It's been an interesting discussion, surprisingly animated for this season of torpor
(in Canada, at least). My comments go back a few days...
I believe there is little stomach in the field for coming to a consensus on the nature
of health promotion any time soon. A cynic might say it is convenient and safe to
keep it fuzzy -- open internecine conflict cannot be "afforded" when we all need
funding so badly. Also, increased clarity about where we stand and what we are
trying to do might lead to a thinning of the ranks just when we need broad support.
But it seems to me that a lack of clarity can leave health promoters (however
well-intentioned) undermining each other's efforts. By this I don't mean that a
plurality of voices isn't both healthy and desirable. But there is a danger that we
will slip into "designer health promotion". There must be a minimum "credo", to
which health promoters of all stripes subscribe. This might include (but not be
limited to) a commitment to equity and social justice, and to empowerment and
participation (as process and outcome).
The Ottawa Charter says most of it, but I sometimes wonder whether that hasn't
become more of a "feel good" piece than a serious guide to action. We seem to like
the breadth of such statements because they offer something for everyone. We
forget that their elements aren't stand-alones but interdependent. When we treat
them like items on a smorgasbord we run into trouble. For example, do we or do we
not believe that the political/economic/social environments are critical
determinants of health? If yes, is it legitimate to keep beavering away at health
promotion initiatives that seemingly close their eyes to the big picture? To do so is
to dig our own grave since ultimately -- if our "declarations" have it right -- that kind
of one-dimensional "health promotion" is not likely to be effective, by any
yardstick.
Do we or do we not subscribe to a holistic, comprehensive approach -- the use of
multiple, mutually reinforcing strategies, some of which have long horizons? If we
do, how is it that we allow ourselves to be intimidated (by calls for our work to be
scientifically rigorous and evidence- based), and stampeded (by government fiscal
arrangements and election imperatives) into hiving off short-term single-strategy
projects, often with unrealistic goals? Are we not, in effect, ignoring our own
precepts, thus leaving ourselves at a loss to show how people's health has been
positively affected?
Just a few thoughts about "evidence". As health promoters we certainly want to
know that we are putting our resources to best use. But it is curious (not to say
instructive, even laughable) how exacting the standards are becoming for poor little
health promotion vis-a-vis other much better known and established domains
whose actions impact on people's health. Writing to Macleans magazine recently
(July 1, 1998), Dr. David Zitner of Dalhousie Medical Scool noted" It is astonishing
... that the Canadian Institute for Health Information ... does not ask health
organizations to report on changes in health status associated with treatment. The
result is that no health organization in Canada can inform its constituents about the
overall benefits of care. Is there another industry so valuable to our community
that measures costs alone, but not benefit?" Further, as Blake implies, government
health-related policies don't seem to be all that evidence- based (are they ever
evaluated, except by the electorate?) -- where is the evidence for relaxing
environmental legislation, or creating megacities? I agree with Blake when he
suggests that hp is possibly being held to higher account than some other areas of
endeavour that are politically in tune with neo-liberal/neo-conservative agendas.
Furthermore, if efficiency takes precedence over equity as a guiding principle, if
individuals are seen as micreants and the authors of their own misfortune, and
piecemeal, preachy, even punitive approaches are favoured over the development
of supportive social policies and communities, there can be little footing on which
to develop meaningful evaluation frameworks. Worse, evaluation may be used as
a weapon to cut down programs whose underlying values (and causal
explanations) run counter to prevailing ideologies.
How many health promoters find themselves working at government expense to
ameliorate the negative health effects of government policies? Aren't we just going
round in circles?
We must guard against becoming complicit with those who would have us fail.
When we are pressured into setting unrealistic goals, we are in effect buying into
the idea that a handful of part- time health promoters working on a shoestring
budget can singlehandedly turn around the health impacts of crippling social
policies on a community or population. Labonte (1994) warns community
developers against becoming an "unintended buttress" for political and public
policy actions that are antithetical to power-sharing. Our work in communities
needs to be linked to what is going on in the larger society -- this implies
simultaneously using or actively supporting other health promotion strategies --
advocating for supportive political action and policies which reduce health and
socio-economic inequities, and foster healthier environments (Wallerstein &
Bernstein, 1994).
To finish up this rather meandering contribution, I too sometimes wonder if health
promotion doesn't overvalue health vis-a-vis other possible goals and priorities
people and societies might have. In trying to answer "what is the point of
promoting health?" we speak of health as a "resource" that we can draw on to fulfill
our potential as human beings. But the very phrase "health promotion" seems to
somehow suggest that health has intrinsic (versus merely instrumental) merit, and
should be pursued for its own sake -- as an end in itself -- and many (predominantly
middle class) members of our Western society appear to subscribe to this notion.
Maybe health is only a goal for people whose basic needs are already taken care
of (As David Seedhouse's foundations theory implies, what priority do you assign
to health when you are hungry or cold or homeless?)
Petersen & Lupton (1996) argue that the new public health is at its core a moral
enterprise that involves prescriptions about how we should live our lives and
conduct our bodies, both individually and collectively. Citing Crawford (1994) they
point out that the healthy body has become an increasingly important signifier of
moral worth, a mark of distinction delineating those who deserve to succeed from
those who will fail. They also cite Metcalfe (1993) who criticizes those health
promoters who "decide that their goal is to make people more health conscious
and healthier, or that their goal is to stop people's consumption of cigarettes,
alcohol and unhealthy foods, to increase the amount of exercise they have, or to
make them 'live longer" or get more from their life'". Metcalfe warns of the dangers
of "healthism" -- the preoccupation with personal health as a primary element in
the definition of wellbeing -- which he says operates on the questionable
assumption that everyone should work and live to maximise their health. He
worries that healthism may "lead to a general intolerance by those who subscribe
to the dominant health norms against those who do not or cannot".
Petersen & Lupton note that the new public health's strong emphasis on self-care
seems to be at odds with its "stated ideals of nurturing social support, redressing
inequality and creating a tolerant democratic polity." In their view, this narcissistic
preoccupation with the self -- which has largely gone unchallenged because it
plays into our society's widely "accepted and privileged notion of autonomous
individuality"-- can divert attention from increasing inequalities in wealth and power
and from attacks on established rights during a period of retreat from welfare
provision.
All of which leads us back to Blake's observation that it is really health promotion's
IDEOLOGICAL STANCE which is at the source of so much of the criticism -- i.e., the
continued opposition is not so much about theory or the lack of it, evaluation or the
lack of it, evidence or the lack of it, vagueness or the lack of it, but about fear of
health promotion's implicit social justice agenda, and resistance to the notion that
our society's power relations need to be critically reexamined.
Elizabeth Rajkumar
The Working Group
1-295 Ashton Avenue
Ottawa, ON K1Z 6T5
(613)729-0953
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