Environmental Awareness in Wound Care

Louis Pasteur (1822–1895), generally considered the father of bacteriology and the germ theory of disease,¹ is purported to have said, “The microbe is nothing. The terrain is everything.” Another famous French scientist and Pasteur’s contemporary, Claude Bernard (1813–1878), wrote extensively about the importance of a balanced internal environment (homeostasis) to keep disease at bay, suggesting that social homeostasis supports bodily homeostasis.² Fast-forward to the 21st century. After more than a decade of focus on individual germs, cells, and organs, realization is growing that the terrain — the external and internal environments — is indeed everything in the broadest sense of the word.

For example, appreciation for and new knowledge of the terrain in which cancer cells develop signaled the start of a new era in cancer treatments.³ Instead of focusing on external methods to destroy cells, new approaches harness the power of the body’s own immune system. With every cancer screening and treatment guideline update, the number of variables, including nontumor-related factors that should be considered, increases.⁴ Similarly, Bernard’s observation that social homeostasis supports bodily homeostasis appears to have been prophetic. Specifically, the biological wear-and-tear from chronic exposure to social and environmental stressors and/or their effect on epigenetic processes offer possible explanations for the observed effects of social determinants (environment) on health.⁵ The inverse association between social class and mortality from various diseases was first documented in the Whitehall studies conducted among British civil servants.⁶ Since then, a plethora of research has examined the underlying variables and confirmed these findings in developed and developing countries. In a study that examined the relationship between all-cause mortality and social factors, Galea et al⁷ found that in the year 2000, 245 000 deaths in the United States were attributable to low education, 176 000 to racial segregation, 162 000 to low social support, 133 000 to individual-level poverty, 119 000 to income inequality, and 39 000 to area-level poverty. These numbers are comparable to the leading causes of death that year from pathophysiological causes such as acute myocardial infarction (192 898) or cerebrovascular disease (167 661).⁷ This is not surprising, because morbidity associated with social determinants includes increased risk for the development of, among others, cardiovascular disease, type 2 diabetes mellitus, stroke, cancers, pulmonary diseases, kidney disease, and infectious diseases.⁸ 

Which brings us back to Pasteur, Bernard, and patients at risk for or who have chronic wounds, among whom the environment appears to be “everything.” Many have at least 1 of the chronic diseases associated with socioenvironmental determinants of health. Not surprisingly (albeit limited in number), wound care studies confirm the important role of the previously mentioned variables. Social support and self-efficacy affect venous ulcer recurrence rates, the odds of pressure ulcer development in spinal cord injury patients are significantly higher among persons with less education and lower incomes, and stress has been shown to significantly slow wound healing.^9-11 Considering the importance of environment, why are these variables not routinely considered in clinical practice and research in all specialty areas, including wound prevention and care? Many are easy to quantify, may improve our ability to plan care, can affect the efficacy of interventions, and remind us that while substantive and broad policy initiatives are the only way to reduce the deleterious effects of these variables on health, interventions to improve self-efficacy will make a difference. As 1 insurance executive recently observed, if 10% to 20% of a person’s overall health outcomes is directly related to health care while 30% is based on genetics and 40% to 50% is based on social determinants of health, the only way to lower utilization rates for direct health care is to address the latter.¹² 

That Pasteur and Bernand may have recognized the broader implications of terrain and environment is not merely a tribute to their genius; it is a reminder of the importance of holistic care and how the interconnectedness of humans to their immediate and extended environment can help or hurt health and well-being. 

This article was not subject to the Ostomy Wound Management peer-review process.