Conceptual Issues in Environmental Epidemiology and Environmental Health

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MSc Environmental Epidemiology & Policy

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PROJECT REPORT
Conceptual Issues in Environmental Epidemiology & Environmental Health
Salim Vohra 1996-97
Conceptual Issues in Environmental Epidemiology and Environmental Health
Cand. No. 1032
Contents
Page Acknowledgements Background Summary 1. Introduction 2. The Process of Knowledge in Science 3. The Process of Knowledge in Epidemiology 4. Concepts and Definitions 5. Scientific Models, Frameworks and Metaphors 6. Methodology and Research 7. Theories 8. Mathematical Models 9. Environmental Health Frameworks 10. Conclusion References 1 2 4 7 11 17 29 31 35 36 46 48
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Acknowledgements
I would like to thank the staff of the Environmental Epidemiology Unit for helping to teach me the core of Environmental Epidemiology and Policy and in particular my tutor and project supervisor Helen Dolk.
My special thanks goes to Professor Tony McMichael for his insightful lectures, seminars and articles for without them I would not have had the idea or impetus to undertake this project.
My thanks also to Nasim Valli and Tessa Kershaw, the long suffering Environmental Epidemiology Unit Secretaries, for putting up with my silly requests throughout the year.
Lastly, and most importantly I would like to thank my fellow students on the course, especially Trevor Leveridge, Meri Koivusalo, Andrea Radnai, Gabriele Munding, Hadijah Musa, Mireille Toledano, Catherine Lillis and Ferdinando Vegni for the many, many enjoyable, interesting, silly, serious and challenging chats we have had about life, the universe and everything in the LSHTM refectory-canteen. Thanks for everything.
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Background Summary:
There has been some recent discussion in the epidemiological literature on the need to elaborate a framework for theory that underpins the knowledge and information produced by epidemiologists. Krieger specifically has argued that epidemiology theory encompasses theories that are different from both theories of causation (the basis for mathematical models of disease causation) and error (the basis for study design and analysis). Epidemiology theory she argues should encompass ecological, evolutionary, social, cultural and political dimensions in its description of disease and health processes and so provide a broader, richer and deeper level of explanation and prediction of health and disease. This would give useful insights not just for epidemiology but for public health and health policy as well.
Other epidemiologists have highlighted different aspects of this perspective notably McMichael, Susser, Pearce, Wing and many more. This has come about largely due to the emergence of phenomena such as AIDS, the impact of global warming, the degradation of ecological life support systems and the increased understanding of the socio-economic and political factors impinging on health, research and health policy. Alongside this, over the last two to three decades, has come a reassessment of the impact of better incomes, sanitation, housing, food and water quality as compared to medical interventions as well as very recent work on the impact of early life events, relative income differentials and social cohesion which have led to a reappraisal of our understanding of health and disease as processes in space and time that have more to do with relationships between social organisational structures and ecological systems than single agent-host-environment or multiple risk factor-disease processes.
This is likely to have profound implications for environmental epidemiology and environmental health as its traditional areas of focus are likely to change as our understanding deepens of the complex, embedded and interdependent processes that are taking place at the global and local levels even in the seemingly simple case of understanding the effects of single chemical exposures on individuals in populations in the real world.
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1. Introduction
...Not everything is equally worth knowing, there are some central, architectonic forms of knowledge without which others would have no value.
1
This project aims to explore some important conceptual issues in environmental epidemiology and environmental health. These issues have been framed in the broadest possible terms so that their scope can encompass epidemiology and environmental health as a whole.
Over the last three decades in particular three interlinked ideas or theories have emerged namely: systems theory, chaos theory and complexity theory. In the essentials these theories deal with the understanding of, prediction of events in as well as the types of interventions feasible in complex systems diverse as physics,
2,3,4
. There is a growing literature on complex systems in areas as biology, economics, ecology, computers and
mathematics,
telecommunications.
Though there are a range of definitions of systems the basic one is that a system is a set of interconnected elements such that a change in the state of any one element induces changes in the state of the other elements. Hence systems are coherent entities in space and time with interrelated elements that act as a whole . Complex systems therefore include cultural forms, social systems, economic systems, politics, ecosystems and organisms. Hence health and disease are phenomena and properties of complex systems (organisms) embedded within larger complex systems (ecosystems, social and cultural systems).
5
Though there is some debate, my intuitive feeling is that the ideas developing in other disciplines of how complex systems work are likely to have a significant, if not profound, impact on how we look at health and disease and hence what kinds of research and policy frameworks we could or are likely to use in the future . In a sense we already are looking in this direction because of the need to look at how changes in global ecosystems are likely to have health impacts on individuals and populations . Some of these ideas have already been developed from a holistic and ecosystem perspective in some areas of public health and health promotion
8,9,10 7 6
. However
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very few of these ideas are seeping into the mainstream health arena and this includes environmental epidemiology and environmental health.
Hence, my objective in this project is to attempt the development of a theoretical schematic framework-model-map placing the various levels of analysis in context to provide a practical tool for looking at the interaction, impact and importance of factors leading to health and disease.
To look at how a complex systems framework-model - a qualitative scientific model - can be developed that encompasses these ideas and links up to and expands upon existing models in epidemiology like the web of causation. I hope to show how this expanded framework-model not only has implications for research epidemiology but also links up to the development of a complex systems-based framework for environmental health.
Specifically, my objective is to clarify and attempt to place on a rigorous footing three important intuitions: First, that the epidemiology and environmental epidemiology appear narrow and fragmented because there has been little attempt to look at the process of how epidemiology works and produces knowledge. Second, that the web of causation, first described by MacMahon, needs to be and could be expanded to provide a more complete framework-model of the interconnections and relationships that influence health and disease at individual and population levels. Third, that this framework-model could be broad enough to provide a primary framework for environmental health and hence environmental health policy.
These areas are complex and hence my task is not to produce a definitive statement, rather it is a concerted attempt to practically integrate these various aspects and show that they are part of a process and framework that can be seen, for what I believe they are, as parts of a coherent whole.
Before we can do this however we need to step back and explore the nature and process of epidemiology as a science i.e. how epidemiology works or seems to work. However, before we can do that we need to look at how the process of science works in general.
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2. The Process of Knowledge in Science
The levels of explanation and the process of science, at least in the physical sciences, is usually seen as having a number of phases that flow back and forth between each other as shown in Fig. 2.1 and 2.2.
2.1 Levels of Explanation in Science
Observation
Empirical Laws
Laws of Nature
Theories
EXPERIMENT Fig. 2.1: Stages of knowledge in science (Casti J, 1995)

10
THEORY
Where: Observation: The observing of events or happenings in the external world where most explanatory schemes, scientific or otherwise are anchored. They constitute what is termed facts and are usually multiple or sequential in nature.
Empirical Laws:
Organisation of observations into some meaningful pattern and order. These laws are very provisional in nature and can easily be overturned.
Laws of Nature:
These laws are more concrete, fixed and immutable. They are more than just an organisation of observations as they predict events that could occur but have not yet occurred.
Theories:
A law explains a set of observations, a theory explains a set of laws. e.g. Newtons theory of mechanics explained Keplers laws of planetary motion.
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2.2 Process of Knowledge in Science
The general process of science and the way scientific theories are employed to explain and make predictions is shown in Fig. 2.2.
Laws & Theories
INDUCTION
DEDUCTION
everyday language observations & facts EXPERIMENT predictions & explanations

4
Fig. 2.2: Process of knowledge formation in science (Casti J, 1995)
Where: Induction: Is the process of arguing from specific instances to general conclusions and is employed on the experimental side of science to generate laws from observation.
Deduction:
Is the process of drawing conclusions from general instances and is used to generate predictions and explanations from scientific theories.
Dotted Arrow Line:
Represents the fact that we speak in everyday language when we make predictions based on observations and also that we use methods of science to test those predictions experimentally.
However this is an idealised portrait as in practice the starting point of the process of science is generally hypothesis or theory not observation
11,12
2.3 Models in Science

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Explanations and predictions are produced through the development of models which are abstractions of external reality that simplify but retain the essence of reality. There are two general types of models - scientific and mathematical.
Scientific Models:
These are mental and physical models e.g. seeing gas molecules in a chamber as hard spheres similar to billiard balls to help visualise the relationship between temperature and pressure, the web of causation.
Mathematical Models:
These are the main types of models used as they allow relationships in the real world to be quantified as shown in Fig. 2.3.
Fig. 2.3: Modelling relation between the natural world and the mathematical world (Casti J, 1995)
4
Observable quantities in the real world (natural system) are encoded into abstract structures in the mathematical world which can then be used to generate new relationships linking the mathematical objects (theorems in M). These valid mathematical assertions can then be decoded into statements (predictions) about the natural system N that is modelled by the mathematical system M.
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3. Process of Knowledge in Epidemiology

The levels of explanation and process of science just outlined does not seem to match exactly the process of knowledge formation in epidemiology.
3.1 Levels of Explanation in Epidemiology
Castellanos has provided a framework for the levels and types of explanations of health and disease that could be developed and how they interact with each other as shown in Fig. 3.1 .
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Fig. 3.1: Levels and types of explanations of health (Castellanos PL, 1990)
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3.2 Process of Knowledge in Epidemiology
A process diagram of how epidemiology works does not seem to have been developed though McMichael has looked at the levels of epidemiological investigations and the influences on it as show in Fig. 3.2 . Where W represents social determinants of an outcome of interest Y and X is a more proximal risk factor/ exposure.
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This diagram however does not deal explicitly with how epidemiology works and my own attempt at a diagram of the process of epidemiology is shown in Fig. 3.3. Like the general science model this is a linear framework which is not what happens in practice as there is continual interchange between the various parts and the elements do not necessarily follow neatly one after the other. The arrows do show however that each element feeds into both the element after it and the one that precedes it. The dashed arrows show that research does not feed into policy in a direct way but in a looser more diffuse manner .
15
Fig. 6: Levels and influences on epidemiological investigations. (McMichael 1997)
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Molecular & genetic measurement techniques (high resolving power of studies)
Scientific Paradigms & Social Values
Population-level influences
W
Social Determinants
Mainstream aetio logical epidemiology
Population Health Impact
Policy Action
incorporation in predictive mathematically modelling
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Fig. 3.3: Process of knowledge formation in epidemiology Concepts & Definitions
Other Disciplines
concepts models methodology, etc e.g. toxicology, medicine, environmental science
1 2 3
Social & Cultural Context & Values + Scientific Paradigms
Framework Metaphor Scientific Model
Hypotheses
Mainstream/ traditional area of work in epidemiology
Methodology
Research & Observation
Associations
4 5 6
Theories
(aetiology, causation, error)
Mathematical models
(deterministic non-deterministic)
Policy Framework
e.g. Quantitative Risk Assessment and Management, etc
RESEARCH-POLICY INTERFACE
Policy Cycle
(problem identification, policy formulation, implementation, evaluation)
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Using the framework in Fig. 3.3, I want to touch upon each of the elements numbered but explore four of the areas in greater detail. These areas are:
How definitions and concepts have an impact on developing and changing frameworks for both epidemiology and environmental health (Element 1).
How an expanded model of the web of causation could be developed that may be useful both for epidemiology and environmental health (Element 2).
Attempt to list the existing theories of disease and health and explore briefly how they might be integrated together using the expanded model (Element 4).
Finally how broad definitions and concepts have lead to interesting ecological and systemsbased models that are or could be used as policy frameworks for environmental health (Element 6).
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4. Concepts and Definitions

4.1 Need for Concepts and Definitions
All sciences have certain core questions that they constantly return to. In physics they are about the nature of matter. In biology they are about the nature of living organisms. Similarly for epidemiology our questions relate to our conceptions of health and disease and how we should look at them at an individual and population level.
Epidemiology is generally defined as the study of the distribution and determinants of healthrelated conditions or events in a defined population and the application of this study to the control of health problems.
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Every so often there is a debate started within a scientific community about what its purpose is and where it should be going. In epidemiology, these in their essence, seem to be about different conceptions of health and disease. A number of authors have detailed a variety of extensions and limitations to the current research effort and body of knowledge. Krieger has rearticulated and advanced the model of the web of causation and attempted a revised model that she terms an eco-social framework . Wing and Pearce have argued for a broader framework where epidemiologists deal much more with social, cultural and economic determinants of health and disease
18,19 17
. Rose has argued for a population-based approach while Brown has advocated
for lay epidemiology where citizens and residents actively participate in the research process
20,21
. Others have talked about using upstream as opposed to downstream

22
approaches in research and policy . Taubes and Shy have catalogued some of the limitations of current epidemiological methods and approaches
23,24
. Importantly McMichael has explored and
highlighted the need for incorporating global environmental factors by taking an ecosystems approach
25,26
Susser and others have argued that concepts of health and disease have framed paradigms of theory and action in epidemiology since the 19 century
th 27,28
. How the idea of miasma shaped the
sanitation movement of the 19th century. How idea of the germ changed this focus to the
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individual, the search for Kochs magic bullets and away from population-based approaches to understanding and intervening on diseases in communities. How this gave way in the 1950s to the idea of the black box of multifactorial aetiology and how new ecological ideas are likely to lead to a future eco-epidemiology.
These perspectives have their critics but at the heart of the debate is the common thread of deciding how we should conceive of health and disease and hence what kind of frameworks, theories and models of reality we should develop to understand and explore them
29,30,31,32,33
What I want to briefly explore here is: what our current definitions are; what new ones have been developed that attempt to more adequately incorporate the complexity of health and disease; and what the problems with these definitions are.
4.2 Definitions in Epidemiology

The standard WHO definition of health is that health is a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity .
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Jedrychowski and Goldsmith have stated that health is a relative state, the baseline from which disease is measured, and in theory this would be the optimum state of the organism .
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The problem with most broad-based definitions of health is that they are difficult to operationalise i.e. to use in practice as a framework for research. In research a definition-concept is needed that allows health to be measured. Hence in epidemiology we find that most measures of health are actually measures of disease e.g. mortality and morbidity, since it is easier to say what health is not than what it is. This is compounded further by the problem that there are many cases where there is no clear distinction between normality(health) and abnormality(disease) for some measures e.g. blood pressure, organ function etc. Hence the importance of accurate classification in terms of strict diagnostic and exposure criteria in study design and analysis. So, in general it seems that health (and disease) definitions fall along a spectrum between qualitative and hard to measure definitions to those that are quantitative and easier to measure. Health is therefore seen as a measurable characteristic that individuals possess, that can be
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aggregated to give a measure of the health a given population. Health seems (at least in everyday terms) to be a thing, a property of an organism that can be abstracted. Something that could conceivably be plotted on a graph see Fig. 4.1.
Fig. 4.1: A theoretical graph of an individuals state of health over time

100% Health
conception Time
Disease
100%
death
Concepts define or frame the kinds of theories that are studied and developed hence with our current disease-based definitions the process of developing disease is seen in terms of individual impacts and exposures as shown in Fig. 4.2.
Fig. 4.2: Process of developing disease at the individual and population levels
Individual impacts/ exposures mum + dad ageing ageing
conception
death
death
illness
hence gene + environment susceptibility + exposure adaptation + disease
Population Aggregate (sum) of individual level health/ disease
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This individual focus means that factors that affect health and disease tend be classified in simple terms such as internal and external factors as shown in Table 4.1.
Table 4.1: Internal and external factors that influence health and disease. INTERNAL FACTORS EXTERNAL FACTORS
Genetic Immune Psychological Other Systems Unknown
Microbes/ Parasites/ Living Organisms Chemical Geophysical Physical Injury Nutritional & unknown
This brings us to the concept of population and what we mean by this term. The debate has centred on whether populations should be treated as simply aggregations of individuals or should be seen as systems made up of individuals that have complex relationships and interactions with each other
18,19
. The implication being that we need to focus on other population
characteristics than those currently being studied. The complex-systems framework-model described later emphasises this point by showing that populations are more than a collection of individuals and hence there are population level characteristics that emerge whenever organisms are grouped together and these properties cannot be inferred from the individual level characteristics of the organism concerned. Another way to put this is that populations are more than the sum of the individuals that make it up.
4.3 Newer and More Encompassing Definitions

With the production of the Ottawa Charter and WHO initiatives such as the Healthy Cities Programme newer definitions of health are being framed
36,37
. In these definitions health is seen
as resource rather than as a potential, a process, a set of complex relationships that an individual or population has with their surrounding environment, not a thing apart but a pattern that connects
38,39
. These definitions have been used and developed in the public health policy
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arena and especially in health promotion. This has led to the development of models like that shown in Fig. 4.3 .
8
Fig. 4.3: The Mandala of Health (Hancock, T 1985)
4.4 Problems with Definitions

The three major problems with these definitions are: firstly, the difficulty in operationalising them for research; secondly, the difficulty in visualising and modelling these kinds of definitions and concepts in terms of theoretical insights; and thirdly, these definitions tend to be placed in an oppositional, antagonistic framework when compared to each other they are treated as either/ or definitions rather than both being seen as having validity and usefulness depending on context i.e. that they are part of a spectrum of concepts and definitions that are useful for different tasks and approaches.
4.5 Implications
The question therefore is could a framework be developed that allowed both types of definitions to co-exist and be placed in context. In the next section I attempt to do just this.
Before we move on there is also another important definition in epidemiology and environmental health and that is the definition of the environment. What is the environment? As with health and disease there are a lot of differing definitions and conceptions. Again the same problems crop
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up, the difficulty of using broad definitions in practice, the use of direct exposure-outcome models excluding more complex aspects of the environment and the use of differing, antagonistic definitions in other disciplines that are involved in health and environment issues . The issue of the environment will be covered later.
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5. Scientific Models, Frameworks and Metaphors

5. 1 Background Ideas
Stallones has elegantly highlighted the multidisciplinary nature of epidemiology and the levels at which understanding can occur and knowledge is produced as shown in Fig 5.1 .
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Fig. 5.1: Depiction of biomedical disciplines along a scale of biological organisation.
This complements Sussers idea of levels of understanding of the factors affecting health and disease being like Chinese boxes nestling one inside the other . While McMichael has described a multi-system context diagram underlying human population health see Fig. 5.2 .
42 28
Fig. 5.2: The multi-system context underlying the status of human population health:
health as an integrating index that reflects the state of the natural and social environments.
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Krieger and others have argued that the current model that epidemiology subscribes to, at least in theory, is the web of causation model. This model was first described by MacMahon in the 1970s see Fig. 5.3 .
17
Fig. 5.3: MacMahon et als web of causation: Some components of the association between treatment for syphilis and jaundice (in Krieger N, 1994).
The web of causation is a metaphor and model of the relationship between risk factors and outcomes. The intersections of the web represent the risk factors while the strands represent the process by which they act upon outcomes. It attempts to show and describe patterns of health and disease as a complex web of numerous interconnections of risk and protective factors that extend in all directions. Hence by intervening or breaking a strand of the web we can prevent certain outcomes from occurring.
Krieger presents a number of important considerations with regard to the web model which are: A theory or model offers a way of seeing and knowing the world and hence what kinds of interventions can take place and what aspects of the world can be modified.
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It is not necessary to understand all the causal mechanisms in their entirety rather epidemiology and public health can work on and use those aspects that are easier to know or modify.
Rather than being used to provide explanations of causal links, the web model has been used to depict and study the narrow relationship between distinct risk factors nearest the outcomes of interest.
Theories explain why phenomena exist and why they are inter-related while models attempt to portray how these connections occur and are usually constructed with elements and relationships specified by particular theories.
Krieger goes on to describe what she terms an eco-social framework. What I would like to explore is the development of an expanded model of the web of causation that allows the integration of a variety of perspectives and that could be a framework-model for Kriegers ecosocial framework.
The development of this expanded framework-model arose from a number of limitations that I perceived of the web of causation. These are:
Its two-dimensional and linear quality. It static nature that does not seem to incorporate a time element. All models are abstractions of reality but risk factors are an especially high level of abstraction. It collapses different levels of understanding that most of the authors quoted above have called for. Hence social factors impacting on health are on the same level as infection by micro-organisms.
5.2 Expanded Complex Systems Framework-Model

The expanded framework-model that I would like to propose is shown in Fig. 5.4.
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Fig. 5.4: Expanded complex systems framework-model of the levels of understanding & interaction of factors affecting health and disease.
6. LEVEL OF EXPOSURE OUTCOME CONFOUNDER
Exposure
Outcome
NODE
Confounder
represents risk/ protective factors or and outcome of interest
5. LEVEL OF NETWORK/ WEB OF CAUSATION
NODE represents any coherent entity that forms part of a system
INTERLEVEL 4. LEVEL OF NETWORK/ WEB OF CULTURE

2-way connections representing relationships between nodes from different levels
3. LEVEL OF NETWORK/ WEB OF SOCIETY
2. LEVEL OF NETWORK/ WEB OF LIFE
WITHIN LEVEL
2-way connections representing relationships between nodes at the same level
1. FLOW OF REALITY IN THE SPACE-TIME CONTINUUM
Represents the abstraction process
ARROW OF TIME
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5.3 Workings of Complex Systems Framework-Model

Each node is not fixed but represents some entity that can be seen in a coherent manner from organisms and inorganic molecules to aspects of social structures and ideas.
The framework-model allows the ability to zoom to different scales hence at the level of the network/ web of life a node can represent an organism and within that node other nodes could represent aspects at organ, cellular or molecular levels see Fig 5.5.
Organism level node
Cell level node Organ level node
Fig 5.5: Different scales or levels that nodes can represent.
The connections also occur between and pass through levels. The levels can be changed, narrowed, reduced or increased. The major conduit that connects the three levels of life, society and culture is the brain-mind that binds the biological, social and cultural together.
Explanation of the levels as shown in Fig 5.4: 1. Flow of Reality: As stated earlier all theories, models and frameworks are abstractions and hence simplifications of reality. Hence the flow of reality in the space-time continuum is the base from which we take our observations and for which we develop our ideas. Hence the arrows in the diagram represent levels of abstraction. At the first level we have the network of
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life, society and culture. The next level of abstraction is that of the web of causation. While an even higher level of abstraction is the exposure-outcome-confounder model. 2. Network of Life: The network or web of life is a visualisation of the interconnections and interdependent relationships that living organisms have between themselves and the inorganic world around them. (stratosphere -biosphere-lithosphere). This level places the molecular on the same level as the global ecosystem. They are both manifestations of life
and are more a matter of scale - the micro and the macro- at one level rather than different levels one on top of the other38.
3. Network of Society: The network of society is the level at which humans have added social systems and processes (social organisation, technology, political and economic systems and processes, etc.) upon existing natural systems and processes (evolution, ecosystems, etc.). At this level theories such as social cohesion, income inequality, and psycho-social factors may be placed. 4. Network of Culture: The network of culture is the level that encompasses the interrelationship between individual and population worldviews, values, ideas, knowledge, ethics, beliefs, perceptions, ideologies, religions, etc. that shape human behaviour and hence social and natural systems. 5. Web of Causation: This is the level of the web of causation which abstracts nodes perceived of as individual risk or protective factors from the earlier three networks and links them to other nodes which are outcomes of interest. 6. Standard Model: This is the standard exposure, outcome and confounder model used in study design and analysis (the agent-host-environment model fits here as well).
The advantages of the framework-model are that: It is a dynamic 4-dimensional network in space and time. Moves beyond an exposure-outcome model or a multifactorial exposures-outcomes model towards a more integrated approach that encompasses both the reductionist biomedical approach and more systems-based ecological approaches. It is flexible in allowing nodes to represent differing entities at various levels. Allows networks of relationships and impacts to be visualised. Though it is crude at the moment it has the potential to be refined.
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It shows how relationships can not only change over time but that the complex network of relationship is unlikely to be exactly the same for different populations. Hence relationships and interactions are context-specific, a point argued by Wing and Pearce
18,19
5.5 Examples of the Utility of the Complex Systems Framework-Model

How this framework-model might work in practice is shown in Fig. 5.6 and Fig. 5.7 though they are crude development and there is not time to develop it further in this project.
Fig. 5.6: Generalised example of expanded model in action.

LEVEL OF NETWORK/ WEB OF CULTURE
LEVEL OF NETWORK/ WEB OF SOCIETY
LEVEL OF NETWORK/ WEB OF LIFE
Organism
LEVEL OF INDIVIDUAL ORGANISM
Organ/ Physiological System
Cell
Gene/ Molecular level
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It is important to note that the levels are only one on top of each other for clarity and convenience and in reality there is no necessarily permanent hierarchical relationship between the levels described above. Though having the network of life at the base does incorporate the value and idea that social and cultural systems are built upon natural ones.
Secondly, the diagram shows that ideologies, values and perceptions impact on social, economic and political systems which in turn impact on human populations and natural ecosystems. Hence relationships and impacts can go from the molecular to the global and from the biological to the cultural and vice versa. Also, perhaps more importantly ideologies, values and perceptions occur in certain social, economic and political contexts which themselves are placed in wider local and global natural ecosystem contexts.
Fig. 5.7: Crude example of smoking and air pollution using the expanded model.
LEVEL OF NETWORK/ WEB OF CULTURE
LEVEL OF NETWORK/ WEB OF SOCIETY
LEVEL OF NETWORK/ WEB OF LIFE
Individual
LEVEL OF INDIVIDUAL ORGANISM
Lung/ Respiratory System
Lung Cell
Gene/ Molecular level
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5.6 Some General Properties of Complex Systems

The expanded complex systems model is a network of complex systems whose general properties include:
Like a cell or person it behaves as a unitary whole, maintaining its identity in space, resisting dissolutionneither a thing nor a concept but a continual flux or process.
Higher-level complexities cannot be inferred by lower level existencies without actually watching/playing out the network in space and time hence society and social organisation cannot be inferred from individual humans neither can population properties like herd immunity. Hence populations are not aggregations of individuals but are complex network systems see Figs. 5.8 and 5.9.
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Chains of causation are linear, sequential and fixed while Nets/Webs of causation are nonlinear, parallel and in flux.
Four important general characteristics are: 1. Absence of imposed centralised control. 2. Autonomous nature of nodes. 3. High connectivity between nodes. 4. Webby, non-linear causality of peers influencing peers.
Systems are collections of many autonomous nodes that react to internal rules and their local environments, are highly connected, form smaller peer networks within the overall system and the control/management of the systems is distributed throughout the system.
Systems produce nested hierarchies that occur from bottom up and can be visualised as a chunking of nodes i.e. nodes with greater and/or specific types of connection that can be seen as distinct sub-systems.
Systems have complex feedback loops that encompass all the nodes in the system hence causality is difficult to abstract out.
The advantages and disadvantages of complex systems is shown in Table 5.1
Table 5.1: Advantages & disadvantages of complex systems compared to linear systems ADVANTAGES Adaptable Evolvable Resilient Boundless DISADVANTAGES Non-optimal Non-controllable (but can be guided) Non-predictable (in the medium/long term)
Non-understandable (i.e. completely because of

circular/horizontal causality due to complex feedback
Novelty
loops)
Non-immediate (incorporates time)
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Three general properties of node connections are: 1. Number of connections per node 2. Connectance i.e. strength of coupledness between pairs of nodes, strength of association. 3. Type and quality of connections e.g. informational, energy, etc.
5.7 Development of Expanded Complex Systems Framework-Model

The ideas and expanded framework-model developed here are a tentative first step towards producing an integrated framework and it is important to remember the words of G. Davey Smith :
45
Leaping forward to the big picture of how it all fits together represents an attractive alternative to merely continuing with this laborious spade work.
Though Davey Smith was criticising certain approaches in the development of psycho-social theories of health and diseases it is a valid and important point. However, it is important to attempt the development of flexible frameworks and models that look at how the various theories and knowledges derived from research might fit together as they may provide greater insights even if the framework-model is flawed. The complex systems framework-model may have the potential to allow us to do this.
The metaphors, frameworks and models we use are at the heart of the process of knowledge formation. Hence their implications ripple through the process and the other elements. Models are a tool that helps us typify and clarify the way we think about certain phenomena and the intrinsic and extrinsic relationships with other phenomena. Hence presenting models in simplified form encourages scientists to be more explicit about their assumptions and expectations, thus playing an important role in hypothesis generation, testing and further refinement.
40
The same can be said for metaphors and frameworks.
Hence complex systems framework-model could act as a primary framework for epidemiology and help explain more clearly the current debates in terms of it being about the kinds of nodes and connections we are examining and whether we should be looking at other nodes and other
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types of connections that are more likely to provide us with a richer and deeper understanding of health and disease. It could act as the primary general framework into which all or most other frameworks and models could be fitted into. The complex systems framework-model could allow us to map out what nodes and connections are being examined and which are being ignored and whether the reasons are scientific (in terms of nodes that are easier to study and connections that are easier to modify or intervene on, etc.), social (in terms of acceptability to the public, etc.), economic (research funding cycles and fads, etc.) or political (in terms of fitting in with current political ideologies, etc.)
The implication for research is to allow a more complex and coherent framework-model to be envisioned which shows and allows for the validity of current (and future) techniques and methodologies whilst also allowing for a broader and more diverse range of factors that impact on health and disease to be explored.
It could also allow us to explore how the major theories of health and disease might fit together. Though this task is beyond the scope of this project I do attempt to list the major theories of health and disease later.
Lastly, it also has the potential to act as a primary framework for environmental health which is also discussed later.
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6. Methodology and Research

The issues in this area are well-covered in the literature and include issues of concepts, definitions, models and methodology in the design, statistical analysis and interpretation of studies and hence will only be touched on briefly .
46
There is however the important question of how different concepts and models of health and disease would change research and methodology. In answer, as stated earlier, it is likely to change the type of research questions asked and the subject area of any research but it is more problematic to answer whether it would change current approaches in methodology and analysis. My tentative conclusion is that at this level it would provide a more coherent framework but not change the methodology fundamentally though newer techniques and rigorous qualitative research is likely to provide insights not found in existing quantitative methods .
47
However there has been discussion by Wing, Pearce and McMichael about whether epidemiological studies are studies of populations or aggregates of individuals. Are we seeing populations as collections of individuals without considering the complex relationships that they have between each other and other systems (e.g. social, economic, environmental ). That populations are context specific groups that have dynamic changing relationships within them over time and hence a history of experiences that extends into the past
18,19,25
There has also been a reappraisal of the role and value of ecological studies as an important and vital part of epidemiological thinking
48,49,50,51
Finally there has been growing literature on the value and limitations of new molecular biological techniques that could enable us to develop biomarkers that more accurately measure exposure and disease
52,53
More concretely our current research answers give rise to multi-factorial associations between each factor and a given outcome/ outcomes of interest. In cohort studies we get Fig. 6.1.
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Outcome 1
Outcome 2 Outcome 3 Exposure Outcome 4
Time Flow
Fig. 6.1: The exposure outcome relationship in a cohort study
While in case-control studies we get: Fig. 18.

Exposure 1 Exposure 2 Exposure 3 Exposure 4
Outcome
Time Flow Fig. 6.2: The exposure outcome relationship in a case-control study
The questions is can we map the information on associations and link them up so that we can see visually the interaction between exposures and outcomes i.e. a multi-part web of causation. I think so, and a general example of one part of this kind of map is shown in Fig. 6.3.
Fig. 6.3: Visual mapping of one set of exposure, morbidity and mortality associations Exposure 3 Exposure 2 Exposure 1
interactions between exposures association between exposure & morbidity Morbidity 3 association between morbidity & mortality
Exposure 4
Morbidity 1
Morbidity 2
Mortality
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7. Theories
Theories are not about truth, they are about explanation and must be judged by their utility. all theories are wrong which promote, justify, or tolerate injustice.
75 40
Going back to Chapter 1 Fig. 2.1 the levels of explanation and knowledge in science was framed in terms of the discovery-production of empirical laws and laws of nature. Stretching these ideas we could say that association in epidemiology are analogous to empirical law while causation is analogous to laws of nature in the physical sciences. Of course the degree of provisionality in epidemiology is overall much greater than that in the physical science.
There are two important issues to be considered here: first as stated in the background summary Krieger has argued for the development of epidemiologic theory and secondly on attempting to integrate and fit together the current theories of health and disease into a coherent framework.
7.1 Conceptual and axiomatic foundations of Epidemiology

There has been some work done on systemising epidemiology and providing some conceptual and axiomatic foundations by Lower . Lower and Karanek then go on to develop a unified criteria of causality applicable to infectious and neoplastic (chronic non-infectious) diseases that provide a different perspective from the more well known Bradford-Hill criteria
55,56 54
. Interestingly
they state four axioms and their corollaries that they feel are the foundations of epidemiology as shown in Table 7.1.
Table 7.1 Axiomatic foundations of Epidemiology
Axiom 1: Corollary 1: Presupposition 1:
Disease exists in human populations as a result of antecedent causes. Antecedent causes are actual and necessary. Antecedent causes occur as a result of cultural-environmental characteristics.
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Axiom 2: Disease is distributed non-randomly in human populations. Corollary 2: Non-random aggregations of disease are a manifested along axes of measurement in space and time and in relation to cultural-environmental and host biological characteristics. Variations in the incidence of human disease occur in response to variations in the intensity of exposure to causal agents and/ or variations in the susceptibility of individuals to the operation of those causes.
Presupposition 2:
Axiom 3: Disease is manifested non-uniformly in individuals in relation to variable underlying processes and mechanisms of pathogenesis. Corollary 3: Disease processes and mechanisms are initiated by actual and necessary interactions of causal agents with host tissues and are manifested over a spectrum of host responses in relation to cultural-environmental and host biological characteristics. Variations in the severity and extent of human disease occur in response to variations in the intensity of exposure to causal agents and/ or variations in the susceptibility of individuals to the operation of those causes.
Presupposition 3:
Axiom 4: Disease is not necessary in human populations. Corollary 4: Disease is preventable by intervention with cultural-environmental determinants of the existence and/ or degree of risk, and/ or intervention with host biological determinants of susceptibility. Antecedent causes occur as a result of cultural-environmental characteristics.
Presupposition 4:
7.1 Frameworks for Theory

In general the types of listing of theories of health and disease or influences on health is given in Table 7.2 described by MacCarthy . MacDowell shows a framework that is similar see Fig. 7.1 . Krieger describes MacKeowns evolution, adaption and man-made environment framework and its counterpart that explores the areas not covered by MacKeowns framework social and political determinants framework that emphasise the political economy of health and the social production of disease . While Pederson has attempted a chronological view of the types of theories that have emerged over the last century or so .
59 17 58 57
Table 7.2 Four major influences on health 1. Genotype/ inherited health potential or human biology = internal aspects 2. Individual behaviour/ lifestyle 3. The socio-economic and physical environment = factors outside the body over which the individuals has little control. 4. Health and medical services or the health care system.
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Fig. 7.1 Influences on Health and Disease (MacDowell ME, 1987)
However the attempts at a framework in table 7.2 and Fig. 7.1 concentrate on the individual rather than the population level and are not an attempt to look at and see how we might fit together the various theories of health and disease and examine how they might be seen as parts of a coherent whole.
Looking at the Table 7.2 specific factors like genotype are listed with the wide all-encompassing factor of the socio-economic and physical environment. As Tesh has criticized what exactly do we mean by the social or economic environment. What parts or aspects of it are causing a specific disease?
32
A first step would be to list the kinds of theories that are currently in use and
are acceptable, this I have briefly attempted and is shown in Table 7.3
Table 7.3 Partial list of some of the theories about health and disease Genetic Lifestyle Physical Environment Social Environment Mutation Germ/ infectious agent Health Care Provision Social production of Disease Biomedical Psycho-social Bio-cultural Transition theories Early Life programming Life events Adaptation Unknown
These are just the standard theories there are also more speculative ideas such as Antonovskys theory of complexity, conflict, chaos, coherence, coercion and civility or Barke and
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Potters ideas about freedom and responsibility
. Unfortunately there is not time or space to
give a brief summary of each of these theories and attempt to look at them in a more systematic and coherent manner. However the complex systems framework-model could be used to see at what level specific theories are acting and how they link the various levels. As an example psycho-social theories of disease link social organisation and environment with biological processes through the means of psychological processes such as stress.
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8. Mathematical Models
Again I will touch upon this element only briefly. This area includes the modelling of infectious disease transmission from malaria to AIDS as well as newer integrated systems- and scenariobased modelling such as those for climate change impacts on malaria transmission and increases in skin cancer rates from ozone layer depletion. A conceptual representation of a modelling framework for looking at the impact on population health of climate change is shown in Fig. 8.1 .
62
Fig. 8.1: Conceptual representation of the modelling framework for the health impact assessment of man-induced atmospheric changes (MIASMA)
The most important consideration in the development of mathematical predictive models is the underlying cumulative increase in uncertainty at each step in modelling process see Fig. 8.2 .
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Fig. 8.2: Layers of uncertainty underlying climate change impact assessment.

(due to the complexity and range of relationships and connections within and between the dynamic complex systems that have an impact on health)
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9. Environmental Health Frameworks

9.1 Definitions of the Environment and Environmental Health
The environmental health framework (generally the health framework) element straddles both the research and the policy area. Research probably has the greatest impact on policy in that it can assist in the development of a knowledge-based framework for policy development. However this is at the very least a diffuse and crooked pathway if not deeply problematic process
15,64,65
In this section I will concentrate here on frameworks for environmental health. Environment has been defined in as many ways as there are disciplines working on the subject see Fig. 9.1 .
66
Fig. 9.1: Layers of uncertainty underlying climate change impact assessment.
McMichael has described the environment as minimally being the physical and chemical conditions in the living space around us such as the quality of local urban air, freshwater supplies and the concentrations of chemical residues in food while a more broader definition includes the conditions of the social environment ... encompassing housing quality, transport, recreational amenities, population density, social networks and political and distributive equity .
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Moeller has defined the environment into four categories : the inner vs. outer environments, the personal vs. ambient environment, the solid, liquid, and gaseous environments and the chemical, biological, physical and socio-economic environments.
Eyles has argued that definitions are about core values and life concerns, hence environment can be seen be viewed from three perspectives: cosmic (where there is a magical and mystical relation between environment and gods to ensure harmony and order in the cosmos); machine (where there are interdependent, repairable parts the stability of which is ensured by their predictability); and the organic (argues for a dynamic self-regulatory entity the health of which is determined by a balance of diverse elements and encompasses the ecosystem perspective) .
40
Similarly environmental health has been defined in diverse ways. Eyles describes environmental health as the health and wellbeing of human populations in specific environments (physical, social, and societal).... the relationships between environment and health are multi-directional, and that just as environments affect human health so too do issues of human health and wellbeing affect environments.
40
One of the WHO definition of environmental health which includes these words environmental health includes .the effects (often indirect) on health and well being of the broad physical, psychological, social and aesthetic environment, which includes housing, urban development, land use and transport and goes on to say the environment should be considered as a resource for enhancing health and well being. People aspire to live in communities free of environmental hazards, with decent homes in which to raise their families, with opportunities for employment, education and culture, and with pleasant and harmonious surroundings that facilitate recreation and social intercourse. Effective environmental protection in its widest sense, provides a framework for many of these aspirations as part of enlightened and sustainable socio-economic development.
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Definitions are important in framing issues and in giving a complete global perspective of what a concept means and what is aimed for. Having a broad context then allows a narrower strategy to be followed without the loss of perspective on the critical issue.
Eyles shows a particularly interesting example of this because he then proceeds, using a medical geographic perspective, to develop five building blocks through which we can look at the relationships between environment and health as shown in Table 9.1 .
40
Table 9.1 Five integrated building block for environmental health knowledge and research BUILDING BLOCK
1 Language & Perception
ONE USEFUL THEORY

Symbolic Interactionism
ILLUSTRATIVE EXAMPLE
Risk, Anxiety, Uncertainty Lay beliefs and actions in everyday life Conceptual & Material Domination Functioning Environments
ONE SUGGESTED RESEARCH TOPIC

Language & perception of environmental risk Living in a stigmatised community Environment & Health
Agency & Negotiation
Structuration
Structure & Power
Structuralism & Poststructuralism Functionalism
System Integration
Consensus & conflict in environmental health policy Connecting ecosystem and human well-being
Ecosystem & Wellbeing
Ecologism
Environmental quality definitional questions
9.2 Existing Frameworks and Potential Limitations

Quantitative Risk Assessment (QRA) and management is the cornerstone of much work in environmental health. It is an important and valuable technique however there is a need for a broader framework that encompasses QRA and goes beyond it . ORiordan has described one way of looking at how the risk assessment and management process works .
71 70
This is where the complex systems framework-model described earlier is likely to help as there seems to be at the very least some confusion if not lack of a coherent framework in current work in environmental health as exemplified by the WHO summary document Concern for Europes Tomorrow . Perhaps it is a little unfair to take look at the subheadings of two sections of the document namely Effects on Health of Environmental Exposure and Environmental Exposures however they are instructive in highlighting some contradictions and perhaps
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deficiencies in existing frameworks see Fig 9.2.The WHO is an important international health agency and as such its ideas and documents have a high degree of credibility, distribution and impact around the world.
Table 9.2: Subheadings in two sections of Concern for Europes Tomorrow Summary Document Effects on Health of Environmental Exposure Priority Issues Environmental Exposures
Cardiovascular disease Cancer Respiratory Diseases Communicable Diseases Injury & Poisoning Nervous System & Mental Disorders
Lack of information about environmental health
Air Quality Water Supply & Quality Waste & Surface water Wastes Contamination of food & drink Selected Chemicals Ionising Radiation Non-ionising Radiation Residential Noise Housing & the Urban Environment (aspects of exposures presented earlier in table)
Microbiological contamination of water and food
Air Pollution Road Traffic Housing & Urban Development Transboundary Issues
Musculoskeletal Disorders Birth Defects & Reproductive Effects
Wellbeing Effects on health of nonenvironmental factors
Occupational health Accidents & man-made disasters (psychological overload) (physical workload/ ergonomic conditions) (allergens)
There seems to be three important problems with this listing which makes it contradictory and perhaps shows that a coherent framework was not followed. The first point is that air quality and water quality are mixing two issues together. The chapter is on environmental exposures and hence on the whole should either be a listing of specific exposures that are hazardous to health that produce the specific conditions mentioned in the earlier chapter on Effects on Health of Environmental Exposure or be broader-based social, economic, and political exposures and
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their more indirect effects. Air and water quality is actually talking about contaminants in air and water rather than the natural components of the air and water being hazardous. Hence perhaps a better framework could have been the one outlined below in Fig. 9.2.
Fig.9.2: Revised layout and framework for looking at the effects of environmental exposure
TYPES OF EFFECT Cardiovascular Disease Cancer Respiratory Diseases Communicable Diseases Injury & Poisoning Nervous System & Mental Disorders Musculoskeletal Disorders Birth Defects & Reproductive Effects Wellbeing
Effects on health of non-environmental factors
ROUTE OF TRANSMISSION Air (pollution) Water (contamination) Soil (contamination) Food (contamination)
TYPE OF EXPOSURE Selected Chemicals Ionising Radiation Non-ionising Radiation Residential Noise (psychological overload) (physical workload/ ergonomic conditions) Housing & the Urban Environment (aspects of exposures presented earlier in table) Occupational health Accidents & man-made disasters (allergens) Waste
SOURCE OF EXPOSURE Manufacturing Industries Service Industries Agriculture & Agricultural Practices Transport Usage
However, this still leaves the second more important point that radiation is considered in the same breath as housing and the urban environment i.e. complex issues like housing and urban environment seem to be reduced to the same level as dealing with radiation exposure. Clearly they are not in any sense a similar level or type of exposure because housing and urban environments covers a diverse range of factors social, political and economic that impinge on health. The question is why was this done?
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There could be two general answers, firstly that environmental exposures are not being seen in a coherent ecological and complex systems framework and/ or secondly that political factors are implicated in the broader determinants of environmental exposures and that this was a roundabout way of dealing with this fact. These could be internal WHO factors or more general international political factors.
Thirdly, in the list of priorities though mention is made of lack of information on environmental health no mention is made of a framework for it. So no framework is suggested either for the information that would allow for a proper and adequate use and assessment of the value of the information. Nor in the broader terms of a framework for creating policy and managing environmental health intervention programmes. An example of an informational framework is shown in Fig. 9.3 and one for developing, managing and more broadly looking at environmental health programmes is shown in Fig. 9.4
72,5
Fig. 9.3: Framework and concept of the environmental health matrix
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Fig. 9.4 A systems-based view of environmental health
9.3 A Complex Systems Framework

The general complex systems framework-model can act as a primary framework for environmental health and this is shown by the framework already developed by Schaefer see Fig. 9.4. What is interesting is that there seems to have been no development of Schaefers perspective since he first described it . This framework echoes the structure of the complex systems framework-model described earlier and hence can and should be developed further and is likely to provide useful insights into environmental health issues and problems at the research and intervention levels.
73
However environmental health also involves policy-makers and communities in its work and Schaefers framework is likely to be too complex to use when communicating with these groups in the policy framing and formulating process. Hence a simpler version of this framework can be
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developed from the complex systems framework-model which is shown in Fig. 9.5, Fig. 9.6 and Fig. 9.7.
Fig. 9.5: Two-dimensional version of the complex systems framework-model
Figs. 9.5 shows in simpler form the way local ecosystems, societies and cultures are embedded within larger global systems and this links to Fig. 9.7 (page 43) which shows the systems that need to be considered when assessing environmental health at a local and global level.
Fig. 9.6: Simple framework-model of the interactions between natural systems, social systems and cultural systems
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Fig. 9.6 describes graphically how natural landscapes (in terms of geography, etc.) shapes natural ecosystems which in turn shapes geophysical cycles and evolutionary processes. While social landscapes shape social systems which in turn shape social, economic and political cycles and cultural landscapes (in terms of ideas and worldviews, etc.) shape cultural systems and in turn human development. The connections also show how these levels are interconnected and affect each other so that natural landscapes and geophysical cycles can shape social and cultural landscapes and geophysical cycles and vice versa
Fig. 9.7: Simple systems-based view of environmental health WIDER CONTEXT
Individual and Population Health Impacts
Values CULTURAL Ethics Worldview
Ideas Knowledge Wisdom
Beliefs Ideology Religion
SOCIAL
Social Infrastructure Urban-Rural Political System Power Relationships Wealth distribution Education Transport Systems
Economic Infrastructure Industrial Agriculture

Manufacturing
Health Services
Technology
Services
NATURAL
Flora
Ecosystems
Air
Geo-physical Systems Fauna Water
Humans
Land
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A proper development of Schaefers framework or my own simpler version is beyond the scope of this present projects but I do feel that the merits of a systems-based perspective are clear especially in visualising interconnections and hence in the communications and interactions of researchers, policy-makers and communities with each other.
Using a common framework across research, policy-making and affected community boundaries can ensure that each set of actors in the process see the differing but valid perspective of the other actors. Hence there is likely to be less misunderstanding as the views of each of the participants can be taken into account. This is likely to lead to greater trust and cooperation between actors and stakeholders and perhaps more importantly it also begins to educate policy-makers and communities about the complexity, difficulties and hence limitations of research and hence its provisional nature.
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11. Conclusion
the facts of disease must be related to each other in such an orderly way as to establish a theory or philosophy of disease; and as this theory must be consistent with all the accepted principles of the broader natural philosophy into which it is fitted, epidemiology must come into relation here with the whole field of natural science...
54
Usually, the conclusion is the place where all the different stands and ideas in a project, article or book are tidily brought together and tied up in nice, neat package. My aim has not been to produce a set of neat and tidy ideas and explanations that explains epidemiology and health that raises no questions or has no weaknesses. Clearly this is impossible given the range and complexity of the discipline. Rather my intention has been to describe and produce a coherent and rigorous argument for an epidemiological perspective that encompasses many aspects of environmental epidemiology and environmental health which can at times appear as useful but fragmented and disparate methods and ideas.
Keeping Lewis Wolperts admonition firmly in mind that science is not commonsense or intuitive at least in the lay sense of these terms and that science is more like uncommonsense and nonintuitive . The perspective that I have developed in this project most closely matches my own intuitions and insights into the process of epidemiology and how a broader way of looking at and exploring the nature of health and disease in environmental epidemiology could be envisioned.
74
The easy part is to set the ideas down on paper, the much harder part is to see if these ideas have practical value. That is likely to come only with time.
My argument has been that the process of epidemiology, of how it works, is broader than the framing and testing of hypotheses to elucidate associations. That concepts-definitions as well as metaphors-frameworks-models have a much greater impact than is realised on the process of epidemiology and the type and nature of research we undertake and the research questions that we ask. That qualitative framework-models are important in science in general. They have value in giving insight both on a theoretical and practical level by helping us to visualise our concepts and definitions as well as later forming the basis for our mathematical models of nature. Hence
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an expanded framework-model of the web of causation is possible and one possible idea is the complex systems-based framework-model described in this project. This could act as a primary framework for both research epidemiology and environmental health. Lastly, a systems-based framework is likely to provide us with greater insight than our current frameworks and models especially in environmental health.
Id like to end this project by providing a complex systems or network view of science. All scientific disciplines are connected to each other. Some of these connections and relationships are strong, thick, important and long-standing. While others are tenuous, strand-like, trivial and short-term. These connections are dynamic and changing over time and the boundaries between disciplines is fluid and overlapping. This applies equally to areas within a particular discipline.
Hence if we focus on one particular discipline in this network of knowledge we find that it can look like being at the heart of all other areas of knowledge. However if we move and focus in on another discipline then that area looks like the centre of this universe of knowledge. This does not mean that all disciplines are alike. Some disciplines have a larger domain, their knowledge may be more certain, some may be the basis for other disciplines, or may even fit within a larger discipline whilst others will have more important consequences for us as human beings than others.
So scientific disciplines, including environmental epidemiology and environmental health, cannot be seen as distinct and separate domains rather they are amoeba-like amorphous entities that expand and contract and overlap with other areas of knowledge. They interact and are shaped by the other areas of knowledge around them. Boundaries and knowing where the overlaps are is important to allow us to focus on specific areas but we need to remember that they are not fixed and immutable structures and that we can and oft times need to change them.
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Salim Vohra 1996-97