Excerpted from Raphael, D. (in press). Barriers to Addressing the Societal
Determinants of Health: Public Health Units and Poverty in Ontario, Canada,
Health Promotion International.
Also see: Ebrahim, S. and Davey Smith, G. (2001), "Exporting failure?  Coronary

heart disease and stroke in developing nations", International Journal of

Epidemiology, Vol. 30 pp. 201-205.

Argument 2: The downstream behavioural approach remains dominant in Canada
despite limited evidence of its effectiveness and increasing evidence of the
importance of societal determinants of health.
     There are three main issues related to downstream -- especially

behaviourally oriented -- approaches to health promotion: a tendency towards

victim blaming; the relative importance of individual risk factors as compared

to societal determinants in disease causation; and the questionable

effectiveness of behavioural change approaches to health promotion. The very

earliest critiques of downstream approaches to health promotion were focussed on

the issue of victim blaming. Over 20 years ago the following concerns were

outlined (Labonte and Penfold, 1981; Labonte, 1994):

     The argument was simple.  The health of oppressed people (poor, women,

     persons from minority cultures, workers, and others) was determined at

     least as much, if not more, by structural conditions (poverty hazards,

     powerlessness, pollution, and so on) than by personal lifestyles.  Moreover

     personal lifestyles were not freely determined by individual choice, but

     existed within social and cultural structures that conditioned and

     constrained behaviour.  Behavioural health education, social marketing, or

     wellness approaches to health promotion fostered victim blaming by assuming

     that individuals were entirely responsible for their choices and behaviour.

     They also blamed the victim indirectly by ignoring the structural

     determinants of health, those causes that are embedded within economic,

     class- and gender-based patterns of social relationships.



" (Labonte, 1994,

     p.79).

     Since then, the critique of individual risk factor approaches has been

further developed with analyses of how the conceptualization of health risk --

especially the individualization of risk -- is dependent upon prevailing

political and economic ideologies rather than actual evidence (Tesh, 1990; Eakin

et al., 1996; Lynch et al., 1997).  The theme of victim blaming is returned to

later.

     The second critique of downstream, behavioural change approaches concerns

findings that individual risk behaviours account for rather modest proportions

of variation in the incidence of a number of diseases.  This is especially the

case for cardiovascular disease. This was known since the early Whitehall

Studies (Marmot et al., 1978) and to date, any number of studies have documented

how societal markers such as individual and community socioeconomic status are

far and away the best predictors of the incidence of heart disease in developed

nations (Feldman et al., 1989; Lantz et al., 1998; Diez-Roux et al., 2000; Roux

et al., 2001). A recent summary of this work in the area of heart disease is

available (Raphael, 2002b). Nevertheless, heart health initiatives in Ontario

and elsewhere have come to reify what terms the "holy trinity" of risks: diet,

smoking and exercise (Nettleton, 1997). She argues:

     As with any area of medical or scientific research, the selection of

     factors to be studied cannot be immune from prevailing social values and

     ideologies. ... It is also evident that so called lifestyle or behavioural

     factors (such as the holy trinity of risks - diet, smoking and exercise)

     receive a disproportionate amount of attention. As we have seen, the

     identification and confirmation of risk factors is often subject to

     controversy and the evidence about causal links is not unequivocal

     (Nettleton, 1997, p. 318).

     In Ontario, the "holy trinity" has been enthusiastically deified by

Ontario's public health units and their associated heart health networks.

Perusal of any and all of their web sites  documents how heart health activities

conform closely to the Ministry-imposed mandate.  The issue is not whether

eating poorly, using tobacco, and remaining sedentary are bad for health.  Such

activities clearly do not contribute to health.  But their impact is limited as

compared to other societal determinants, and the sole emphasis upon individual

risk factors to the exclusion of all other considerations is problematic (Shaw,

2002).

     The third issue related to downstream, behavioural approaches to health

promotion in general, and heart health promotion in particular, is the

increasing recognition of the limited effectiveness of such approaches,

especially among disadvantaged groups. It is well beyond the scope of the

present paper to provide a comprehensive review of these but Ebrahim and Davey

Smith (2001), commenting on the most well-known heart health community-based

programs,  concluded: "Intriguingly, these uniformly disappointing developed

country programmes have been reported as successes" (Ebrahim and Davey Smith,

2001)p. 202).

     More recently, Fitzpatrick has offered a comprehensive and critical

assessment of the limited effectiveness of behavioural change-oriented health

promotion programs -- an assessment that is, as noted, consistent with an

emerging academic and scholarly literature (Fitzpatrick, 2001). In Inequality is

Bad for Our Hearts: Why Low Income and Social Exclusion are Major Causes of

Heart Disease in Canada, it was concluded that, for at least four reasons, the

emphasis on explaining poor health as a function of unhealthy behaviours and

exhorting individuals -- especially those on low income -- to give up these

behaviours was likely to be ineffective.