I brought up the Poverty/Lifestyle debate within a group of planners,
mainly within my current health region. Dr. Lawrence Green, author of
the Precede-Proceed model and several texts on health planning, has
offered comments and permission to repost on this listserv ...

> Dear Ron, nice commentary. I think you are right to draw the discussion of the upstream vs downstream determinants back from
> the brink of potentially self-defeating political rhetoric to a recognition that we must address all determinants, not just the upstream
> (distal), not just the downstream (proximal). The upstream-downstream debate, when pursued as an either-or choice is as
> self-defeating as the prevention vs medical care debate. We are not going to gain resources for prevention (upstream) by taking
> resources away from the sick people who need medical care.
>
> You also correctly note that contemporary health promotion planning and evaluation models are increasingly ecological in their
> recognition of social circumstances and other more distal determinants that must be incorporated as targets in the focus of
> intervention efforts. But most local health units have little authority and fewer resources to address most of the more distal social
> determinants. They have always had and always used to great advantage their authority and resources to address the distal and
> proximal physical environmental factors (chlorination and fluoridation of water supplies, regulation of emissions and water
> pollutants, solid waste management, control of vectors and food safety), as you well know from your own sanitation background.
> But to take just two of these, food safety protection upstream on the farms and meat packing plants is no substitute for restaurant
> inspections and other downstream interventions to prevent contamination of otherwise safe food, or water coliform testing to
>
> Raphael does us a service by encouraging more authority and resources for local health units and for provincial and federal health
> promotion programs to give greater attention to upstream social environmental determinants, as public health has had in
> addressing upstream physical environmental determinants. He might unwittingly do us a disservice if his arguments are taken as
> justification for taking resources away from our evidence-based, downstream interventions on lifestyle. Let us use the arguments
> to expand the scope of our programs, not to disparage the sincere, scientifically grounded and people-focused lifestyle intervention
> efforts of practitioners in local health units, medical care, school, and workplace settings.
>
> Much of the economic, poverty-focused argument re upstream social determinants must be taken outside the public health sector
> to the broader political arena. Blaming public health practitioners for doing the jobs they are resourced and authorized to do is too
> much like the victim-blaming inherent in an exclusively individual behavioural approach to lifestyle change. At least since the
> Ottawa Charter and the Epp Report in Canada, if not sooner there and in other countries, health promotion has given increased
> attention to the social circumstances surrounding individual behaviour, as you note with respect to adolescent risk behaviours, and
> as we can demonstrate more broadly with the great public health success stories of the twentieth century: smallpox eradication,
> polio nearly eradicated, a 50% reduction in smoking, and similar reductions in cardiovascular deaths, stroke deaths, and
> automobile crash deaths in the last third of the century. If the only hope for change in health is income redistribution, t
>
> These are important discussions Ron and Dr Raphael. Thanks for weighing in. I like the BC preliminary Model attached to your
> e-mail, but would give a little more prominance or explanation to the "Intersectoral Partnerships" dot point in the "community" box
> to acknowledge the need for such partnerships to address the important determinants that Dr Raphael emphasizes. --Larry Green
>
text of an email received from Dr. Lawrence W. Green
posted by
--
Dr. Ronald A Dovell
Health Planning Researcher
Interior Health

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