Rhonda:
Thank you for this:
> Of course, we have to define health. We have all read the various attempts
> to define health which range from "the absence of disease" to the
> attainment of "complete spiritual, physical, etc... a la the WHO..."
> We've all read the documents from the Lalonde Report to the Jakarta
> Declaration, or at least heard of their contents.
>
> Defining health seems to be an elusive task.
It is difficult, but not impossible. It looks elusive because there
are so many casual/weak definitions about.
>Current research treatises on
> health are often really discussions of the factors that contribute to
> mortality...even morbidity isn't very well measured or discussed. So, in
> earlier emails, I have referred to research that indicates a strong
> relationship between health and income disparity. To be more precise,
> many, but not all, of these studies are about DEATH, not HEALTH.
> That is becase the measures of health status are often measures of
> death and disease rates.
Absolutely - and this medical notion of health will remain dominant
until clear and well-reasoned alternatives emerge.
> However, there are respectable studies which
> attempt to talk about health and not just death rates...and, there are
> similar economic issues affecting the attainment of "health."
>
However respectable they are they must be clear about what health
means - very few are.
> So, there is powerful information about the role of *class* and health.
> The social justice issues are simple are they not?
No, they are not. 'Social justice' is also a disputable notion. For
example, there are well-established and often competing social
outlooks which argue (respectively) that:
a) Justice is achieved if people get what they deserve
b) Justice is achieved if people get that to which they have a right
c) Justice is achieved if people get what they need.
Ideally these three notions will be compatible - but they mostly
aren't in this iniquitous world.
>If improving health is
> a value to you, work anywhere and anyway you can to redistribute income
> (or some issue about access to resources). Good luck, but that is what you
> "should" be doing.
There are people who argue that it is unjust to redistribute income
(I'm not one of them I hasten to add). It is merely 'rearranging the
deckchairs' to say that what we're really concerned with is 'justice'
or 'well-being' and so on: whatever word HP turns to sooner or later
it will be time to state clearly what _sort_ of health or justice we
are after.
> I am fairly certain that Blake did not say "get whatever funding is
> available on any terms-even if someone's else's." Without referring to
> past communications, I believe he said we are in dangerous political times
> and should be cautious about disclosing our theories, etc.
>
.... in order to retain funding. I wasn't quoting Blake but in the
absence of a clear idea what counts as legitimate HP and what does
not the implication is plain.
> There is absolutely NO doubt that HP is rife with "ambiguity," is
> "eclectic" and "focused on the short-term..." But, when I read the Ottawa
> Charter and Jakarta Declaration and the CPHA statement on world trade and
> its health implications, I am NOT that confused by ambiguities,
> eclecticism and short- term thinking. I KNOW what is being said, and in my
> mind it IS a form of social justice, and it IS about redistribution of the
> world's resources, and THAT is no short-term goal.
>
Right. But not everyone in HP agrees with you. Surely it is time to
become more explicit so that everyone (not least the recipients of
HP, many of whom are not concerned about world poverty) knows where
they stand. The fear that this will lead to splitting into
competing factions and so undermine HP as a 'movement' is
unwarranted - it isn't a movement anyway at the moment.
> It is time
> > for health promotion to state a) where it stands and b) what this
> > implies practically (in particular, health promoters must begin to be
> > able to say which practical ventures we will NOT engage in -
> > otherwise, where is health promotion ethics?).
>
> Well, OK, somebody do it...I have refused to engage in research on topics
> I thought to be insulting to "victims" (eg, just how hugry are the
> hungry?..)
Me neither.
>I would NOT take tobacco money,
I would, under some circumstances.
>I would NOT
> take the money from any corporation which is "blacklisted" by the Jesuits
> Social Justice Committee; I would NOT work with men's groups attempting to
> discredit feminists working in the violence against women movement, ETC...
>
Me neither.
> David keeps asking people to disclose in a public forum. David, let's hear
> from you...what are your limits..what guides your values...what are the
> "practical ventures" that you won't engage in.
I'm pleased you asked (but I hope you won't rue the day when your
computer jams up under the latest storm of mail from down under!).
First of all my views are already in the public arena, in several
books and papers. The books are not well-known in Canada and the
States (though I'm hoping that will change, naturally) but are widely
used in the UK and parts of Europe and Australasia - it is all
there, definitions, limits, ethics and all if you ever find you have
a few days to spare to wade through it.
I'm sure you have better things to do, so here's a brief taste of the
foundations approach:
"The bones of the foundations theory of health
The foundations theory of health has been developing for over a
decade, forms a large part of four books (1,2,3,4), and cannot be
adequately explained in a short space. Therefore I restrict my
discussion to a short general outline of the basis of the theory,
and a brief synopsis of the theory's usefulness for health workers
who wish to work for health with individuals and small groups.
The foundations theory of health is derived from conceptual analysis
of the meaning of health, from study of other theories of health,
from empirical observation of work actually done in the name of
health, and from certain untestable beliefs about the morality of
social arrangements. My analysis of these matters has led me to
conclude that any plausible account of health must understand the
purpose of health work to be the identification, and if possible
removal, of obstacles to worthwhile (or enhancing)(1) human
potentials. That is:
`Work for health is essentially enabling. It is a question of
providing the appropriate foundations to enable the achievement of
personal and group potentials. Health in its different degrees is
created by removing obstacles and by providing the basic means by
which biological and chosen goals can be achieved.
A person's (optimum) state of health is equivalent to the state of
the set of conditions which fulfill or enable a person to work to
fulfill his or her realistic chosen and biological potentials. Some
of these conditions are of the highest importance for all people.
Others are variable dependent upon individual abilities and
circumstances.
The actual degree of health that a person has at a particular time
depends upon the degree to which these conditions are realised in
practice'. (6) (Quotation slightly changed from original.)
RHONDA - THE ABOVE IS MY DEFINITION OF HEALTH - YOU CAN SUBSTITUTE
GROUP FOR PERSON
This idea can be depicted in the abstract:
Figure One here
I CAN'T REPRODUCE FIGURES HERE - BUT SHERRIE AND DENNIS RAPHAEL
WILL HAVE THE ACTUAL FIGS. BASICALLY THIS IS A PICTURE OF A
MATCHSTICK FIGURE STANDING ON TOP OF FOUR BOXES, WITH A FIFTH BOX TO
THE SIDE - IN MY VIEW IT IS THESE BOXES AND THE CONDITION OF THE
MATCHSTICK FIGURE WHICH TOGETHER CONSTITUTE THE MATCHSTICK
FIGURE'S HEALTH.
The boxes in Fig. 1 may be described either as conditions for health
or constituents of health (though ultimately only the latter
understanding can be sustained). (2,3) Their importance,
whichever way you look at them, is that they provide a platform for
action. If a person can stand upon the four central blocks in good
order then she will have a high level of health. If her boxes are
in bad shape she will tend to have fewer options for fulfilling life
performance than if they were sound. How many different sorts of
boxes there are, their exact content, and how important each is
compared to the others is contestable, varies according to
circumstance, and is at least partly a matter of human social
judgment. On my theory of health the numbered blocks shown in
Figure 1 have the following substance:
`Some of the foundations which make up health are of the highest
importance for all people. These are:
1. The basic needs of food, drink, shelter, warmth and purpose in
life.
2. Access to the widest possible information about all factors
which have an influence on a person's life.
3. The skill and confidence to assimilate this information. In
most societies literacy and numeracy are needed in older children
and adults. People need to be able to understand how the
information applies to them, and to be able to make reasoned
decisions about what action to take in the light of their
information.
4. The recognition that an individual is never totally isolated
from other people and the external world. People are complex wholes
who cannot be fully understood separated from the influence of their
environment, which is itself a whole of which they are a part.
People are not like marbles packed in boxes, where they are a
community only because of their forced proximity. People are part
of their whole surroundings, like cells in a single body. This fact
compels the recognition that a person should not strive to fulfill
personal potentials which will undermine the basic foundations for
achievement of other people. In short, an essential condition for
health in human beings who are aware of the implications of their
actions is that they have an awareness of a basic duty they have
because they are people in a community.
Other foundations for achievement are bound to vary between
individuals dependent upon which potentials can realistically be
achieved. For instance, a diseased person, a person in a damp and
dilapidated house, a person in prison, a fit young athlete, a
terminal patient, and an expectant mother all need the central
conditions which constitute part of their healths, but in addition
they require other specific foundations in order to enable them to
make the most of their present lives'. (1)
The idea is that boxes 1 - 4 represent the central conditions for a
fulfilling life, and that lack of (or serious defect in) them will
severely impede a person in the achievement of enhancing potentials.
Box 5 represents additional support made necessary by individual
circumstance. When faced with a life crisis people sometimes find
that the four central boxes, even in excellent condition, are of
much less use than usual. If people are `falling over the edge' of
their platform they will need the support of a fifth box. That is,
they will require the:
`... other specific foundations (necessary) to enable them to make
the most of their present lives ...'. (1)
The content of box 5 depends entirely upon the nature of the
particular problem. Thus the fifth box may represent medical
services and support; improved facilities for a disabled person;
hospice care for a terminally ill man; special protection and
counselling for a battered woman, and so on. The fifth box is
needed when a particular life problem becomes bad enough to impede
significantly a person's movement on the platform formed by the
other four boxes. This box then either permanently extends the
platform, substitutes for an irreparably damaged central box, or is
the means by which a person is enabled to climb back onto her normal
platform.
It will be immediately obvious that this notion of health does not
have traditional medical provision as its focus. This is not a
problem or an error, rather it is a logical consequence of the fact
that work for health seeks to remove impediment to human
achievement, and that problems that are tackled by medicine do not
constitute a special category of impediment. (3) Just as a person
becomes substantially immobilised in his life in general if he
becomes seriously diseased or injured, so he is equally likely to be
severely impeded in life if he does not have a home, or possesses no
useful information, or has not been educated, or does not realise
the extent to which he is formed by and depends on the existence of
a community of others.
It may also appear that this theory of health implies that any
effort to help people live better lives is work for health.
However, while the theory certainly does extend the idea of health
beyond medical endeavour, it nevertheless sets limits on the
interests of health workers. The task for any genuine health worker
working with an individual or a small group is to recognise the
importance of the foundations in context - to identify with or for
each individual those components which are lacking, or those which
are most in need of renovation - and then to work on those aspects
most appropriate to the skills of that health worker. In this way
the theory begins to offer guidance to individual health workers,
and may help establish practical priorities (for example, see my
discussion of the `case studies' in (1) and two decision-making
methods: the Ethical Grid (2) and the Autonomy Test).(3)
Crucially:
THIS IS WHERE SOME OF THE PRACTICAL LIMITS ARE STATED
`... work for health cannot be fully comprehensive - not all work
should be thought to be health work. Such a state of affairs is not
possible, nor is it desirable to have professional interference in
the name of health covering all aspects of individual's lives. Once
suitable background conditions have been created, the achievement of
the particular potentials that have been chosen is up to the
individual and not the concern of health workers, although permanent
maintenance work will often need to be carried out on the
foundations.
The analogy of work for health is very close to the work needed to
lay the foundations of a building. Obstacles such as poor drainage,
subsidence, awkward outcrops of rock (analogy: disease, illness,
poor housing, unjustified discrimination, unemployment) have to be
eliminated or overcome in some other way. Then firm foundations and
reinforcements have to be added (analogy: good general education,
confidence in thinking things through personally rather than relying
on what one has been told, good opportunities for self-development).
But, unlike the case of building construction, work for health
should stop here. What a person makes of the foundations he has is
up to that person, as long as he possesses at least the essentials
of the central conditions. Given this then an individual must be
allowed to become the architect of her own destiny. (1) (Quotation
slightly changed from the original.)
This understanding of health can be fleshed out. For example:
Figure Two here
THIS IS THE PREVIOUS FIGURE WITH THE BOXES' POSSIBLE CONTENT SPELT
OUT IN PRACTICAL DETAIL
This is a general elucidation only. In fact in every case - whether
the matchstick figure is a person, group or larger community still -
the specific content will vary dependent upon the figure's
circumstances. One way to imagine this is to think of a one-armed
bandit - or the departures board at a large airport. When the
matchstick figure changes so too does the content of the foundations
- different concerns click into place dependent upon the prevailing
situation.
A family who have a badly handicapped neonate, a forty year old with
inoperable cancer and two young children, the increasingly forgetful
septuagenarian - each will require the best foundations possible,
but the exact nature, size and strength of each foundation will be
different in each case. For example, the family with the
handicapped neonate will require all five foundations in depth, and
may particularly need boxes 4 and 5. In this case box 4 might be
spelt out to mean all those supports already included in figure two
plus extended contact with other families in similar situations.
Box 5 will change from figure two and will reflect the specific
needs of the baby (for medication, physiotherapy and so on) and the
rest of the family (for counselling, grief support, extra financial
support and so on).
Note that the foundations theory makes no distinction between
obstacles that are primarily tangible (lack of painkilling medicine,
lack of money) and those that are primarily mental (the family's
lack of understanding of their situation, a sense of loss, confusion
about how to carry on). There is no need to divide these obstacles
into separate categories for they are inextricably related: they are
all part of the general problem. Attention to physical matters will
have mental effects, and vice versa."
References:
1. Health: The Foundations for Achievement, Wiley 1986
2. Ethics: The Heart of Health Care (2nd Edn.), Wiley 1998
3. Liberating Medicine, Wiley 1991
4. Health Promotion: Philosophy, Prejudice and Practice, Wiley 1997.
Rhonda,
There is a lot more to it than this but I hope there is enough to
assure you that a clear theory of health promotion - one that allows
us to set practical priorities and choose between them cogently - is
possible. I'm not saying that this is the _right_ or only possible
theory. Furthermore - like any other approach to HP it is obviously
politically prejudiced - but I admit this and have constructed the
theory to be ethically and practically self-limiting (as I hope the
above shows).
I _am_ saying that I would like the majority of health
promoters to adopt this theory as the philosophical basis for health
promotion practice - if they do then we will see a powerful force for
social change emerge at last.
Thanks for reading this far.
David
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