Dear Theresa,

I guess you raised some important issues here. *Healthism* is
certainly a great hazard for public health. As Lowell S. Levin once
wrote in a WHO-EURO paper: *Health - the ultimate disease*.

It is difficult indeed to discuss public health issues from a
critical point of view because the instant reaction quite often will
be: are you against health? Or: are you for disease? Or, in case of
tobacco, are you an agent of the tobacco industry? In other words:
you may run the risk of  stigmatization or, even worse, *exclusion
from professional discourse* if you raise critical questions
regarding our own concepts, policies, and practice.

I always felt uncomfortable with *Public Health Ayatollahs* because
I do not believe we're living in a one-dimensional world. Despite
lip-service paid to *holistic concepts* or *comprehensive health
promotion action*, the practice of many approaches is rather narrow
and refers to one topic only. As regards tobacco, for example, a
cross-cultural study on smoking would probably reveal that there is
not one culture on this planet, which is 100% smoke-free (if this
assumption is wrong, please fill me in). A few years ago, I was
stunned when watching a TV feature on tribal communities in Africa -
and what did I see? Well, they were smoking. Not for ritual purpose,
no, just for the fun of it. Drug consumption seems to be human -
whether we like it or not.

Tobacco control policies are necessary - no doubt about this. The
question, however, is whether these policies should consume such an
amount of energy of PUBLIC health practicioners. It seems to me that
this topic has been picked because it's an easy one: there's a
clearly defined *enemy* (tobacco industry) and there's crusaders (or
Ayatollahs) for good health. One side is evil, the other is good.
That's a nice little world, unfortunately, it's an unreal one as
well.

When it comes to more complex issues like housing, urban development
& planning or, even worse, international health, we do not seem to
put as much energy on the table as with tobacco. On the contrary,
regarding international health, I have seen really bad things
happening in the context of foreign aid projects. Health promotors
became agents of engineering companies when it came to selling, for
example, badly devised water & sanitation projects (recently, I came
across an Australian project in the Philippines in which health
promotors acted like sales agents and they were not aware of the type
of their activities because they believed they would *help* the
people; the people, on the other side, claimed that they did not want
the services and the facilities this project was installing in the
province). I believe we should look at our projects and check their
adverse effects regularly.

Of course, health has always been value-loaden. Take for example the
way dictatorial systems exploit public health issues for their
purposes (the Nazi's *population health* - this is the literal
translation of *Volksgesundheit* - aimed at building a uniform
society aiming at total control of body, mind & soul; however,
everything was covered with the banner of *population health*). I
sometimes do see similarities with current *health* policies.

There is a dilemma we have to deal with: we certainly cannot stop
formulating, implementing and evaluating public health policies; but
we also have to be aware of their restrictive implications as far as
individuals and collectives are concerned. In many cases, our
policies have a very weak research basis, and in many cases the
research basis is discussed controversially among *experts*. Take
*drug prevention policies* as an example. Some believe that it should
be *war against drugs*, others favor non-militaristic approaches, but
both sides claim that *research shows ...* Or take a current
Australian debate: the Federal Government intends to put higher
insurance premiums on people who smoke, drink alcohol, and/or take
illicit drugs. At the same time it will put higher insurance premiums
in old-age people because health care costs for old people are
sky-rocketing. Now that's a real dilemma, isn't it? If you want to
contribute to reducing health care costs for old people by smoking
yourself to premature death, you get punished. If you stop smoking
and you may get old, you get punished, too. What does this policy
communicate? It communicates that politicians do not seem to care of
health but of budgets. The electorate gets cynical, that's probably
the most health-hazardous effect of this type of public health
policy.

Public health has not yet become an integral element of policy
development in general. It's more or less seen as an appendix of
policies rather than a principle of policy formation. Plus, in most
of the cases I know of, it's not public HEALTH but public DISEASE
PREVENTION being addressed which, for me, is a completely different
topic.

I apologize for the long posting, but I guess the issues you raised
need even more thoughts than I was able to sketch here.

Thanks for your attention & keep on rocking.


Eberhard Wenzel MA PhD
Griffith University
Faculty of Environmental Sciences
Nathan, Qld. 4111
Australia
Tel.: 61-7-3875 7103
Fax:  61-7-3875 7459
e-mail: [log in to unmask]
http://www.ens.gu.edu.au/eberhard/welcome.htm