Bryan, Sherrie, Adeline, Linda, Peter, Dennis et al

My, this has been a robust topic.

I appreciated all of your comments about the overlaps between the various
"Models". I entirely agree. In fact, I've used the metaphor sent earlier as
part of a larger discussion piece to suggest that positioning these models
as mutually exclusive is rather missing the point.

(It's not nearly as much fun, however, without my multi-coloured eliptical
loops on a flipchart, complete with tiny stickpersons representing the
communities).

I would argue that there are theoretical and practical tools to be gleaned
from all the models, if our goal is to respond to the full spectrum of
health care needs. I think the distinctions between the models are often
overstated. Does the medical model ignore determinants of health? Most
nurses I know, and quite a few docs, are rather passionate advocates against
poverty.

And I worry sometimes that, in our thirst to illustrate the strengths of one
paradigm, we overlook the benefits of others.

I'll offer two illustrations from my own background as an AIDS activist. The
early response to the epidemic (although even getting this response required
community activism) was largely a health promotion response. "The only cure
is prevention," went the slogan.

Well, um, fine. But what about the thousands of people who were already
HIV+? They were "the reservoir of infection". That's an actual quote from
the then head of the Federal Centre for AIDS. Public health and health
promotion had little to offer them (except, perhaps, the threat of coercive
intervention to regulate 'safe' behaviour). It took considerable
mobilization by people with HIV and their advocates to bring some attention
to treatment - the good old much condemned Medical Model.

The second illustration is from a few years back, when the powers that be at
Health Canada decided to adopt Population Health as their model. Turns out,
that meant that there would be no more dedicated funding for an AIDS
Strategy. If I recall the argument, HIV/AIDS was a health outcome, not a
determinant of health. Rather than rant further on this particular argument,
I would refer you to a well done (and superbly titled!) policy paper,
"Paradigms Lost" from the Canadian AIDS Society (www.cndaids.ca).

The result of Health Canada's 'Population Health' decision would have been
the loss of much valuable community-based services for prevention, care and
support, a dramatic reduction in research, and a loss of government
infrastructure to coordinate responses. Fortunately, some vigourous activism
reversed this decision and the AIDS Strategy was renewed.

This isn't an argument against health promotion or population health as
theories, but  a cautionary note about how governments can coopt our
language (and our debates). About the same time as Health Canada was proudly
proclaiming its discovery of Population Health, the rest of federal policy
was galloping in the other direction. The ink was barely dry on NAFTA.
Fiscal and monetary policies were quite methodically redistributing wealth -
to the wealthy. Women's services and organizations were being reduced or
eliminated. The result, from Health Canada,  was just to reduce the
'downstream' activities: cut health services. The upstream? Not our
department.

So I hope we can force governments to focus on what is needed - in policy,
economics, health services and other areas - to help people keep healthy and
to help those who aren't. Medical model? Health promotion? Population
health? I'm not sure how much I care about the title.

Glen Brown