Feature

A broader horizon for health promotion

Our environment is too important to be left to environmentalists. Public health and health promotion specialists must get involved, argue Andrew Rogers and Desmond Whyms

Sustainable development represents a major new opportunity for health promotion. At the Rio summit conference in 1992 many governments, including our own, committed themselves to a comprehensive blueprint for achieving the global shift towards sustainable development - Agenda 21.

That plan includes a chapter on the protection and promotion of human health and is based on the premise that progress towards a healthy life requires a powerful input from public health and health promotion professionals.

Yet it seems as though health promotion is in danger of missing this opportunity. In June 1994 a symposium on ‘Health and the Urban Environment’ organised by the UK Health For All Network, the Public Health Trust and the British Council, was held in Manchester alongside Global Forum ’94 - the official follow-up to Rio. While it attracted wide international representation, the response from public health and health promotion specialists at home was disappointing despite the calls of the early 1990s for public health to ‘turn green’ and return to the environmental approach characteristic of the 19th century’s ‘golden age of public health’. Sustainable development not only offers the chance to resurrect this model, but also ‘re-invents’ public health with an environmental and strong socio-political core.

So why does it seem we are missing the boat? We believe there are a number of reasons.

Public health within the NHS has been diverted from the wider influences on health to the Health of the Nation paper-chase, or to medical consultancy to the contracting process. The ‘champion of the people’ role has been curtailed because of the pressure to perform this fundamental - and fundamentally narrow - function. At the same time public health departments are being reduced in size and health promotion departments are being cast out into provider trusts. Often these contain the very people that had been performing wider public health work, such as working across agency boundaries developing initiatives aimed at tackling the root causes of ill health.

There is evidence from around Britain that previously robust interagency structures based upon Health For All have been ‘hijacked’ and redefined as ‘healthy alliances’. But these alliances are now focused narrowly around a medical agenda rather than being focused around HFA settings and principles. While most districts now have interagency groups for the Health of the Nation target areas, this appears to have taken time, energy and resources away from other interagency groups.

In theory, sustainable development should be core public health work, yet it doesn’t have a box to tick in the Corporate Contract or Purchasing Plan, which are now the main drivers within HAs. The input required to progress sustainable development is great, both conceptually and in terms of time. At the moment the most common reaction to sustainable development from health promotion and public health specialists is either total ignorance or a recognition of the issue, but a difficulty in fully grasping the concept and its importance. But unless this is recognised as legitimate and essential public health activity, practitioners will find it is yet another area of work done in their own time, unsupported, or not done at all. The alternative is that sustainable development will progress with a health input being provided by practitioners who may not have much understanding of the social, political, economic and environmental underpinning of health.

A number of authors have written extensively on the connection between health and sustainable development. Unfortunately, these are often little more than descriptive lists restating that at every level the environment determines the health status of individuals and communities. The concept of sustainable development is difficult. But is this new to us? Health as a concept is difficult! In both cases not attempting to dig deeper into the issues can lead only a superficial approach, without tackling the underlying causes.

Draper suggests two strategies for keeping on top of the task.¹ First, he suggests we learn and teach about the relationships between health and sustainable development, citing the position paper published by the Public Health Alliance.² But worryingly, Draper suggests we focus on ‘anything that helps sustainable development’. The concept of ‘think global, act local’ is well known to those active on environmental issues. To adopt a similar approach to health and sustainability is attractive, as it allows us to feel at least we are doing something constructive. The critique offered by the renowned psycholinguist and philosopher Noam Chomsky is sobering here. Whether the issue is environmental degradation, determinants of health status or the causes of criminal behaviour, focusing at all on the surface manifestation in itself diverts attention away from the fundamental economic and political foundations of the problem. In doing so we effectively conspire to ensure these fundamentals are neither adequately addressed nor changed.

The issues identified above are exaggerated by the divisive mechanisms by which, conceptually and practically, the issues of health, environment and economics are kept apart. The agenda for improving health is regarded primarily as the responsibility of the NHS, whereas the sustainable development agenda is the remit of local authorities. While this evidently should not be so, we need only examine the dissemination process of the Health of the Nation and the UK government’s sustainable development strategy to see how only token acknowledgement is given to the role of building effective healthy alliances, usually at the most superficial level.

Although these add up to powerful obstacles to integrating health and sustainable development, they are not insurmountable. Labonté believes health professionals should not wait to be invited to participate in sustainable development debates, but should invite themselves.³ Before doing so it is important to clarify the place of health in relation to the other major dimensions of sustainable development: community, economy and environment. Hancock proposes that health is the central consideration and the product of the interaction of these three spheres.⁴

This is contentious: sustainable development is a broad church, and other members of the congregation will claim other issues to be the central focus of the interacting dimensions. Whatever its place, it is essential that ‘health’ in its fullest sense is emphasised in the ongoing discourse of sustainable development.

Labonté offers ethical and health-based principles to guide the process of conflict resolution when community, economy, environment and health are brought together. We should not allow ourselves to be side-tracked from preoccupation with one set of symptoms (individual ill health) to another (specific examples of environmental degradation) without being aware of the underlying cause: namely a profoundly flawed and unsustainable economic infrastructure which seeks to create short term ‘profits’ (of resources, money and health) for the few, while exploiting individuals, communities and the natural environment to ensure ‘growth’.

We recognise that this article may stir up debate within health promotion, public health and sustainable development circles. We believe debate is necessary and long overdue - not a debate about whether health is affected by environment, but a much more fundamental debate about the factors that underpin both.

For a readable and critical analysis of such factors we recommend a chapter by Eric Ross which reminds us of the need to understand the political ecology of health and not to get side-tracked into a ‘fluffy bunny’ romantic construction of nature and environmentalism.⁵

At local level Agenda 21 groups should already have been set up. We urge health promotion practitioners to get involved. The role of sustainable development needs to be articulated clearly within the NHS. Greater academic debate is needed on sustainable development and health promotion. The Public Health Alliance has made its views clear. Now we should expect to hear from the Faculty of Public Health Medicine, the British Medical Association, the Royal College of Nursing and the Society of Health Education and Promotion Specialists.