Rhonda,

Thank you for your response.  It is pleasing to have debate started
on this subject.

> So, David wrote:
>
> > It is impossible to have health, economic and social policy driven by
> > evidence.  It is always - all of it - driven by values.
> ............
> > Show your evidence to someone who disagrees with your beliefs and all
> > they need do is show you some other evidence that coheres with
> > theirs - how, then , do you arbitrate between the two?
>
> The arbitration over different points of view is what the lay person sees
> played out in the media everyday and the scientist professes to engage in.
> How does one theory PROVE itself to be more explanatory than another; how
> is one set of evidence more powerful than another is the stuff of what is
> called "science." (Forgive me for being simplistic or obvious.)
>

This may be true in some cases.  For instance, if people disagree
about the effects of one particular practice (say smoking) then it is
possible to investigate who is right scientifically, so long as the
disagreement is about the evidence.  However, it is a different
matter if people disagree about pursuing _different_ possible
health promotion goals (for instance, anti-smoking and offering free
additional general education to educationally deprived youngsters).
If you can't do both then deciding between them becomes at least
partly a value-judgment: both options are equally politically
inspired but we have become so used to the anti-smoking work that we
think this (for example) is central to health promotion.

> > This need not be a negative conclusion.  It seems to me that health
> > promoters should ditch the myth that 'we are obviously right because
> > this is a _health_ matter' (as if health were an objective notion)
> > and recognise that the health promotion task is to work out a
> > comprehensive justification (based on values) for the health
> > promotion endeavour, and then try to implement this, bearing in mind
> > that to do so is inevitably a political action.
>
> I think it is unfair to cast people interested in health promotion as
> believing they are "obviously right because this is a _health_ matter" but
> David and I probably have different experiences with health promotion. My
> experience has almost always been that, by and large, people working in
> health promotion have had to fight an uphill battle to get _health_ on the
> agenda. By this of course I mean that prevention is almost never
> poitically palatable because it requires a redistribution of resources
> from the haves to the have-nots. I can't think of anything much more
> political than that.
>

That's right.  It is political, but some people use the notion of
health as if it is a neutral idea.  What this tends to mean in
practice is that it is the medically inspired interventions (which
most people are accustomed to associating with health) that become
the priorities (because they seem safer).  But these are equally
political notions (not least because to pursue these goals often has
the effect of maintaining the status quo).  We need to make this
clear, so that the choice isn't 'which medically inspired
health promotion goal should we pursue' but 'which health promotion
goal should we pursue full stop'.

> >
> > Health promotion plays into the hands of the new right because they
> > have a political outlook (albeit a brutal and simplistic one)...
>
> The health promotion that I know doesn't play into the hands of
> the new right..it gets grabbed by the neck and beaten into submission by
> the blunt hammer called deficit-reduction and all the ideological baggage
> that goes with that concept and political actions. What we do about this
> is the test of our savvy and mettle, to say the least, isn't it?
>

Of course - so we need to make out the strongest case why health
promotion is a moral issue (which it is).  I've been working for
years to do this and have developed - through logical analysis for
the most part - an egalitarian understanding of health.  I would like
to see this given a chance but it won't be while we make
over simple links between health and disease (and between
health/disease and individual responsibility - as the right do).
Health is not discovered only by examining an individual in vacuo
socially, a person's health should be assessed by inspecting the
physical, mental and social conditions which make up her life (it is
not a matter of using a stethoscope - though this can be useful - but
of taking a holistic inventory of her life and her possibilities).
>
>         ... and
> > health promotion has nothing more than a collection of woolly
> > declarations about what is wrong with the world.
>
>
> DAVID, with friends like this......! Declarations of what is wrong with
> the world are not woolly in my view. They are acts of faith and bravery in
> the face of real threats to jobs and even life, in some instances. So, I
> choose to woollyily declare that abuse, unemployment, poverty, etc. are
> among the things that are "wrong with the world" and ought to be changed,
> period. Acting on these beliefs in the _health_ arena is a choice
> also..and maybe not a good choice...we all know that there are arguments
> that we should just get out of the health area and get to the
> "basics" of housing, income, etc..
>

The health area _is_ to do with housing and income.  It is a fatal
mistake to think that these matters 'cause health problems'.  They
_are_ health problems because they impede people's human potentials.

It is very hard to see this if we rely on Declarations to reinforce
our own political convictions.  The right have 'theorists' to which
they subscribe.  Presently much of their stuff goes unchallenged
because we haven't developed sufficiently strong arguments against
rampant individualism - of course, many people hate it (as I do) but
I think this isn't enough.  There are many ways to fight back - I'm
convinced clear thinking is one of these.

>   Health promotion
> > needs to get theoretically tough - until it does it will remain a
> > pawn of both the political and medical establishments (just as it
> > always has been).
>
>
> There is health promotion and there is health promotion. The health
> promotion I choose to support is actually well-grounded theoretically in
> the disciplines of psychology, sociology, political science, economics,
> liberation theology, etc.

No it isn't.  Health promotion as a discipline borrows from these
more established disciplines - dipping into them to get a method
from here, a technique from there - but it does not have a clearly
expressed view of its purpose (so a lot of the borrowing is either
indiscriminate or medically inspired, and so further reinforces the
status quo when most health promoters would dearly love to improve
the social world).

>Unforutnately (in my view) too many front line
> practitioners are not aware of the strong base from which the ideas
> and practices of what- I- choose- as- health- promotion grew. Also
> unfortunately, all the knowledge of both the theory and the data, don't
> always give the help you need in the political times in which we live. The
> worm WILL turn.

Rhonda, my response will probably seem strange.  I am aware that what
I write can sound peculiar on a brief reading,  but there is a lot to
it once you see it spelt out more.

In a nutshell my position is that health promotion is not making the
progress it could because it is philosophically immature (it has no
clear view about why health matters, why some goals are to be
preferred over others, about who should be the primary recipients of
health promotion if there is not enough to go around, about when to
cease an intervention, about how much public consultation there
should be, about the relationship between medicine and health, about
whether health or well-being matters most .... I could go on!).
Because of this combination of theoretical ambiguity and largely
undirected enthusiasm for change health promoters tend to say one
thing and end up doing what conventional employers and funding
bodies instruct.  Only by expressing a thorough view about what
health promotion is for can this be avoided (of course it is for
health - but there are numerous, conflicting understandings of
health).

Anyway - thank you so much for replying.  I hope we can take this
further.


David Seedhouse

PS:  Rhonda, I don't seem able to post my messages from here - if you
don't receive this on the list would you mind posting it for me?
Thank you.