Dear David,

Thank-you for continuing the dialogue. This has been most interesting. I
think on fundamental points (principally the need for critical reflexivity)
we agree wholeheartedly. While we may at times draw different conclusions,
the field is immesurably enriched by being provoked to wrestle with the
issues you raise.

Of considerable interest to me in this discussion is the extent to which
the alleged lack of consensus regarding the core aims and purpose of health
promotion is seen as problematic or not, and whether it is interpreted as
vagueness, false consensus, polivocality, or (more likely) some combination
thereof. I suspect that there is a fine line between vagueness and
plurality (the latter often being used inappropriately as evidence of the
former).

I guess this brings me to my next point: is it (formal) theory that is
going to "save" (legitimize, strengthen, rejuvinate) health promotion, or
(as Rhonda so ably points out), are the criticisms of health promotion's
ostensible weaknesses (vis a vis theory, evidence-based practice etc) a
cover for some people's discomfort with the ideological stance (or social
justice agenda) of more radical approaches to health promotion (such that
addressing those criticisms will not necessarily legitimize hp, but rather
succeed in persuading them to find different bases for critiquing or
ignoring the hp agenda)?  I'm not arguing against thoughtful reflection on,
and articulation of, the theoretical traditions from which health promotion
draws its inspiration, or the evidence used to determine the efficacy of
its interventions. Rather, my concern is that we see calls (not necessarily
yours, but those of others) for health promotion to "get with it" vis a vis
the tenets of traditional science for what they often are: ideological
challenges (challenges that don't always have to be met on the 'opponent's'
turf - ie in their terms). I remain, for example, profoundly ambivalent
about calls for health promotion to more fully account for its use of
resources in the language of "evidence-based practice". On the one hand,
enthusiasm for learning from theory and practice, and growing in our
understanding of what makes a difference is laudable. On the other hand,
the models of practice that undergird calls for "evidence-based practice"
are ill-suited to community-oriented health promotion (fail to fully
acknowledge implications of open systems, puny influx of resources relative
to the magnitude of the problems addressed, vast array of social and
economic forces aligned against the efforts of health promoters, which
conspire to stacking the deck against hp being able to demonstrate
effectiveness in traditional ('hard' health outcome) terms, which of course
plays right into the hands of those who suspected hp never could argue
convincingly for itself on these grounds and who made the demand, not in
the interest of advancing hp, but in effect to silence it). In my
observation, calls for "evidence-based practice" are, furthermore, applied
selectively and with, at times, some hostility, directed at arenas of
practice where those making the challenge are unconvinced of the merits of
the practices they call into question (e.g. there is little evidence that
neo-conservative social policy is "effective" even on it's own terms, and
growing evidence that it's impacts in terms of weakened social capital may
have profound economic as well as social consequences).

I believe that critical reflexivity about theory and practice in hp means
not only _conceptual_ clarity about our own goals and objectives, but also
a politically astute assessment of the (ideological, economic and social)
climate in which hp operates, and what exigencies this places on the
practice of hp which has a more overt social justice agenda (acknowledging
that disease prevention that takes a more biomedical or behaviourist
perspective does not face the same exigencies or challenges - and why (a
theory that explains this); and also that we need to guard against
excessive "healthism" in which social goals are assessed exclusively in
terms of their impacts on "health", however defined, thereby simultaneously
devaluing other social goals or forms of human suffering or alienation for
which more or less direct "health" impacts cannot be demonstrated).

I've probably said enough for now. Hope this stimulates additional comments
from yourself and others. Thank-you again for engaging the dialogue.

blake










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Blake D. Poland, Ph.D.
Department of Public Health Sciences
Faculty of Medicine, McMurrich Building
University of Toronto
Toronto, Ontario
Canada   M5S 1A8

tel: 416-978-7542; fax: 416-978-2087
email: [log in to unmask]
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