Usual apologies for cross-postings...
The following will be appearing in Newsletter #13 of the Research in
Healthy Cities Collaborating Centre at University Maastrich, Netherlands.
Since this is the 10th anniversary of the House of Commons' pledge to
abolish child poverty in Canada by the year 2000, it seems appropriate for
today. [By the way, they failed miserably].
It will eventually be available electronically on the Maastrich WWW site.
Dennis Raphael
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To Appear in Issue #13 of Research for Healthy Cities Newsletter
World Health Organization Collaborating Centre for Research on Healthy
Cities, Universiteit Maastricht.
Paradigms, Politics, and Principles
A Cautionary Tale from Toronto, Canada, Birthplace of the Healthy Cities
Movement
Dennis Raphael
The City of Toronto is in crisis. The percentage of children living below
the Statistics Canada low-income cut-offs is now 38%. Homelessness is at
levels not seen since the 1930's and food banks are used on an ongoing
basis by 135,000 Toronto residents, a doubling in number since 1990.1 This
is occurring even as the Canadian economy is in the midst of an economic
recovery. As a health promoter trying to make sense of this, I have been
forced to consider the economic and social forces within Canada
contributing to these developments. The purpose of this column is to lay
out some issues as a cautionary note to all those working within the
Healthy Cities framework.
Paradigms: Whatever Happened to Health Promotion?
How we think about and work to improve health is strongly influenced by
our world views. Within Canada the concept of "population health" has
replaced "health promotion" as the dominant health discourse in many
federal and provincial government statements. It has been argued that the
acceptance of population health reflects a government retreat from the
welfare state.2 What is especially disturbing is that population health's
ideology, focus, and methods are clearly embedded within epidemiological
modes of thought. As its primary means of promoting health -- and
population health uses the biomedical definition of health as the absence
of disease and illness -- population health advocates call for the carrying
out of large-scale quantitative surveys that identify risk and protective
factors across the entire population. As such it offers a vision of health
that is fundamentally different from the values-based, pluralistic,
contextualized, and community-oriented vision of health promotion. In
fact, the Canadian architects of population health identify Healthy Cities
work as the most ambitious effort to develop healthy public policy, and
then go on to state:
At best, healthy public policy represents modern utopianism. At worse,
it is simply a form of clever propaganda, piggybacking a set of other
policy interests onto the powerful and broadly based public support for
health. 3, p.227
Not surprisingly, public health practice in Toronto is in retreat from its
activist, participatory, and innovative vision that led to the development
of the Healthy Cities concept.4 These developments must be viewed within
the context of the current political situation in Canada.
Politics: What Has Resulted from the Rise of Neo-Liberalism?
Population health has arisen at a time of increasing influence in Canada
of neo-liberal ideology. The key tenets of neo-liberalism have been
outlined as follows: a) markets are the most efficient allocators of
resources in production and distribution; b) societies are composed of
autonomous individuals (producers and consumers) motivated chiefly by
material or economic considerations; and c) competition is the major market
vehicle for innovations.5
Within Canada, the rise of neo-liberalism has been associated with
freezing or reduction of government spending on social infrastructure
including education, social and health services. Indeed, Federal program
spending as a percentage of GDP has been decreasing since 1987 such that
current spending is at 1950 levels.6 Not surprisingly, this shift has been
associated with dramatic changes in the tax structure such that economic
inequality is showing unprecedented increases reminiscent of the United
Kingdom experience during the Thatcher years.1 The practical consequences
for cities such as Toronto have been reduced resources for social
infrastructure at the same time as need has increased. Health promoters
find it increasingly unlikely that governments will support the idea that:
Since housing, environment, education, social service, and other city
programs have a major effect on health in cities, strengthening these are
important.7, p.13 Indeed, both the federal and Ontario provincial
governments have removed themselves from funding social housing, a policy
decision that is directly responsible for the increase in the number of
homeless in Toronto. The Mayor of Toronto is committed to not raising
property taxes, come what may.
Principles: What are Healthy Cities All About?
One distinguishing aspect of the Healthy Cities movement is its commitment
to principles that are informed by a set of values. One clear statement of
principle that informs Healthy Cities work is the definition of health
promotion offered by Healthy Cities workers:
The key concepts in this definition [within the Ottawa Charter] are
‘process' and ‘control'; and therefore effectiveness and quality
assurance in health promotion must focus on enabling and empowerment.
If the activity under consideration is not enabling and empowering, it
is not health promotion.8, p.6
Core principles of Healthy Cities work include commitments to health,
political decision-making for health, intersectoral action, community
participation, innovation, and healthy public policy.7 Healthy Cities work
is also committed to the concept of the "common good" -- an idea that is
essential to the practice of health promotion in these difficult times:
The public ideas – and the language associated with them – which
currently envelop us are those of the market, corporatism, fiscal
restraint, and globalization, ideas which are driving the near universal
dismantling of the welfare state, and eroding any notion we might have
of the common good. Health promotion represents one possibility for
countervailing ideas: ideas about equity, social justice,
interdependence, the common good.9, p.130
It is therefore, essential that Healthy Cities adherents recognize that
powerful economic interests associated with economic globalization will
resist this vision of the common good. In Canada, these forces have had
notable successes in influencing government actions. Cities such as Toronto
have suffered the consequences. Healthy Cities advocates must continue to
forcefully argue for, and act upon, their vision of community life and
health. After all, "What's the point of cities, built without the people's
wisdom?"10, p. 440
References
1. Raphael, D. (1999). From increasing poverty to societal disintegration:
How economic inequality affects the health of individuals and communities.
Chapter to appear in H. Armstrong, P. Armstrong, & D. Coburn (eds). The
Political Economy of Health And Health Care in Canada. Toronto: Oxford
University Press.
2. Robertson, A. (1998). Shifting discourses on health in Canada: From
health promotion to population health. Health Promotion International, 13,
155-166.
3. Marmor, T. R., Barer, M. L., & Evans, R. G. (1995). The determinants of
a population's health: What can be done to improve a democratic nation's
health status? In R.G. Evans, M.L. Barer, & T.R. Marmor (eds), Why Are
Some People Healthy and Others Not?: The Determinants of Health of
Populations, pp. 217-230. New York: Aldine de Gruyter.
4. Raphael, D. (1999). Health inequalities in Canada: Current discourses
and implications for public health action. Invited manuscript submitted to
Critical Public Health's Special Issue on Health Inequalities.
5. Coburn, D. (in press). Income inequality, lowered social cohesion, and
the poorer health status of populations: The role of neo-liberalism.
Social Science and Medicine.
6. Yalnizyan, A. (1998). The Growing Gap: a Report on Growing Inequality
Between the Rich and Poor in Canada. Toronto: Centre for Social Justice.
7. World Health Organization (1995). Twenty Steps for Developing a Healthy
Cities Project. Copenhagen: WHO Regional Offices.
8. MacDonald, G. & Davies, J. 1998). Reflection and vision: Proving the
improving the promotion of health. In J. Davies & G. MacDonald (eds).
Quality, Evidence, and Effectiveness in Health Promotion: Striving for
Certainties, pps. 5-18. London, UK: Routledge.
9. Robertson, A. (1999). Health promotion and the common good: Theoretical
considerations. Critical Public Health, 9, 117-133.
10. Brecht, B. (1953, 1976). Great Times, Wasted. In J. Willet & R.
Manheim (eds), Bertolt Brecht, Poems 1913-1956. New York: Methuen.
Dennis Raphael [[log in to unmask]] is an associate professor of Public
Health Sciences at the University of Toronto.
Visit our Web Site for information about our Seniors Participatory and
Community Quality of Life Projects! Free Reports Also.
http://www.utoronto.ca/qol http://www.utoronto.ca/seniors
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Long have I looked for the truth about the life of people together.
That life is crisscrossed, tangled, and difficult to understand.
I have worked hard to understand it and when I had done so
I told the truth as I found it.
- Bertolt Brecht
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Dennis Raphael, Ph.D.
Associate Professor and Associate Director,
Masters of Health Science Program in Health Promotion
Department of Public Health Sciences
Graduate Department of Community Health
University of Toronto
McMurrich Building, Room 101
Toronto, Ontario, CANADA M5S 1A8
voice: (416) 978-7567
fax: (416) 978-2087
e-mail: [log in to unmask]
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