Is there Value in Identifying Those
who Oppose Health Promotion?
Dennis Raphael, PhD
School of Health Policy and Management
York University
Keynote Address at
Health Promotion Research: An International Forum
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Trondheim, Norway, August 7, 2012
Today’s Presentation
• Health promotion (HP) is essentially about
power, influence, and resource allocation, i.e.
politics
• Differing models of HP, politics, and policy
change identify differing problems and means
of responding to these problems
• Some models emphasize knowledge
development and transmission, others
emphasize competing interests and competition
among sectors
• Why identify those whose interests are opposed
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to those associated with HP?
Health promotion is essentially
about power, influence, and
resource allocation
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HP Concepts Related to Power and Influence
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As such, HP is Essentially Political
• Quality and distribution of the social
determinants of health are key HP
considerations
• What are the determinants of the quality and
distribution of these social determinants of
health?
• What are the means by which these
determinants of the determinants can be
influenced in the service of HP?
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The World Health Organization states:
• “This unequal distribution of healthdamaging experiences is not in any
sense a ‘natural’ phenomenon but is
the result of a toxic combination of
poor social policies and programmes,
unfair economic arrangements, and
bad politics.”
• Source: World Health Organization. (2008). Closing the Gap in a
Generation: Health Equity Through Action on the Social Determinants
Of Health. Geneva: World Health Organization.
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Four Aspects of Politics
• *Politics as government - Politics is primarily
associated with the art of government and the
activities of the state.
• Politics as public life – Politics is primarily concerned with the
conduct and management of community affairs.
• Politics as conflict resolution – Politics is concerned with the
expression and resolution of conflicts through compromise,
conciliation, negotiation and other strategies.
• *Politics as power – Politics is the process through
which desired outcomes are achieved in the
production, distribution and use of scarce resources in
all areas of social existence.
• Source: Bambra, C., Fox, D., and Scott-Samuel, A. (2005). Towards a
politics of health. HPI, 20, 187-193.
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Politics as Governments and HP
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Politics as Public Life
Percentage of Activity
Percentage of Non-profit Work that is Unpaid Voluntary Activity, mid
1990s
80
70
60
50
40
30
20
10
0
76
61
50
49
39
Sweden
Norway
UK
Finland
USA
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Australia
Wijkström, F. (2004). The Role of Civil Society. The Case of Sweden in International
Comparison. Stockholm: The Stockholm School of Economics.
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Politics as Conflict Resolution and HP
• Finnish politics has a multi-party system and
long tradition of coalition governments. There
has not been a one-party majority
government during the entire time of
Finland’s independence (Mikkonen, 2012).
• Except for the Progress Party, it is fair to say
that the other parties support the Norwegian
welfare state model. However, it is clear that
the parties on the conservative side aim to
reduce public spending and increase
privatisation of public services (Fosse, 2012).
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Politics as Power and HP
Union Densityand Bargaining Coverage
Figure 9.5. Union Density and Collective Agreement Coverage, 2008
100
92
90
90
80
70
72
68.3
67.5
60
60
53.3
50
40
35
27.1
30
32
27.1
18.6
20
11.9 13
10
0
Sweden
Finland
Norway
Union Density
Australia
United
Kingdom
Canada
USA
Collective Bargaining Coverage
11
25
100
20
80
70
60
50
15
40
10
30
Child Poverty Rate
90
5
20
10
0
0
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Union Densityand Bargaining Coverage
Figure 1. Union Density, Collective Agreement Coverage and Child
Poverty, 2008 (density and coverage rates) and Mid 2000s
(poverty rates)
Union Density
Collective Bargaining Coverage
Child Poverty Rate
Data Sources: Organization for Economic Cooperation and Development (2010). Trade Union Density. Available at
http://stats.oecd.org/Index.aspx?DataSetCode=UN_DEN; Venn, D. (2009). Legislation, Collective Bargaining and Enforcement:
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Updating the OECD Employment Protection Indicators, OECD Social Employment and Migration Working Papers, No. 89, Paris:
OECD; Organisation for Economic Cooperation and Development. (2008). Growing Unequal? Income Distribution and Poverty in
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Differing models of health
promotion provide differing ways
of identifying problems and
means of responding to these
problems
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Models of HP
• Health promotion is the process of enabling people to
increase control over, and to improve, their health. It
moves beyond a focus on individual behaviour
towards a wide range of social and environmental
interventions (WHO, 2012).
• Health promotion is the art and science of helping
people discover the synergies between their core
passions and optimal health, enhancing their
motivation to strive for optimal health, and supporting
them in changing their lifestyle to move toward a
state of optimal health (Am. J. Health Promotion,
2012).
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Differing models of HP provide
differing ways of interpreting
policymaking and policy change
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HP Discourses 0: Health Problems…
• Health Problems Result from Genetic
Differences and Biological Dispositions
• Health Problems Result from Inadequate
Access and Quality of Health and Social
Services
• Health Problems Result from Important
Modifiable Medical, Behavioural, and
Community Risk Factors
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HP Discourse 1: Health Problems Result from
Adverse Material Living Conditions
• Health can be improved by improving material
living conditions.
• Carry out research and community
development activities that document a) how
living conditions shape health; and b) means of
improving these conditions.
• Assumes that governmental authorities are
receptive to and will act upon research findings
and community voices.
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HP Discourse 2: Health Problems Result from
Adverse Living Conditions that are a Function of
Group Membership
• Health can be improved by improving the living
conditions of particular disadvantaged groups.
• Target research and development activities
among disadvantaged groups to improve
material living conditions.
• Assumes that governmental authorities are
receptive to such activities and anticipated
outcomes.
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HP Discourse 3: Health Problems Result from
Adverse Material Living Conditions Shaped by
Public Policy
• Health can be improved by advocating for
healthy public policy that reduces
disadvantage.
• Analyze how public policy decisions impact
health (i.e., health impact analysis).
• Assumes that governments will create
public policy on the basis of its effects upon
health.
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HP Discourse 4: Health Problems Result from Adverse
Living Conditions that are Shaped by Economic and
Political Structures and their Justifying Ideologies
• Health inequities can be reduced by influencing
the societal structures that create and justify
health inequities.
• Analyze how the political economy of a nation
creates adverse conditions identifies avenues
for social and political action.
• Requires health promoters engage in building
of social and political movements that will
improve living conditions.
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Source: Saint-Arnaud, S., & Bernard, P. (2003). Convergence or resilience? A
hierarchial cluster analysis of the welfare regimes in advanced countries. Current
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Sociology, 51(5), 499-527.
HP Discourse 5: Health Problems Result from the
Power and Influence of those who Create and
Benefit from Adverse Living Conditions
• Health can be improved by increasing the
power and influence of those who experience
these inequities.
• Critical analysis empowers the disadvantaged
to gain understanding of, and means of
increasing, their influence and power.
• Requires health promoters engage in the
building of social and political movements that
increase the power of the disadvantaged. 23
Consensus models emphasize
knowledge development and
transmission
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The Pluralist View of Public Policy
• Public policy decisions result from
governments and other policymakers
choosing public policy directions based
on the competition of ideas in the public
arena.
• This competition of ideas is facilitated by
various interest groups who lobby
governments to accept their position.
• Those with the better ideas will come to
see their views adopted by governments.
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Therefore, we need to educate
and lobby elected officials and
policymakers to convince them
to promote health
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Conflict models emphasize
competing interests and
competition among sectors
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The Materialist View of Public Policy
• Governments in advanced market-economy
societies enact policies that primarily serve the
interests of economic elites.
• These elites are the owners and managers of
large corporations whose primary goals are to
maximize profits, provide robust profits to
shareholders, and institute public policies that
keep business costs down.
• These interests are usually those who lobby for
minimal governmental intervention in business
practices and resist business and labour
regulation.
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Therefore, we need to educate
and organize citizens to force
policymakers to promote health
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Freidrich Engels, 1844
• In view of all this, it is not surprising that the workingclass has gradually become a race wholly apart from
the English bourgeoisie. The bourgeoisie has more
in common with every other nation of the earth than
with the workers in whose midst it lives. The workers
speak other dialects, have other thoughts and ideals,
other customs and moral principles, a different
religion and other politics than those of the
bourgeoisie. Thus they are two radically dissimilar
nations, as unlike as difference of race could make
them, of whom we on the Continent have known but
one, the bourgeoisie.
• Source: Engels, F. (1845/1987). The Condition of the Working Class in
England. New York: Penguin Classics.
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Rudolf Virchow, 1848
• “The bureaucracy would not, or could not, help the
people. The feudal aristocracy used its money to
indulge in the luxury and the follies of the court, the
army and the cities. The plutocracy, which draw
very large amounts from the Upper Silesian mines,
did not recognize the Upper Silesians as human
beings, but only as tools or, as the expression has
it, “hands.” The clerical hierarchy endorsed the
wretched neediness of the people as a ticket to
heaven.”
• Source: Virchow, R. (1848). Report on the Typhus Epidemic in Upper
Silesia
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Graham Scambler, 2002
• “The GBH (Greedy Bastards Hypothesis)
states, without a hint of hyperbole, that
Britain’s persisting – even widening -- health
inequalities might reasonably be regarded as
the (largely unintended) consequences of the
ever-adaptive behaviours of its (weakly
globalized) power elite, informed by its
(strongly globalized) capital executive.”
• Source: Scambler, G. (2002). Health and Social
Change: A Critical Theory. Buckingham UK: Open
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University Press.
Vicente Navarro, 2009
• “It is not inequalities that kill, but those who
benefit from the inequalities that kill. The
Commission’s studious avoidance of the
category of power (class power, as well as
gender, race, and national power) and how
power is produced and reproduced in political
institutions is the greatest weakness of the
report.”
• Source: Navarro, V. (2009). What we mean by social
determinants of health. Global Health Promotion, 16(1), 516.
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David Langille, 2009
• “The driving forces shaping our social determinants of
health have been the owners and managers of major
transnational enterprises—the men who have defined
our corporate culture and wielded an enormous
influence over public policy. Their main instrument has
been macroeconomic policy, which they have used to
set constraints on the role and scope of government.
They have pushed for Canadian governments to adopt
a free market or neo-liberal approach to
macroeconomic policy.”
• Source: Langille, D. (2009). Follow the money: How business
and politics shape our health. In D. Raphael (Ed.), Social
Determinants of Health: Canadian Perspectives (2nd ed., pp.
305-317). Toronto: Canadian Scholars Press.
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What is the value of identifying
those sectors whose interests
are opposed to those
associated with health
promotion?
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Canadian Case Study
Figure 3.5: Total Average Income by Income
Quintile, All Family Units, Canada, 1995-2008
169,000
55,100
Lowest Quintile
Second Quintile
Fourth Quintile
Highest Quintile
08
20
07
20
06
20
05
22
04
20
03
20
02
20
01
20
00
20
99
19
98
19
97
15,000
19
96
19
19
95
180,000
160,000
128,400
140,000
120,000
100,000
80,000
60,000 47,500
40,000
20,000
0 13,100
Middle Quintile
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Source: Curry-Stevens, A. (2009). When Economic Growth Doesn’t Trickle Down: The
Wage Dimensions of Income Polarization, In D. Raphael (Ed.), Social Determinants of
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Health: Canadian Perspectives (2nd ed., pp. 41-60).
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Langille (2009) argues that in Canada
• By identifying the political actors behind what
are often seen as impersonal market forces,
citizens come to understand that progressive
change is possible—and how they might
improve the social determinants of health.
• If citizens are to reassert their power and
restore democracy, they will first have to raise
public awareness about the threat of
corporate control.
• Source: Langille, D. (2009). Follow the money.
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Canadian Case Study
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Source: Langille, D. (2009). Follow the money.
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Source: Langille, D. (2009). Follow the money.
The value of the approach…
• “Such an analysis puts a human face on the abstract notions
about capital, corporate power, and economic restructuring,
so citizens can know in concrete terms who we are dealing
with if we hope to regulate and redistribute in the public
interest. Regulation and redistribution are key to improving
the many social determinants of health.
• Although some gains can be achieved via local initiatives, it
is clear that overall conditions are continuing to deteriorate
because the federal and provincial governments are being
run according to the needs, interests, and priorities of
transnational corporations. Despite their rhetoric to the
contrary, such corporate policies stand in fundamental and
concrete opposition to the public interest—they are not
conducive to improving the health of Canadians.”
•
Source: Langille, D. (2009). Follow the money.
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New Democrats call for adoption
of national food strategy
• May 16, 2012
• OTTAWA – New Democrats hailed recommendations from
the United Nations Special Rapporteur on the Right to Food,
Olivier De Schutter, who concluded his 11 day visit to
Canada today. Members of the Official Opposition urged
Conservatives to act quickly on the proposals as soon as
possible.
• “Like it or not, the situation is bleak for millions of Canadians.
Food security is a right. Hunger and malnutrition are
unacceptable anywhere, but especially in a country as
wealthy as Canada,” said NDP Aboriginal Affairs Critic, Jean
Crowder.
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Take Away Messages
• Apply analytic models that are helpful in
explaining the threats to health promoting
public policy
• Be willing to put a face to these threatening
forces
• Use these activities to identify means of
harnessing citizen energies in the service of
health promotion
• Engage in politics in all its forms in order to
promote this agenda.
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Dennis Raphael
[email protected]
This presentation and other presentations
and related papers are available at:
http://www.atkinson.yorku.ca/draphael
[go to the library there]
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