Feature

Tripe and bondage

Lee Adams takes sides in the health promotion debate

There seem to be so few articles about health education or promotion that it was good to see two in healthmatters issue 2.

One dubbed health education ‘a lot of tripe’ and had a rather unsophisticated go at health education — or what the author described as such anyway. The second was an intriguingly accurate account of recent government actions in relation to national health education organisations — “Bound, gagged and blindfolded”!

The two juxtaposed highlighted the major differences between a medically oriented model of health promotion — or education, as it was known back in the 1950s and early 1960s, and the social or collective action model of health promotion supported by most practitioners today — with good reason.

Turing first to the ‘tripe’ article (I couldn’t make up my mind if it was of a Digby Anderson genre or helpfully attempting to show the narrowness of victim blaming), it is rather disquieting to see effectiveness in health education being equated with Edwina Currie’s promotional activities.

Clearly Dr Lefanu has not been keeping up with research in health education in recent years. Swimming Upstream by Margaret Whitehead was an excellent report published last year on the effectiveness of health education work: sympathisers of the ‘tripe’ view would do well to read it.

Health education/promotion is effective in the right circumstances and with adequate resources. It is very relevant, particularly to major health issues like HIV and Aids, when it is the sole source of preventive programmes. I would agree with Dr Lefanu that social class is a major factor in ill health — although to be fair he only mentioned it in relation to cervical cancer — and that the processes employed by politicians and some health educationalists simply that chronic illness is due to personal weakness, thus obscuring underlying causes.

The second article described approaches favoured by health promotion workers that seek to highlight the link between poverty and ill health and address health inequalities. One such approach — community development — aims to involve people in determining their health needs and deciding how they might be met, focusing on action and change at a variety of levels so that health might be promoted.

This is very much part of the World Health Organisation’s Health For All (HFA) philosophy — that health can most ethically and effectively be promoted by empowering people, and that healthy public policy must be built on public participation in decision making.

I was the director at the Health Education Authority with responsibility for community development during the time of the events the article described. I have chosen not to speak publicly and fully about these events myself yet, although there was substantial press coverage and speculation during 1989.

I hope it will be possible for a full account of this important chapter of health promotion history to become available in the future.

As it happens, the health minister was happy for community development to continue to be supported by the HEA — albeit with the interpretation of self help.

The article concludes that if the HEA drops strategies to reduce inequalities in health, HFA will be a dream that might have been.

The public health movement committed to HFA in this country is vital and strong. Regardless of the HEA, it will continue to thrive. It is important that the HEA takes on its role of lead responsibility for health education — a health education which is not of a crude mode but which reflects the aspirations of thousands of health and welfare workers in this country; one which is potentially very effective is concerned with quality of life as well as quantity.

If it is unable to do so, for whatever reason, it may become irrelevant and opposed to the way theory and practice are developing — that would be a tragic disaster.