I think we are all stuck in the same quandary on this list - whether we
believe in and practice behavioural related health promotion, or whether was
ascribe to (and speak passionately about) the social determinants of health.

The quandary is not about the "science", although that has provoked a good
deal of "my approach can beat up yours" over the last year. I am no
scientist, but based on the micro/meso/macro model put forward by Joe Levy,
I the non-scientist believe that good work does - or can - achieve results
at all levels.

The quandary, though, has to do with how the powers-that-be see either
behavioural or more systemic approaches to improving health. Our political
leaders by and large still don't get it. They still believe in blaming
people (no matter how gently they phrase it) for their health status. After
all, the poor often don't vote, don't make large contributions to political
parties and don't go to too many $200 a plate dinners.

It seems the challenge to the behavioural health promoters is to avoid being
pressured by politicians and managers into acting as if the blame game was,
indeed, true (with all due respect to the behavioural health promoters, you
do run the risk of becoming preachy, as I and my family have found out).

The danger for the supporters of social determinants of health is that the
approach threatens profound political and sometimes social values held by
the more powerful people in our society, who have a stake in supporting the
blame game ("I'm OK, you're not OK"). Faced with this opposition, supporters
of social determinants of health  run the risk of becoming self-exiled if
they assume mere imperfect mortals will never "get on board", when in fact
some will and some won't (and the ones who will may eventually constitute
the critical mass needed for paradigm change). So by all means preach, but
in the language your audience can understand and - just possibly - accept.

So if I had my druthers, I'd druther see more dialogue on how the respective
techniques can work together to deal with the blame game - to convince our
fellow citizens (the poor and marginalized as well as the rich and
comfortable) that health promotion is not about blame, and that addressing
the social determinants of health is necessary as a morally, socially and
politically more acceptable route than reinventing the Victorian poor laws.

Unless we support the political tools and actions we already have (and I
applaud Dennis R. for the often effective politics of letter writing and
speaking in public) and unless we develop new ones as well, we yield the
field to all those who use politics more effectively - particularly the
neocons and the big institutional curative players.

A whopping good fight between the two perspectives helps sometimes - but not
if we don't use the debates to find common or complementary ground for
action

John Butler
The Agora Group


----- Original Message -----
From: "Dorothyanne Last" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Sunday, December 21, 2003 8:32 PM
Subject: Re: discussions about poverty, trans fats, and more


> Hello and happy holidays to everyone -
> I have recently resubscribed to this listserv after a period of absence
and
> I am discouraged to see that the discussion seems to have narrowed to one
> between Dr. Raphael and one or two others.  There seem to be very few
people
> on the list and I wonder if it is because, although most of us would agree
> with the vital importance of addressing the determinants of health, we
would
> also like to see some other discussions about different areas of health
> promotion?  Dr. Raphael would perhaps argue all the rest of health
promotion
> activity is meaningless, but I would differ.  I have worked in physical
> activity promotion, in healthy family promotion, and am now working in
> injury prevention and tobacco addiction prevention.  I have seen that we
can
> actually make a difference in the health of people with health promotion
> measures - maybe we are not reaching everyone - but we are reaching many.
> Without assigning blame.
>
> Is this listserv a free and open one?  Are others welcome to voice an
> opinion without being flattened by rhetoric?  When I first subscribed to
the
> listserv, some years ago, it was a wonderful place to hear about ideas and
> new research and to share our challenges.  Right now, I find it
intimidating
> and barren.  I remain hopeful it will return to its former broad and
> welcoming focus.
>
> Wishing everyone a more egalitarian new year, in discussion as well as in
> wealth.

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