Is organic agriculture a potential public health indicator? Evidence from literature

3.1 Literature overview

3.2 Outcomes from search in online databases

By researching in online databases, several documents about organic agriculture (Figure 1) were found. However, when we refined our search, by combining the keywords ‘organic agriculture’ and ‘organic farming’ with ‘health,’ the number of results substantially decreased. The word ‘indicator’ was also added, leaving us with zero results (zero published papers) in two databases, PubMed^® and Scielo.

Figure 1

Results found in four online databases according to specific keywords.

Several results including the word ‘indicator’ were found in b-on and ScienceDirect databases. When we carefully analyzed each result, we realized that the publications did not refer to the concept of ‘organic farming’ as a ‘health indicator,’ as we were looking for. The results found were mostly about ‘soil health indicators’ or ‘environmental health indicators,’ instead.

Some documents and reports that integrate statistical information and/or relevant strategies focused on recent and future developments in the field of organic agriculture in different countries and regions have been published. Some of the most relevant are presented in Table 2.

In 2008, Hamm proposed a conceptual frame with four dimensions of healthy, livable communities: farming, economics, environment, and health. According to this author, in the agricultural dimension, it is proposed to maintain a diversity of cultures to shape the landscape; in the economic dimension, the existence of interconnected rural and urban communities stands out, assisted by networks of small business owners, instead of rural communities with financial problems; in the environmental dimension, the maintenance of natural resources for future generations is highlighted; and finally, in the health dimension, the maintenance of quality of life throughout the life cycle is emphasized and not only the concern in the treatment of the disease. In the conceptual model presented by Hamm (2008), there was no clear possibility of considering organic farming as an indicator of health. However, the author shows two case studies from Michigan (USA), that identify opportunities to link agricultural production opportunities directly to dietary orientation and public health issues, while also encompassing notions of community and economic development and environmental sustainability.

3.3 Health indicators

An indicator is a measure used to express the behavior of a system or part of a system. Indicators are largely used in the public sector for performance management of public health (Flowers et al. 2005).

The 2018 revision of the Global Reference List of 100 core health plus SDG (Sustainable Development Goal) related indicators (WHO 2018a) contains a selection of priority indicators relating to four domains that comprise risk factors, health status, service coverage, and health systems. Across this document there is a lack of organic agriculture and its possible contribution in health promotion or maintenance.

Health indicators are measures of health and of the factors that influence health. They can be used to manage the health care system, to improve our understanding of the broader determinants of health, to identify gaps in the health status and outcomes for specific populations, and, finally, to provide information to health policy.

Although there are countless indicators that could be calculated, the challenge is to find the most important to measure and track; what types of indicators best show the needs of those who use them; which of the present indicators are no longer relevant and may therefore be discarded or replaced by more appropriate measures; and lastly, how can the cross-cutting dimension of equity be addressed in the assessment of the indicator set (CIHI 2009). In Table 3, health indicators from Canada but which are also adopted by Portuguese DGS are presented.

Organic agriculture, if seen as a health indicator, could be included as a “Non-medical determinant of health,” inside the categories of “Health behaviours,” and/or “Living and working conditions” and/or “Environmental factors.”

In fact, there is substantial evidence on the influence of consuming organic products in health status (Vigar et al. 2020). Moreover, a report of the European Parliament (2016) about human health implications of organic food and organic agriculture referred that epidemiological studies underline negative effects of some insecticides on children’s cognitive development at current levels of exposure. Those risks can diminish with organic food, particularly during pregnancy and in infancy.

In another perspective, there are studies that showed the link between working conditions of organic farmers and their health condition. Recently, in a systematic review, Maas et al. (2020) showed that despite the absence of technical assistance and appropriate technology, there is an increase in job satisfaction and an improvement in the health of the family, enhancing the quality of life.

Since the implementation of EC Reg. 2078/92, the EU promotes organic farming based explicitly on its positive effects to the environment. The environmental impacts of organic farming are landscape, soil, ground and surface water, and biodiversity (Stolze et al. 2011). Organic products reduce public health risks to farmworkers, their families, and consumers by minimizing their exposure to persistent and toxic chemicals in food, on the farm, soil, air, and water.

Moreover, the development of short food supply chains, where the intermediaries between organic farmers and the consumers are less or even inexistent, is also beneficial. This can be achieved by the creation of local markets that give the consumers a better access to fresh and seasonal products, also having a smaller impact on the environment, because of the smaller distances of transportation (Lopes et al. 2019; Guilherme 2020; Jarzębowski et al. 2020; Tankam and Djimeu 2020). For the first time, The Common Agricultural Policy focused on the short food supply chains, during the current funding period (2014–2020). Local producers can now be supported by the European Agricultural Fund for Rural Development.

3.4 Organic agriculture as a potential public health indicator

An original pictorial conceptual model, which intends to suggest that organic agriculture could be a public health indicator, was developed, which is shown in Figure 2.

Figure 2

Proposal of organic agriculture as a public health indicator.

According to Mondino (2014) and Sayão (2001), models are fundamental entities in scientific and pedagogical practice and are helpful to investigate complex phenomena from which there isn't complete understanding. Moreover, the conceptual model building consists of choosing the system parts and the relationships that link these parts, specifying how the parts interact and identifying missing information (Tilden et al. 2013).

The central figure of this model (Figure 2) is represented by a rocker, based on the simple lever theory of Archimedes. Archimedes, a Greek physicist and mathematician, was responsible for one of the most important inventions, the use of levers to move heavy loads. He became famous with the phrase “Give me a lever and a point of support and I will raise the world.” The swing or lever is directly linked to the concept of balance; advance or promote development (Heath 2002).

1. Levers are made up of three fundamental elements:

   • Fixed or support point, around which the lever can turn, which is represented by the sustainability triangle that rests on the balance, between the three pillars that compose it, that is, ecologically balanced, economically viable, and socially fair. In fact, the principles of Health, Ecology, Fairness, and Care are the roots from which organic agriculture grows and develops (IFOAM 2020).

   • Potent force or potency, exercised with the objective of lifting, sustaining, and balancing, which is represented by organic agriculture.

   • Resistant force or load, exerted by the object to be lifted, supported, and balanced, is represented by public health.

2. Organic agriculture positively influences public health. The strength exerted by organic agriculture will raise the public health “flag” higher. The globe of organic agriculture represents the biosphere (sphere of life). The biosphere is formed by all living beings present on the planet Earth. It contains soil, air, light, food, and all the necessary elements for the development of life. The green color symbolizes nature. Around the globe, farmers and family farming are represented. Farmers have a fundamental role in society, as they produce food that is intended to be safe and of high quality; and they also have the important role of taking care of the natural resources (e.g., functional diversity, water resources, and crop diversity, i.e., landraces and germplasm that can be used for breeding and selection for organic) helping to fight climate change and emphasize cultural elements (e.g., landscape, gastronomy, traditions, and architectural elements).

3. The public health “flag” represents the resistant force or the load that is dependent on the strength or energy of organic agriculture, i.e., investment in organic farming promotes the improvement of public health. The yellow color symbolizes health. Together, with the public health banner, there is a society that includes farmers (producers) and consumers of all ages. Who benefits with organic food? The farmworkers, because there is a reduced pesticide exposure in organic agriculture; the consumers, because there is some evidence proving the increased nutritional quality and reduced pesticide contamination in organic products; and, finally, it is proven that children living in areas with high pesticide use are at a great risk of health effects, because of their high susceptibility to pesticides. We should not only look at pesticide residues in food as a measure of exposure, as, although some foods do not have high final levels of residues, they were produced using pesticides and this exposure put the farmer’s health at risk. Pesticide use in production and the farmworker exposure are important issues to consider, while looking at the whole pesticide problem. A shift to organic agriculture is the key to eliminate toxic pesticide exposure. The green background, present in the entire image, symbolizes nature (refers to the set of living beings and phenomena that occur naturally), hope, balance, and ecological awareness.

This model aims to provide a representation for the organization of the relationship, in a macro view, between organic agriculture and public health, supporting the view of organic agriculture as a health indicator, based on different aspects, such as:

• Organic agriculture is identified with the concept of sustainability. It is concerned with the management and sustainable use of natural resources, in promoting equality and social justice, not only focusing on the economic model (Newton 2004; Lichtfouse 2010). In fact, according to the principle of fairness, organic agriculture should build on relationships that ensure fairness regarding the common environment and life opportunities (IFOAM 2020). The Rodale Institute (Rodale 2011) has been, for 30 years, conducting a long-term comparative Farming Systems Trial. Starting in 1981, the Rodale Institute began studies comparing organically fertilized fields and conventionally fertilized fields on its 330 acre farm in Pennsylvania, USA. The main results reported were as follows: (i) organic farming systems improve soil organic matter, making it a more sustainable system; (ii) organic farming uses 45% less energy and is more efficient; (iii) conventional systems generate 40% more greenhouse gases; and (iv) conventional farming systems are less profitable than organic systems.

• Organic family farming is a sustainable production strategy that promotes the food sovereignty and nutritional security of the populations. It contributes to the social dignity of farmers; it reduces environmental risks related to food production and therefore it should be considered an important factor that promotes public health. Organic farming encourages healthy products, biodiversity, and genetic resources used to tackle with climatic changes, pest, and diseases and resilience (Nandwani 2016; Chable et al. 2020). In addition, there is a positive contribution to rural development through training in organic farming (Guiné et al. 2015).

According to Reganold and Wachter (2016), organic farming systems produce lower yields compared with conventional agriculture. Nevertheless, they have social benefits, are more profitable and environmentally friendly, and bring equally or more nutritionally dense foods that contain less (or no) pesticide residues, against conventional farming. More recently, Costa et al. (2020) published a book with the compilation of several works conducted about the bridges between family farming and organic farming. According to this publication, the success of family farming explorations may involve adopting production methods such as organic farming, based on principles such as feeding the soil, optimizing nutrient cycles through the management of animals and plants in space and time, or maintaining close relationships with the market, to guarantee product quality and to ensure the improvement of household income. There are several success cases focused on building bridges between family farming and organic farming, integrating the principles of organic farming in the logic of production and contributing to its technical and economic improvement (Auerbach et al. 2013; von Dach et al. 2013; Jouzi et al. 2017). Furthermore, some projects were developed about family farming and organic farming. For example, the ECONewFARMERS project was a partnership with different countries, such as Portugal, Hungary, Spain, Italy, Turkey, the United Kingdom, and Slovakia, focused primarily on improving the quality and performance of education and vocational training to strengthen the European dimension in organic farming (Correia et al. 2017).

• The Mediterranean dietary pattern (Mediterranean Diet, MD) shares the principles of organic agriculture, generating a potentiating effect on all pillars of sustainability, public health, and, consequently, health gains. Being a dietary pattern, whose offer is mostly of plant origin (Willett et al. 1995), environmentally friendly, local, and incorporating a high diversity of seasonal products, it responds to many of today’s concerns about food production, distribution, and consumption. Although the relationship between human diet and health is benefited by this dietary pattern, according to several epidemiological studies carried out in the last 50 years, this dietary pattern presents other perspectives that can be evidenced: food as a cultural activity and a decisive factor in protection of the environment (Graça 2015). Several studies show that a dietary pattern inspired by MD principles is associated with numerous health benefits (D’Alessandro and De Pergola 2018; Galbete et al. 2018). Moreover, there is a relevant evidence from different countries that organic food consumers have a healthier eating pattern (Kesse-Guyot et al. 2013; Bradbury et al. 2014; Torjusen et al. 2014; Eisinger-Watzl et al. 2015).

• Healthy eating is an essential condition for disease prevention. If we consider, in the concept of healthy food, the socio-environmental perspective of organic farming and the exemption of synthetic chemicals, it is certain that organic food promotes health and quality of life. In fact, “Health” is reported as the foremost reason why consumers purchase organic food in an overwhelming majority of studies reviewed (Zanoli and Naspetti 2002; Lockie et al. 2004; Hughner et al. 2007; Brantsaeter et al. 2017; Apaolaza et al. 2018). Possibly, the most evident public health benefit from the consumption of organic food is the reduction of pesticide exposure and the risk of neurodevelopmental deficits, cancer, and other adverse health consequences that can be triggered, or worsened, by pesticide exposures (Baker et al. 2002; Smith-Spangler et al. 2012; Brantsaeter et al. 2017). In addition, also with great apprehension is the widespread use of antibiotics in conventional animal production as a promoter of antibiotic resistance in society (Mie et al. 2017), whereas in organic agriculture its use is much more restricted.

On the contrary, other studies showed a positive influence on the health effects of organic food in humans, namely, reduced risk of pre-eclampsia, prevention of pregnancy malformations, less allergies incidence, lower body weight and prevention of obesity, lower risk of eczema in children, inhibition of the development of cancer cells, and more resilience (Huber et al. 2011; Kesse-Guyot 2016; Barański et al. 2017). Furthermore, nutritional quality improvement of several organic food versus conventional, such as passion fruit, apples, milk, and meat, has been shown in recent publications (Oliveira et al. 2017; Popa et al. 2019).

1. The rural environment must be a space that promotes health and healthy lifestyles, with the potential for producing quality food, free from toxic products, with respect for the environment that will be reflected in the health and quality of life of the rural and urban population (FAO 2019). Public health policies are responsible for creating programs to promote healthy eating, to guide the consumers, without forgetting the fundamental farmers’ role, who are at the base of the entire food production chain, producing food, who are intended to produce quality food, making a valuable contribution to society and favorably influencing public health.

2. Scientific evidence allows us to state that organic agriculture is a sustainable strategy for promoting public health, which is why the inclusion of organic agriculture as a health indicator in the group of health determinants is proposed. Organic agriculture is a health promoter; therefore, we are proposing organic agriculture to be a health indicator, belonging to the group of health determinants, with the intention of planning, developing, and implementing public health policies adjusted to the needs of the population and obtaining health gains. Health promotion is based on the improvement of health status, and also by improving the quality of life and well-being and disease prevention. It is, undoubtedly, one of the essential pillars of health promotion. Health promotion and quality of life are inseparable factors. We cannot have a good quality of life without health (Sícoli and Nascimento 2003). The Health 2020 Strategy emphasizes the role of promoting the raise of healthy environments and resilient communities, in achieving health gains and reducing health inequalities. The actions to be developed must consider the relevance of the environment to health in general and throughout the individual and family life cycle, as well as specific environments, considering environmental or occupational factors. It is essential to empower people to learn throughout their lives, preparing them for their different stages and to cope with chronic illnesses and disabilities (WHO 2013). These interventions must take place in schools (Botelho and Lameiras 2018), at work, and community organizations, such as urban agriculture and social farming (Lohrberg et al. 2016), to reach the maximum number of citizens (WHO 2013).

3.5 Organic agriculture in Portugal

In Portugal, according to data from Directorate-General for Agriculture and Rural Development (DGADR 2019), in 2018 the agricultural area used in organic farming was 2,13,118 hectares, which corresponds to a decrease of 16% compared to 2017. In 2018, another 251 new operators were recorded in relation to 2017, reaching a total of 5,905. Producers increased and stayed at 5,213, with 539 new farmers. The interest in organic aquaculture must be highlighted, with 11 new operators registered in this sector. In relation to crops, in 2018, pastures (58%), forages (14.2%), and arable crops (1.3%) represented 73.5% of the total organic farming area. However, in global terms, and compared to 2017, the total area of these crops decreased by 0.8%. These crops are used for animal production. National production for human consumption remains low, occupying about 25% of the total area of organic production. The olives (8.3%), dry fruits (7.85%), grapes (1.71%), vegetables (1.55%), and citrus fruits (0.12%) stand out. Regarding products of animal origin, the number of animals in 2018 increased 5.6% compared to 2017, especially in poultry and cattle, with a drop in sheep production.

In the public consultations carried out within the scope of the creation of the National Strategy for Organic Agriculture, more than 50% of the Portuguese said that they intend to consume organic products, especially fruits, vegetables, cereals, legumes, dairy products, and some meat (ICS/UL 2019). Portugal has a National Strategy for Organic Agriculture (ENAB) and the Action Plan (PA) 2017–2027 that needs to be promoted and implemented, but financial resources have been lacking to carry them into practice. Despite these difficulties, the following fruits from organic production were recently integrated into the scholar fruit and milk regimen: apple, pear, clementine, tangerine, orange, banana, cherry, grapes, plum, peach, carrot, and tomato. An increase in the payment of products from quality certified schemes is granted, namely organic production, according to budget availability.

The Resolution of the Council of Ministers No. 110/2017 of 8 June created the National Observatory of Organic Production through which it is intended to collect, process, and disseminate in a portal on organic agriculture, of free access, the information available on production, transformation, and commercialization of organic products, including their consumption and the various existing markets. Moreover, the creation of the Competence Center for Organic Agriculture and Products in Organic Production (CCBIO) in 2017 based on the same Resolution was crucial. Then, in 2018, this Competence Center was modified into an Association, and nowadays it brings together 35 partners at a national level, and it is focused on production and dissemination of scientific and technological knowledge that contributes to the robustness and sustainability of the sector either through innovation or through the contribution to the resolution of some constraints (CCBIO 2020).

According to Ferreira (2020) from Agrobio (Portuguese Organic Agriculture Association, created in 1985), there are some key actions that should be implemented in the future: (1) increase national organic production; (2) encourage specific technical support for organic agriculture; (3) promote, raise awareness, give recognition and information about organic production; (4) allocate financial resources to the full implementation of the National Strategy for Organic Agriculture (ENAB) and the Action Plan (PA) 2017–2027; and finally (5) integrate organic agriculture into the future Common Agricultural Policy.

We can conclude that in Portugal there is a great opportunity for the increase in organic production (including aquaculture) in the next decades, and the attention in organic food consumption is growing. This interest in demand by consumers needs a strong coordination among different sectors such as producers, certification entities, governmental and public organizations, and consumers sharing a common interest about organic products, i.e., a multisectoral approach is needed.

The institutions and social actors identified, considered as potential agents of public health, are the Government and the Municipalities; the National Health Service; the Social (as Private Institutions of Social Solidarity) and Private Health Sectors; Education, Science and Research institutions; Environmental Protection Organizations; Associations of Professionals and Citizens; Non-Governmental Organizations; Pharmacies; the Business Sector; Non-Organized Citizens and the Media, among others (DGS 2016). The Government Programme establishes as a priority the promotion of health through a new ambition for Public Health, underlining that, to achieve health gains, it must intervene in the various determinants in a systemic, systematic, and integrated way. The National Health Plan 2012–2016 – Review and Extension to 2020 (DGS 2015) reinforces the citizen’s position in the center of the health system and has, as strategic axes, citizenship in health, access and equity, quality, and health policies.

As a strategy, investments are made in strengthening citizens’ power and responsibility in contributing to the improvement of individual and collective health, by promoting literacy in health, in a culture of proactivity, commitment, and self-control (training/active participation) for maximum individual and individual responsibility and collective autonomy (empowerment) (DGS 2015). Within this perspective, if organic agriculture makes an evident positive contribution to health, then its inclusion as a public health indicator will be of great interest, benefiting everyone.