef

24. Community-Centered Health Homes: Bridging the gap between health services and community prevention . Accessed October 23, 2011

o View In Article

25. Accessed October 23, 2011

o View In Article

Jamie Harvie, PE, is the Executive Director of the Duluth, MN-based Institute for a Sustainable Future (ISF). () In this led capacity he led the founding of Health Care Without Harm's (HCWH) Healthy Food in Health Care Initiative. His organization won an MN Governor's Award for his work on Healthy Food in Healthcare, and he was recognized as a “National Thought Leader” for his work on healthcare and sustainable food systems. He would like to acknowledge the contributions of Ted Schettler, MD, Science Environmental Health Network in the development of this Commons Health Care framework.

PII: S1550-8307(11)00305-3

doi:10.1016/j.explore.2011.11.005

© 2012 Elsevier Inc. All rights reserved.

Explore: The Journal of Science and Healing

Volume 8, Issue 1 , Pages 59-64, January 2012

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download