Health Promotion International, Vol. 29 No. 3
doi:10.1093/heapro/dat028
Advance Access published 9 May, 2013
An ecological public health approach to understanding
the relationships between sustainable urban
environments, public health and social equity
MICHAEL BENTLEY*
Southgate Institute for Health, Society and Equity, Flinders University, GPO Box 2100, Adelaide, SA 5001,
Australia and School of Medicine, University of Tasmania
*Corresponding author. E-mail: michael.bentley@flinders.edu.au
SUMMARY
The environmental determinants of public health and
social equity present many challenges to a sustainable ur-
banism—climate change, water shortages and oil depend-
ency to name a few. There are many pathways from urban
environments to human health. Numerous links have been
described but some underlying mechanisms behind these
relationships are less understood. Combining theory and
methods is a way of understanding and explaining how the
underlying structures of urban environments relate to
public health and social equity. This paper proposes a
model for an ecological public health, which can be used to
explore these relationships. Four principles of an ecological
public health—conviviality, equity, sustainability and
global responsibility—are used to derive theoretical con-
cepts that can inform ecological public health thinking,
Key words: ecological health; public health model; urban environments; environmental justice
INTRODUCTION
More than half the world’s population now live
in cities (United Nations Department of
Economic and Social Affairs, 2010), so it is not
surprising that increasing attention has been paid
to urban environments and health (Pacione,
2003; Kearns et al., 2007; Kjellstrom et al., 2007;
Bambrick et al., 2011). A number of reports from
Australia and elsewhere have stressed the im-
portance of creating healthy urban environments
for humans [World Health Organization, 1997;
Centre for Urban & Regional Ecology, 2002;
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which, among other things, provides a way of exploring the
underlying mechanisms that link urban environments to
public health and social equity. Theories of more-than-
human agency inform ways of living together (conviviality)
in urban areas. Political ecology links the equity concerns
about environmental and social justice. Resilience thinking
offers a better way of coming to grips with sustainability.
Integrating ecological ethics into public health considers
the global consequences of local urban living and thus
attends to global responsibility. This way of looking at the
relationships between urban environments, public health
and social equity answers the call to craft an ecological
public health for the twenty-first century by re-imagining
public health in a way that acknowledges humans as part of
the ecosystem, not separate from it, though not central to it.
National Heart Foundation of Australia
(Victorian Division), 2004; Planning Futures Pty
Ltd, 2009; Commission for Architecture and the
Built Environment (CABE), 2010].
The environmental determinants of public
health and social equity present many challenges
to a sustainable urbanism—climate change,
water shortages and oil dependency to name a
few. There are many pathways from urban envir-
onments to human health (Frank and Engelke,
2005). The ‘science of discovery’ (Catford, 2009)
has been very successful in describing the many
links between urban environments and public
528

health, going back to the nineteenth century
when, in countries such as Great Britain,
crowded cities with poor sanitation saw diseases
such as tuberculosis and pneumonia flourish,
with polluted water leading to outbreaks of
cholera and typhoid. The response to these pro-
blems ‘was the gradual development of a public
health movement, based on medical officers of
heath, sanitary inspectors and their staff, sup-
ported by legislation’ [(Ashton and Seymour,
1988), p. 15] and resulted in the 1848 and 1875
Public Health Acts (Ashton and Seymour, 1988).
This, in turn, influenced similar responses in the
British colonies (Baum, 2008).
However, the underlying mechanisms behind
some of these more recent links (e.g. urban
green spaces) are less understood (Sadler et al.,
2010). Catford [(Catford, 2009), p. 1] argues for a
‘science of delivery’, asserting that ‘the delivery
mechanisms for effective health promotion may
be poorly researched’. Combining theory and
methods is a way of revealing the mechanisms
behind a phenomenon (Danermark et al., 2002).
This paper proposes an ecological public health
model that is theoretically informed and can be
used to examine the relationships between sus-
tainable urban environments, public health and
social equity. As Krieger notes, ‘models do not
exist independently of theories’ [(Krieger, 1994),
p. 891].
PUBLIC HEALTH: OLD, NEW,
ECOLOGICAL
There are a number of descriptors of public
health, which include conventional, old, new and
ecological. Baum (Baum, 2008) provides a brief
history of (old) public health and the evolution
of the new public health. She observes that the
new public health evolved during the 1970s and
1980s, a time when social movements were active
in campaigns for women’s rights, gay liberation
and environmental protection. Rayner (Rayner,
2009) provides a comparison between conven-
tional and ecological public health. He argues
that an ecological public health has its roots in
the Victorian era, a time when structural inter-
ventions including policy and legislation were
seen to be important mechanisms for public
health action. Suffice to say that there are ten-
sions within and between these terms that are
based on the debate between structure and
agency. Baum and Rayner (Baum, 2008; Rayner,
An ecological public health approach 529
2009) agree that the focus on agency—individual
choice, social marketing—is prevalent in the
current milieu. The new public health is increas-
ingly concerned with sustainability and viability
of the physical environment and its human
impact (Baum, 2008). So, rather than grafting an
ecological public health onto existing structures,
the challenge for the twenty-first century is craft-
ing an ecological public health in a way that
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acknowledges humans as part of the ecosystem,
not separate from it and not central to it. As
Baum (Baum, 2008) notes,
Ecological sustainability is at the heart of the
aspirations of a public health for the twenty-first
century . . . Crafting an ecological public health is
an absolute priority for public health practitioners
( p. 387).
Models of public health have attempted to go
beyond the biomedical view of health that
focuses on symptoms, diseases and patients.
Figure 1 illustrates a health determinants model
(Dahlgren and Whitehead, 1993) that places
people, and their age, sex and hereditary factors,
at the core of a number of layers of influences
and conditions (from individual lifestyle factors,
social and community influences, living and
working conditions to general socio-economic,
cultural and environmental conditions).
It is a model that has been widely used
(Ministry for Health, 2002; SACOSS, 2008; The
Scottish Government, 2008) and adapted
(Institute of Medicine, 2003; Barton and Grant,
Fig. 1: The main determinants of health (Dahlgren
and Whitehead, 1993; reproduced in [(Dahlgren and
Whitehead, 2006), p. 19]. Reproduced with
permission.
530 M. Bentley
2006; VicHealth, 2009). The focus is on people
and their environment. Barton’s (Barton, 2004)
conceptual model of human settlements, which
draws on the model of Dahlgren and Whitehead
(Dahlgren and Whitehead, 1993), is explicitly an-
thropocentric:
People are at the heart of the model, in line with
the anthropocentric view of sustainability. The
health, well-being and quality of life enjoyed by
people are the core purpose of settlement planning
( p. 10).
Hancock (Hancock, 1993) posited three eco-
logical models to link health, human develop-
ment and the community ecosystem. In his first
model, the mandala of health, humans are at the
centre, illustrating the interrelationships between
human health, culture and environment (Brown
et al., 2005a; Baum, 2008; Nicholson and
Stephenson, 2009). Hancock’s (Hancock, 1993)
two other models each have three intersecting
circles: the first of these places human develop-
ment as the intersection of health, economy and
environment, the second centres (human) health
as the intersection of a convivial community, a
viable environment and an adequately prosper-
ous economy. Health, in this model, is linked to
liveability, sustainability and equity. Dooris
[(Dooris, 1999), p. 374] takes this latter model
(substituting social values for community) and
argues for ‘a gradual convergence of the three
circles’ towards an integrated approach. So, how
might we integrate health and environment in a
just and sustainable way? Grootjans and
Townsend (Grootjans and Townsend, 2005) give
an account of the various frameworks developed
for health (e.g. the Declaration of Alma-Ata, the
Ottawa Charter for Health Promotion) and en-
vironment (e.g. the Rio Declaration on
Environment and Development, the Kyoto
Protocol on Greenhouse Gases) and see that the
development of a holistic framework such as the
Earth Charter might provides the guiding princi-
ples needed to integrate health and environment
into a coherent framework. The Earth Charter,
developed by the United Nations Educational,
Scientific and Cultural Organisation articulates
four principles: respect and care for the commu-
nity of life; ecological integrity; social and eco-
nomic justice; democracy, non-violence and
peace (The Earth Charter Initiative, 2000).
These principles also form the four pillars of
global green parties (Global Greens, 2001).
Though these are broad principles, they offer a
starting point for developing a theoretical per-
spective for a critical examination of the relation-
ships between sustainable urban environments,
public health and social equity. The next section
takes this further by developing a model for an
ecological public health.
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ECOLOGICAL PUBLIC HEALTH
The concept of an ecological public health is not
new. In the 1980s and 1990s, several authors
(Kickbusch, 1989; Chu and Simpson, 1994) paid
particular attention to how ecological public
health could be applied to sustainable develop-
ment and health promotion. Indeed, the Ottawa
Charter acknowledges that the ‘inextricable
links between people and their environment
constitutes the basis for a socio-ecological ap-
proach to health’ (World Health Organization,
1986). Recently, ecological public health has
re-emerged as a focus for sustainability and
health (Brown et al., 2005b), and in areas of
concern such as obesity (Lang and Rayner,
2007), healthy lifestyles (Fitzgerald and
Spaccarotella, 2009) and climate change
(Morris, 2010). MacDougall et al. (MacDougall
et al., 2007) also revisit the ecological metaphor
as a way of re-imagining health promotion.
Morris [(Morris, 2010), p. 34] is succinct in
stating that ecological public health is ‘under-
pinned by the paradigm that, when it comes to
health and well-being "everything matters"’.
However, when public health takes an ecological
turn, it presents the problem of complexity
(Gatrell, 2005; Rayner, 2009). Rayner [(Rayner,
2009), p. 590] observes that complexity ‘is then
used as an excuse for inaction or, worse, for its
trivialisation’. Despite various approaches that
take up the challenge of complexity (Dimitrov,
2001; Resnicow and Page, 2008; Poland and
Dooris, 2010), when faced with complex issues,
public health often reverts to ‘lifestyle drift’
(Popay et al., 2010). The new public health move-
ment has been critical of public health promotion
campaigns that focus only on tackling individual
behaviours around smoking, alcohol consump-
tion, physical activity and nutrition (Keleher,
2007; Baum, 2008). The appeal to individual
agency dominates these strategies—‘please
behave differently!’ [(Rayner, 2009), p. 590]. In
isolation, these campaigns at best are unlikely to
bring about sustained improvement in

population health and at worst will increase
social and health inequity (Murphy, 2007). At an
ecological level, this type of thinking is limited.
Moore [(Moore, 2010), p. 33], in his examination
of fire, trees and climate change, warns that a
‘focus on one ecological factor to the exclusion
of others is usually a recipe for environmental
disaster’. An ecological approach would ‘con-
sider what changes we need to make to social
and ecological determinants to bring about, at the
population level, health, well-being, social justice
and a sustainable ecosystem’ [(MacDougall et al.,
2007), p. 358]. These are complex matters and beg
the question, what are we to do with this thing
called complexity?
One approach comes from Kickbusch who
draws on Bateson’s (Bateson, 1979) concept of
the pattern which connects to stress the need to
connect the physical, social and political into
ecological thinking. In doing so, she answers the
call to ‘get the politics out of hiding’ by making
the values embedded in theory explicit (Tesh,
1988). Kickbusch (Kickbusch, 1989) posits the
following principles for an ecological public
health: conviviality, equity, sustainability and
global responsibility. These principles relate
closely to the principles of the Earth Charter:
conviviality (respect and care for the community
of life); equity (social and economic justice); sus-
tainability (ecological integrity) and global re-
sponsibility (democracy, non-violence and
peace). Kickbusch’s (Kickbusch, 1989) principles
provide a way into theoretical concepts that can
inform ecological public health thinking.
Conviviality
At the core of this ecological public health think-
ing is the concept of conviviality. According to
the Oxford dictionary, a convivial atmosphere is
one that is friendly, lively and enjoyable. Its
origin lies in the Latin convivialis, which can be
taken literally to mean: ‘live with’. In an eco-
logical sense, this can connote the relations of
the entities of an environment to each other and
their surroundings. Conviviality has been con-
ceptualized as
a political project that is concerned with a more
broadly conceived accommodation of difference,
better attuned to the comings and goings of the
multiplicity of more-than-human inhabitants that
make themselves at home in the city (Hinchliffe
and Whatmore, 2006, p. 125).
An ecological public health approach 531
This project is relevant to an ecological public
health. The cities where the majority of the
world’s population now live are a setting for
human and more-than-human health. There is
congruence in the standpoints of health promo-
tion and urban ecology. The Ottawa Charter for
Health Promotion states: ‘Health is created and
lived by people within the settings of their every-
day life, where they learn, work, play and love’
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[(World Health Organization, 1986), p. iii].
Relatedly, the new field of reconciliation ecology
calls for ‘inventing, establishing and maintaining
new habitats to conserve species diversity in
places where people live, work and play’
[(Rosenzweig, 2003), p. 7]. In this sense, nature is
not out there but part of the urban fabric
(Davison, 2005; Jones and Cloke, 2008) and,
moreover, the more-than-human inhabitants can
exercise agency (Jones and Cloke, 2002; Latour,
2004). This is not to say that trees (or birds,
insects, etc.) ‘possess the particular and extraor-
dinary capabilities of humans . . . [but] they do
possess very significant forms of active agency,
which have usually been assumed to exist only in
the human realm’ [(Jones and Cloke, 2008),
p. 81]. In Australia, a general pattern is for
people to separate the more-than-human envir-
onment from their built environment (Head and
Muir, 2005). The private space of the backyard
(or back garden) is best for people and the
natural environment (referred to as the ‘The
Bush’ in Australia) is best for wildlife. In
between these spaces—the neighborhoods,
streets, local parks and bushland areas—people
and wildlife encounter each other in different
ways. That is not to say that the
more-than-human environment is not valued—
sometimes it is just somewhere else. However,
this pattern is not homogenous. Diversity in
garden types varies with income and education;
people with tertiary degrees favour more
complex native gardens (Kirkpatrick et al., 2007).
In the USA, ecological patterns also vary with
socio-economic gradients, with larger variations
produced by bottom-up human influence at the
household level and more uniform patterns pro-
duced by the top-down human influence at the
government level (Kinzig et al., 2005).
Conviviality requires a shift in thinking about
health and ecology separately. Living with the
more-than-human inhabitants of urban areas
opens up new ways of thinking about health
ecology and the equitable distribution of conviv-
ial areas.
532 M. Bentley
Equity
Equity in health has a long history deriving from
theories of justice and fairness. In an ecological
sense, equity and justice are social and environ-
mental concerns [see, e.g. (Agyeman and Evans,
2003; Heynen, 2003; Heynen et al., 2006; Wilson,
2009)]. Theories of political ecology are germane
to equity in this sense (Low and Gleeson, 1998;
Forsyth, 2001; Heynen, 2006). A tenet of political
ecology is that there is no nature-culture divide
(Uggla, 2010), long recognized by Australia’s
Indigenous peoples (Burnam, 1987; Memmott,
1994; Bayet-Charlton, 2003). Rather than
examine nature and culture separately, they can
be seen as a socio-nature, ‘a hybrid that mediates
both part of nature and society’ [(Roy, 2011),
p. 2]. This hybrid is an entangled entity of assem-
blages, within which various interactions occur
(Latour, 1993, 2004). To understand these inter-
actions, urban political ecology draws on the
concept of metabolism as a socio-ecologic
process (Swyngedouw, 2006). Thus, urban areas
are sites of socio-ecological production that (re)-
produce social and environmental inequities at
different scales (Heynen, 2003). How social and
environmental goods are equitably distributed
points to thinking about sustainability.
Sustainability
Sustainability is so widely used as a catch-all
term that its meaning has taken on many (often
conflicting) aspects (Low and Gleeson, 2005).
There are many initiatives that are sustainable,
yet (re)produce inequity (Marcuse, 1998). It is
important to consider sustainability in the light
of social and environmental justice (Dobson,
2003), which inextricably links sustainability to
health and equity. This is brought into sharp
relief by the issue of climate change (Baum and
Fisher, 2010; Poland and Dooris, 2010). If we
accept that we are all part of socio-ecological
systems, which are complex and adaptive
(Resnicow and Page, 2008), then sustainability
takes on particular significance. Resilience, that
is ‘the capacity of a system to absorb disturbance;
to undergo change and still retain essentially the
same function, structure and feedbacks’ has been
proposed as the key to sustainability in complex
adaptive systems [(Walker and Salt, 2006), p. 32]
and a better way of thinking about sustainability
(Hopkins, 2009) and health (Eckersley and Cork,
2011). A key to resilience thinking is the notion
of the threshold or tipping point, which, if a
socio-ecological system crosses, may result in ir-
reversible change—‘Sustainability is all about
knowing if and where thresholds exist and having
the capacity to manage the system in relation to
these thresholds’ [(Walker and Salt, 2006), p. 63].
Global responsibility
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At a time when a growing majority of the world’s
population live in urban areas, the local actions of
living in cities and towns have global conse-
quences. The ecological footprint of all cities is
much larger than their land area (Rees and
Wackernagel, 1996). There is an urban blind spot
in environmental ethics (Light, 2001) and an eco-
logical public health would take into account eco-
logical ethics. One approach comes from Curry
(Curry, 2000), who makes the case for an eco-
logical republicanism, which acknowledges the
virtues of the ecological common good and incor-
porates humans into ecology. The reconciliation
of nature and society requires the participation of
urban ecological citizens (Light, 2003). Ecological
ethical thinking links the other three principles of
an ecological public health. As citizens of an eco-
logical republic, we are dependent on the integ-
rity of the ecosystem (sustainability), on the
sharing of the ecological common good (equity)
and on living together in human and natural com-
munities (conviviality). In one sense, this model
fits the thinking of futurists such as Robertson
(Robertson, 1983), Hancock (Hancock, 1994) and
Lowe (Lowe, 2005).
Figure 2a illustrates the interconnectedness of
the four principles of an ecological public health.
The choice of three conviviality circles is the
minimum number to show more than one rela-
tionship between different convivial communi-
ties interacting with each other in equitable
ways, although in practice there would be many
more than just three communities, especially
when those communities contain both human
and non-human communities. In this model,
each conviviality circle has a fractal nature
(Figure 2b), allowing for a self-similarity at mul-
tiple scales (Krieger, 1994), whether they are at
the neighbourhood, suburb or city level. Bateson
(Bateson, 1979) asked:
What pattern connects the crab to the lobster and
the orchid to the primrose and all the four of them
to me? And me to you? . . . What is the pattern that
connects all living creatures? ( p. 8).

Fig. 2: (a) A model of ecological public health. (b) The fractal nature of conviviality.
This model gives us such a pattern. It reasserts
the new public health’s call for a stable ecosys-
tem and sustainable resources and focuses on the
health of the ecosystem. Equity and justice are
seen as social and environmental concerns. In
this ecological public health model, people are
no longer at the centre of the model but one part
of it, reflecting the theoretical concepts that
inform an ecological public health.
BACK TO SUSTAINABLE URBAN
ENVIRONMENTS
Theorizing how urban environments relate to
public health and social equity goes beyond the
mere appearances of urban environments to
An ecological public health approach 533
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understand and explain the underlying structures
of urban environments that relate to public
health and social equity. The relationships
between sustainable urban environments, public
health and social equity can come into a new per-
spective when viewed through an ecological
public health lens and point to several topics for
further investigation.
Theories of more-than-human agency inform
ways of living together (conviviality) in
urban areas and cast biodiversity in a new light.
A convivial urban community includes many
biotic inhabitants (Daniels, 2011). Stronger rela-
tionships between public health and urban
ecology could build on the interest in the
environmental, social and cultural factors that
influence, amongst others, the diversity of birds
534 M. Bentley
(Loss et al., 2009) and trees (Kuo, 2003) in
urban areas.
Political ecology links the equity concerns
about environmental and social justice, such as
the distribution of environmental ‘goods’ and
‘bads’, industrial and suburban development, for
instance (Pearce et al., 2011). Moreover, there is
an argument that ‘nature has certain rights, while
humans also have obligations, to nature and to
each other, to ensure that individual animal
species and indeed whole ecosystems are not
degraded to the point of non-sustainability’
[(Haughton, 1999), p. 237].
Resilience thinking offers a better way of
coming to grips with sustainability. How can the
process of urban development and regeneration
retain and strengthen the basic functions and
structures of convivial and equitable urban living
and healthy ecosystem functioning? The social,
environmental, economic and cultural sustain-
ability of urban environments is subject to the
socio-natural processes of urban metabolism
(Heynen, 2006). Urban metabolism models have
been used in socio-ecological frameworks for
health, which illustrate how physical and social
resources are transformed or metabolized by
urban systems and processes, resulting in out-
comes that influence liveability, environmental
quality and waste (Kearns et al., 2007).
Integrating ecological ethics into this thinking
considers the global consequences of local urban
living and thus attends to global responsibility.
In seeking to inform ecological public health
thinking, this model has drawn from several lit-
eratures. It remains to assess the extent to which
conviviality can inform social and environmental
justice, how political ecology informs resilience
thinking and how the local informs the global.
Kurt Lewin [(Lewin, 1951), p. 169] said, ‘There is
nothing so practical as a good theory’. In practice,
ecological public health thinking can inform
efforts to develop ‘holistic approaches to holistic
policies’ [(Mulgan, 2010), p. 46] and to create
local sustainable communities that are globally
connected (Hopkins, 2009). Crafting an ecologic-
al public health for the twenty-first century
re-imagines public health in a way that acknowl-
edges humans as part of the ecosystem, not separ-
ate from it, though not central to it. The saying,
‘think globally, act locally’ may well apply here
though it is better described as ‘think and act
locally, nationally, transnationally and globally all
at the same time, and do so in an ethical way’
[(Mulligan and Adams, 2003), p. 297].
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