My dear colleague Dennis Raphael has a knack for poking a stick at vulnerable
spots in any declaration dealing with health goals. That he also has a tendency
to poke a stick in a few eyes as well is.....well....just Dennis.

But, to build on his point, any health promotion agenda that focuses excessively
on behaviour modification is suspect from the get go. That is clear to most any
economist who sees behaviour, including health choices, as choices made facing
constraints. To focus excessively on educating the individual to modify one's
health behaviour is to ignore those social determinantes of health that are so
dear to Dennis Raphael's beating heart. 

As an example of the behavioural problem, many US economists are critical of the
US Food Stamp program as a way of improving the health of the poor. They argue
that food stamps simply free up other money to buy, on the margin, what the poor
might want to buy. A better strategy would be to pursue policies that reduce the
cost of healthy foods in the market place. Subsidies for  growing corn, to
produce sweetners for soft drinks, sweetened cerals, etc. should give way to
subsidies to lower the costs of healthy foods. This is more efficient and
effective than simply trying to educate the poor to spend more on more expensive
but better foods.

If there is a role in health promotion for beahviour modification education is
is not 'down or out' to individuals but 'up or in' to these who have the
stewardship of policy and control funding. It is those in positions of power,
using our tax dollars, who need to be educated as to the consequences of their
decisions, not on their personal health, but on the health of others. 

A spoon full of improving the access to healthy foods by reducing their relative
costs (and removing the subsidies to unhealth foods) is better than a pound
(kilo) of good "healthy behaviour" advice. This message needs to be 'up and in'
to those that make policy and those that administer the funding. Many of those
in the target groups for health promotion are much smarter than much of health
promotion is willing to admit. A significant part of the problem is how their
choices are constrained, and a significant part of that problem can be placed at
the feet of policy makers, and some program implementation, that could use a
strong dose of education. 

Sam Lanfranco
Distributed Knowledge Project
York University

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