Health Promotion - a basic concept
The ‘speciality’ of health promotion strives towards having ‘healthy public policies’. This had been accepted as a basic tenet of public health long ago. The new crusaders for health education in WHO/EURO were obviously ignorant about the fact that the concept of health promotion was recognised as a basic component of the discipline of public health as early as in 1920. One of the pioneers in public health, C.A.E. Winslow, had given a key place to health promotion in the famous definition of public health in a major contribution to the learned journal, Science. Later, in the early 1950s, another eminent public health scholar, H.R. Leavell had very clearly given the first place to health promotion when he defined his famous five ‘levels of prevention’ in a textbook on preventive medicine.
The levels of prevention is based on Leavell’s analysis of the natural history of a disease in an individual. According to him, health promotion is a part of an integral framework for planning and programming for solving a particular community health problem, as dictated by its natural history and the resources available to a community/country. The other levels identified by Leavell are: specific protection; early diagnosis and treatment; disability prevention; and rehabilitation. Both Winslow and Leavell had emphasised that health promotion cannot be seen in isolation. It should emerge as a part of the evolution of health services in a community/country. Providing such basic public health facilities as safe water, safe disposal of human and animal waste, environmental sanitation, adequate and nutritious food, etc., are the prerequisites to good health.
The reference to the new approaches to health education for primary health care is made here to underline the need for giving primacy to people, particularly to the voiceless, so that they get their due from the authorities concerned.

Health Promotion in the 1980s
WHO/EURO ought to have taken into account an important factor before it launched its initiative on health promotion in the mid-1980s. There was already a market driven trend in the rich countries to develop ‘health industry’ as an integral component of their process of market driven economic growth. It must be noted that it was the market activities, and not a conscious action on the part of the health authorities in individual countries in the West, which originated the ‘fashion’ of proper lifestyle among the affluent. The multi-billion dollar fitness industry, with designer clothing, footwear and other paraphernalia, was very much there and thriving at a rapid rate at the time of the conceptualisation of health promotion action by the WHO/EURO. It seems likely that the initiative was more a response to the market needs.
All the concerns mentioned in the foregoing were at the back of my mind as I got ready to attend the Inter-regional Conference on Health Promotion, organised by WHO/EURO in 1985. I had known from my long experience of raising the voice of the voiceless in such gatherings, that those would be dominated by people who would like to ‘forget’ the voiceless. I had also foreseen that there would be very few participants from the poor countries who would have the knowledge, commitment and courage to speak out for the voiceless. They too would love to forget my contentions, however well-argued and objective they might be. I had, therefore, prepared a well supported document to put forward my views. It so happened that my paper was published in the inaugural number of the journal, Health Promotion, published by WHO, under the title: Health Promotion - A View from the South.
As I had feared, the participants from the poor countries showed enthusiasm for the ideas generated at the WHO/EURO. They were almost taken aback when I called into question some of the fundamental principles behind the proposal. It took quite an effort to hammer in these points into them. As their counterparts in the West, they were reluctant to be ‘reminded’ of those whom they have actively banished to live ‘on the other side of the moon’. Those from the rich countries made a valiant effort to divert attention from the basic issues and delve into the areas of healthy lifestyles and healthy public policies, without going into specifics even in their own countries. I had to painstakingly elaborate the conditions that existed in the poor countries of the world and how out of place, indeed hypocritical, would be any campaign for health promotion in countries where a vast majority of the people were forced to live a most degrading life. Those from the rich countries tried hard to ignore these ‘disturbing’ contentions.
In a recent article by Vicente Navarro, a professor at the Johns Hopkins University School of Hygiene and Public Health in International Journal of Health Services, which was the text of the address he delivered to the special session arranged in his honour in the last Annual Conference of the American Public Health Association, he narrated the witch-hunt he and his like-minded colleagues had to suffer during the infamous McCarthy era in the US. Appropriately, Navarro had called this as ‘Intellectual Fascism’. The Intellectual Fascism that is being practiced by the rich on the poor people of the world now is of a more malignant variety.

The unanswered questions
At the time of the WHO/EURO Conference, the coal miners in the United Kingdom were on their historic strike, when the British Coal Board had started its programme of massive closure of the mines. How relevant would be health promotion measures to the hundreds of thousands of those miners in one of the foremost Member State of WHO/EURO?, I asked. There was no answer.
Then taking up the case of the affluent countries as a whole, I harked back to the seminal book of Ivan Illich :Medical Nemesis, where he had called into question some of the basic features of the medical services in the West. Provocatively, he had observed that: ‘Medicine is becoming a threat to the health of the people’! He had drawn attention to the dominant position that the medical profession had secured for itself. There was ‘medicalisation of life’, rapidly eroding people’s own capacity to cope with their health problems. He also spoke, very appropriately, of ‘mystification’ of medical practices. There were also very penetrating observations about medical, social and cultural iatrogenesis, meaning ‘diseases caused by the medical profession itself’. How would practice of health promotion in the affluent countries cope with the issues raised by Illich?, I had asked. After all, dealing with the pathologies that have crept into the medical profession should become an important agenda item for developing the concept and practice of health promotion; it should be an important part of ‘healthy public policy’. There was nothing in the ideas presented by the exponents to deal with such afflictions in the medical profession. This patent reluctance of the participants from the WHO/EURO to touch such ‘sacred cows’ of the market place in effect exposed the political economy of the movement for health promotion. Their message was clear: ‘Health promotion is most welcome when it supports the fast growing health/fitness industry. But do not ask us to do something that comes in the way of one of the most powerful engines for economic growth’!
Predictably, almost deterministi–cally, WHO/EURO could sell its wares on health promotion to the Headquarters of WHO and it became a worldwide concern of WHO. WHO had to ‘forget’ about advocating all the key pillars of the new approaches to health education for primary health care. There were three factors which had to be taken into account by the advocates of health promotion. Firstly, the contradictions in the situations existing in the poor countries were so formidable that it became virtually an impossible task to ‘sell the idea there’. Secondly, even in the WHO/EURO region there were many communities in many countries which needed attention in many other areas of conventional public health and preventive medicine. Thirdly, and by far the most important factor, the exponents of health promotion in WHO/EURO ‘globalised’ this initiative in an effort to legitimise that speciality. With the hindsight of more than a decade and a half, indeed, they succeeded in bringing health promotion in the global agenda of the WHO. But this brought in the overwhelming problems of coping with health issues in the world’s poor countries, which contain a huge majority of its population. In this context, certainly, the cart was firmly placed before the horse.

A selective approach
Unable to cope with the very formidable problems of advocating health promotion in poor countries, or, for that matter, contend with the problems of the underprivileged in the rich countries for example, the unemployed, the drug addicts, the alcoholics, the elderly and the mentally ill and the very serious issues raised by Illich and others, WHO took the now familiar ‘selective’ path of focusing on the rich people who might gain from their drive. The Ottawa Declaration on Health Promotion was their first major initiative taken with the now well familiar fanfare. Almost wearily, I once again pointed out the inadequacies of such thinking in a publication in the World Health Bulletin. Not surprisingly, the caravan of selective health promotion moved on. There was a drive against smoking. Another landmark was the Sydney Declaration on Health Promotion. Some rich cities in the Western countries enthusiastically joined WHO in pushing their programme of ‘Healthy Cities’.

A disturbing score-board
Rather hesitatingly, they finally ventured to test the waters in the poor countries. News went out that Delhi would join the WHO programme of Healthy Cities. The idea was so ludicrous that the Delhi venture became too uncomfortable. Pre-crisis Jakarta, then presided over by President Suharto, was chosen as an alternative. A worldwide conference was held there. The organisers had considerable difficulty in getting their agenda through. Some compromises and some backroom tactics gave shape to the Jakarta Declaration on Health Promotion. It is not necessary here to enter into any discussion on that Declaration. The fact that recently (August 18 1998), when the very severe Indonesian crisis had completed one year, there were newspaper reports quoting a UNICEF warning about the serious condition created by a doubling of the prevalence of severe malnutrition among infants and children. Jakarta thus provided almost an apt, even though somewhat macabre, epithet to health promotion in poor countries. How can they have cake when they do not even get bread?

[top] [index]