HEALTH PROMOTION INTERNATIONAL
# Oxford University Press 1998
Vol. 13, No. 2
Printed in Great Britain
Shifting discourses on health in Canada: from health
promotion to population health
ANN ROBERTSON
Department of Public Health Sciences, University of Toronto, Toronto, Canada
SUMMA RY
This paper argues that discourses on health are products
of the particular social, economic and political context
within which they are produced. In the early 1980s, the
discourse on health in Canada shifted from a postLalonde Report lifestyle behaviour discourse to one
shaped by the discourse on the `social determinants of
health'. In Canada, we are currently witnessing the
emergence of another discourse on healthÐ`population
health'Ðas a guiding framework for health policy and
practice. Grounded in a critical social science perspective
on health and health promotion, this paper critiques the
population health discourse in terms of its underlying
epistemological assumptions and the theoretical and
political implications which follow. Does it matter
whether we talk about `heterogeneities in health' or
`inequities in health'? This paper argues that it does,
and concludes that population health is becoming a
prevailing discourse on health at this particular historical
time in Canada because it provides powerful rhetoric for
the retreat of the welfare state. This paper argues further
that it is health promotion's alignment with the moral
economy of the welfare state that makes it a countervailing discourse on health and its determinants.
Key words: health discourses; health promotion; population health
INT ROD U CT I ON
Discourses on health come into and go out of
fashion, but not arbitrarily. Rather, they emerge
and gain widespread acceptance primarily because
they are more or less congruent with the prevailing
social, political and economic context within
which they are produced, maintained and reproduced. In addition, because they are always
attached to other interests and agendasÐprofessional, economic, political, cultural, ideologicalÐ
the ways in which we conceptualize and speak and
write about health are never just about health; they
also function as repositories and mirrors of our
ideas and beliefs about human nature and the
nature of reality, as well as about the kind of
society we can imagine creating and how best to
achieve it. Examining particular discourses on
health, therefore, provides a unique window onto
these deeper ideas and beliefs.
Discourses on health include the ideas we have
about, and the explanations we offer for, what
health is and what determines it, as well as the
particular practices that are produced by these
ideas. Biomedicine represents the most successful
discourse on health, at least in the Western
industrialized world. Characterized by scientific
medicine with its principles of the specific etiology and nosology of diseases, particular clinical
diagnostic and treatment protocols, all in the
context of the individual physician±patient relationship, biomedicine has functioned as the
dominant discourse on health in Canada, as elsewhere, for most of this century (Lock and
Gordon, 1988). In the last few decades, a countervailing discourse on health has emerged in the
public health arena. Variously called `the new
health promotion' or `the new public health',
155
156 A. Robertson
this alternative discourse has been characterized
by a broad socio-environmental conceptualization of health, a recognition of the social determinants of health, and a call for broad-based
changes in the social and economic environment
in order to improve health (Robertson and Minkler, 1994).
Recently, another discourse on health has
emerged in Canada. In the last 5±6 years, `population health' has become the new `buzz-term' in
health policy circles at both provincial and federal levels, reflected, in some cases, in a change in
name of certain government branches and
departments. Likewise, the term is finding its
way into the health research domain by being
incorporated into the language and guiding principles of recent requests for proposals issued by
major health research funding agencies in
Canada. This paper critically examines the shift
from health promotion to population health as a
guiding discourse for public health policy and
practice in Canada. It argues that this shift is
occurring in the context of an increasingly pervasive public discourse on `fiscal crisis' which, in
turn, provides much of the rhetoric for the current dismantling of the welfare state in Canada.
The first part of this paper discusses briefly the
historical background for this shift in the discourse on health, outlining the central features of
both the new health promotion and population
health. It should be noted here that, while neither
the new health promotion nor population health
exist and function as homogeneous discourses,
for the purposes of this discussion they will be
examined as ideal types. The fundamental differences between the new health promotion and
population health are explicated and, finally,
the policy implications of the shift from health
promotion to population health as a guiding
framework for health policy in Canada are discussed.
HE ALT H DI SC O UR SES I N C AN AD A
Part 1: from lifestyle to social determinants
In the immediate post-World-War-II period in
CanadaÐa period of intense nation-buildingÐ
the discourse on health was very much tied up
with the issues of accessibility to health care. The
provision of universal access to health care has
been regarded as a cornerstone of the Canadian
welfare state, and its final implementation in 1967
strategically coincided with the Centennial celebration of Canadian Confederation. However,
no sooner had the last piece of Canadian medicare been legislated into existence, than the federal government established a task force to
examine the costs of this now universal and
comprehensive health care financing program.
Shortly after this task force reported its findings
(Health and Welfare Canada, 1969), Health and
Welfare Canada published a key health policy
document, A New Perspective on the Health of
Canadians, otherwise known as The Lalonde
Report (Health and Welfare Canada, 1974).
The discourse on health articulated in the
Lalonde Report provided a guiding framework
for health policy, both nationally and internationally; for example, the principles it laid out
were incorporated into the 1980 US Surgeon
General's report (US Surgeon General, 1979).
The Lalonde Report introduced the `Health
Field' concept, an explanatory model of the various factors which determine health. The main
argument of this concept was that access to
health care was not the onlyÐand, perhaps, not
even the most importantÐdeterminant of health,
the other determinants being lifestyle, human
biology and the environment. The lifestyle component of the Health Field came to dominate
health discourse in Canada, and elsewhere,
during the 1970s and early 1980s, institutionalized in health policy and manifested in public
health program planning which emphasized individual-level behaviour change as the most effective strategy for improving health (O'Neill and
Pederson, 1994).
Many critiques have been written of the lifestyle approach to explaining and improving
health (Labonte and Penfold, 1981; Hancock,
1986; Minkler, 1989). Briefly, the primary thrust
of these critiques was that the lifestyle approach,
by neglecting to consider the social, economic
and political context within which individual
health behaviours are both formed and occur,
essentially ends up `blaming the victim' (Ryan,
1976; Labonte and Penfold, 1981). As a result of
these critiques, and also as a result of the growing
awareness that access to health care had not
significantly reduced the inequalities in health
between the richest and the poorest in Canada
(Manga, 1987), an alternative discourse on health
promotion began to emerge in the mid-1980s.
Premised on the notion of the `social determinants of health', and informed by World Health
Organization (WHO) discussion papers (WHO,
Shifting discourses on health in Canada 157
1984, 1986a), documents such as The Ottawa
Charter (WHO, 1986b) and initiatives such as
the `Healthy Cities' movement (Duhl, 1986), this
`new' health discourse found expression in
Canada in the 1986 publication, by Health and
Welfare Canada, of Achieving Health for All,
otherwise known as The Epp Report (Health
and Welfare Canada, 1986). This document,
explicitly recognizing that health outcomes are
affected by factors outside of the health care
sector, emphasized the social determinants of
health, such as poverty, unemployment, poor
housing and other social and economic inequities. It also called for such broad health strategies
as `strengthening communities', `healthy public
policy' and intersectoral action to achieve health.
This health discourse, also known as the `new
public health' or the `new health promotion'
(Robertson and Minkler, 1994), employed concepts such as `community development' and
`empowerment' as key public health strategies
for improving health. It could be argued that
this more socio-environmental discourse on
health did not represent so much a new discourse
as a return to the social reformist character of the
public health movement of the late 19th century
(Labonte, 1986; Szreter, 1988).
Embodying an explicitly social explanation of
health as opposed to a biomedical explanation,
the Epp Report provided a guiding framework
for health policy discussions and initiatives in
Canada, at both the federal and provincial
levels, for the remainder of the 1980s (See Pederson et al., 1994, for a comprehensive overview
of this period in Canada). As indicated earlier,
the field of health promotion is not homogeneous, and encompasses a diverse range of theories, concepts, principles and intervention
strategies. For the purposes of this discussion,
`health promotion' refers to this post-OttawaCharter health promotion discourse, which has
had its greatest influence in North America and
Europe (Kickbusch, 1994). [The recent Jakarta
Declaration on Health Promotion into the 21st
Century (WHO, 1997) and UK Charter for
Health Promotion, National Consultation Draft
(Coronary Prevention Group, 1997) both reiterate much of the language and intent of the
Ottawa Charter, as well as elaborating on the
principles introduced in that earlier document.]
In the early 1990s, another shift in the discourse on health began to occur in Canada.
Part 2: from social determinants to determinants
In 1991, Canadian health economists Robert
Evans and Greg Stoddart published a highly
influential paper in Social Science and Medicine
(Evans and Stoddart, 1990). Entitled `Producing
health, consuming health care', this paper laid
out what were to become the central features of a
newly emerging discourse on health, namely,
population health. This paper was followed in
quick succession by two more influential publications: a 1994 book entitled Why are Some People
Healthy and Others Not? (Evans et al., 1994a);
and the entire fall 1994 issue of Daedalus, The
Journal of the American Academy of Arts and
Sciences, entitled `Health and Wealth' (Daedalus,
1994). The key features of the population health
approach are briefly outlined as follows.
Like the earlier Lalonde Report, the advocates
of population health make the central claim that
health care is not the most important determinant
of health, grounding their arguments in what has
come to be known as `the McKeown thesis',
namely, that medical care had little to do with
the improvements in life expectancy (a commonly
used aggregate measure, along with infant mortality, of the health status of a nation) observed in
the UK at the end of the last century (McKeown,
1979). They also invoke the often-observed relationship between overall health, again measured
as life expectancy, and economic growth as measured by gross national product (GNP), observed
in both developed and developing nations (Wilkinson, 1990, 1992). In spite of later analyses by
Wilkinson (1993, 1994), indicating that those
countries with the smallest income gap between
the richest and the poorest (as measured by the
Gini coefficient) have experienced the biggest
improvements in overall life expectancy, the proponents of population health, explicitly adapting
the `Health Force Field' of the Lalonde Report,
offer a complex model for the explanation of
health, in which everything appears to cause
everything else. In this model, equal weight is
given to all putative `causes' of ill health, and
economic inequities are neutralized and reduced
to a single causal box called `prosperity'. Clearly
missing in the model is any reference to the social,
political and economic context within which
these `causes' are produced (Coburn et al.,
1996; Poland et al., forthcoming).
With their emphasis on epidemiological explanations of health (Hertzman et al., 1994) and the
promises offered by genetic research (Baird,
158 A. Robertson
1994), population health advocates reveal their
commitment to and faith in an ultimately biological explanation of health (Evans et al., 1994b).
In addition, their major recommendation for
improving health status is to take money out of
the health care sector and divert it to the more
`wealth producing' sectors of the economy in
order to increase the GNP, the argument being
that more wealth overall will result in more
health overall. Population health thus reveals
itself as not so much a new discourse on health
as a return to a reductionist epidemiological
explanation of health (Labonte, 1995), but now
wedded to economic thinking. Indeed, the key
formulators of this new discourse on health are
all members of the Canadian Institute for
Advanced Research (CIAR)Ðan eÂlite international group of, primarily, health economists
and epidemiologists, with a smattering of social
scientists and little representation from either the
health promotion or public health fields.
Population health and health promotion, as the
currently competing discourses on health in
Canada, appear to have much in common: both
argue for an explanation of health beyond the
strictly biomedical; both argue for a shift of
resources away from `high-tech', acute, hospital,
physician-based care; both argue for the key role of
income and economic well-being as determinants
of health. However, health promotion and population health differ in several significant ways. One
of the underlying principles of population health,
often expressed by its proponents, is the notion
that, with respect to explanations of differences in
health status and what can be done about them,
`theory divides, data unite' (Evans, 1995); that is,
theory can be dispensed with because the data, or
the `facts', will provide both the explanations as
well as strategic directions for remedial action. As
will be shown below, this notion declares the
foundations of population health in what Guba
(1990) characterizes as the epistemological assumptions of positivism. These assumptions, and
what they reveal about the theoretical underpinnings and political implications of population
healthÐand how these differ from the underlying
principles of health promotionÐare the subject of
the remainder of this paper. By explicating the
fundamental differences between these two discourses on health, this paper also attempts to
show how a health promotion approach gives a
better account of health and the kinds of social
actions we need to take in order to improve it, than
does a population health approach.
Just as with health promotion, the term `population health' has been used to refer to a diverse
range of explanations of and strategies for
improving the health of populations. For the
purposes of this paper, population health refers
to that discourse on health specifically advanced
in the writings of the CIAR.
EP IS TEMO L O GI C AL A SSU MP TI O NS OF
PO P ULA TI O N H EALT H AN D H E ALT H
PR O MO TI O N
Before considering the theoretical and political
implications of population health, it is useful to
examine more closely the positivist epistemological assumptions underlying this discourse, as
revealed in the notion that `theory divides, data
unite', and to compare these with the assumptions underlying health promotion.
Nature speaks
The notion that `data unite' is founded on the
epistemological assumption that `Nature
Speaks'Ðthat is, that social phenomena exist
`out there' in the world, simply awaiting the
right methodological tools in order to be `discovered'. This epistemological positionÐcharacteristic of a positivist stance with respect to the
nature of knowledgeÐignores the extent to
which, according to an alternative epistemological view, social phenomena are socially constructed and that, therefore, the data with which
we represent them are second-order social constructions (Lincoln and Guba, 1985; Guba,
1990).
How is it that data can be considered to be
socially constructed? Firstly, what counts as data
depends on what we judge to be important to
notice in the first place, and then to measure. As
historian of science Thomas Kuhn (1970, p. 7)
says, `the commitments that govern normal
science specify not only what sorts of entities
the universe does contain, but also, by implication, those it does not'. Indeed, the very methodological tools we use for gathering and
analysing dataÐthe survey, the in-depth interview, the logistic regression equation, participant
observationÐthemselves carry ontological and
epistemological assumptions, predicated, first,
on what we think exists `out there' to be discovered and, second, on what phenomena we choose
to isolate and legitimate as data. Again, as Kuhn
argues:
Shifting discourses on health in Canada 159
In short, consciously or not, the decision to employ a
particular piece of apparatus and to use it in a particular way carries an assumption that only certain
sorts of circumstances will arise. (Kuhn, 1970, p. 59)
The second way in which data can be regarded
as socially constructed has to do with the nature
of what it is that typically constitutes data,
namely `variables'. But what is a variable? In
her article on `The tenacious assumptions of
biomedicine', medical anthropologist Deborah
Gordon offers the following definition:
It is an aspect of the situation that can be lifted out of
its context and altered without affecting that context.
In other words, underlying the notion of a variable is a
vision of the universe as a collection . . . of relatively
discrete and encapsulated items. (Gordon, 1988, p. 26)
The idea that aspects of a situation not only
can be but should be decontextualized and still
have any meaning seems problematic (Nord,
1989). We use variables to generate statistics
which, we claim, tell us something about the
world we live in and who we are in it. With its
emphasis on aggregate data, it is difficult to find,
in any of the writings on population health,
actual persons in the context of their particular
concrete daily lives.
On the other hand, with its emphasis on a
broad conceptualization of health and on
person-centred (Edwards, 1996; Raeburn and
Rootman, 1997) and community-based definitions of health issues (Labonte and Robertson,
1996), health promotion makes room for the
stories which individuals and communities tell
about their everyday experiences of health, and
legitimizes them as being as important to our
understanding of health as statistics on morbidity
and mortality rates. In other words, health promotion attempts to put the human faces back on
the statistics, thereby recontextualizing the `variables' which had been removed from their original context.
Data are superior to theory
Another epistemological position revealed in the
statement of `theory divides, data unite' is that
somehow data are superior to theory. This appears
to be based on two underlying assumptions: (i)
that unity is preferable to diversity; and (ii) that
theory is ideological in a way that data are not.
Unity is preferable to diversity
Underlying this view is the assumption that the
different or even contradictory explanations,
which may result from diversity, can and should
be eliminated; and that order and consistencyÐ
as features of unityÐare the `normal' state of
things, or at the very least desirable and achievable. The goal of research is to find the right tools
to get the `facts' right so that we can all agree on
what the problem is and how it should be solved.
Not only is there a `real' Nature to speak, but she
speaks in a univocal way.
Health promotion, on the other hand, acknowledges diversity and does not seek such consensus
(Labonte and Robertson, 1996). Rather, it recognizes that there are multiple discourses on health
and that the accounts we give of health depend
on where we are located in the broader social,
political and economic context (Eakin et al.,
1996). Indeed, with its emphasis on a broad
conceptualization of health and with its explicit
commitment to empowerment, community-based
health planning and participatory action
research, health promotion focuses on opening
up space for those whose voices are often ignored
or left out, namely, the voices of people living
their daily lives in particular locations in the
broader social, political and economic context,
locations that have particular consequences for
their health (Labonte and Robertson, 1996).
Theory as ideological
It would appear that the most damning charge
that can be leveled at any scientific observation or
argument is that it is `ideological'. What this
tends to mean is that it is not objective, not
neutral and, therefore, is `contaminated'Ðat
best, with the investigators' theoretical and methodological biases, at worst, with politics.
The assumption about the ideological nature
of theory and the non-ideological nature of data
is based on an even deeper assumptionÐthat
theory and data can be separated. However, as
many have argued, the criteria with which scientists go into the world in order to investigate it by
gathering data are already theory-laden (Kuhn,
1970; Lincoln and Guba, 1985; Guba, 1990;
Longino, 1990). This is not to say that there is
no world `out there' which we can know, but
rather that we encounter the world `out there' in
terms of the multiple worlds `in here'. As philosopher of science, Helen Longino, says:
Our experience is a product of the interaction of our
senses, our conceptual apparatus, and . . . what aspects
of `the world out there' we choose or are directed by
intellectual or other commitments to interact with. There
160 A. Robertson
is always much more going on about us than we are
aware of, not just because some of it is beyond our
sensory thresholds or behind our backs but because in
giving coherence to our experience we by necessity
select out some facts and ignore others. (Longino,
1990, p. 221; emphasis added)
In other words, Nature may speak but what
she says is always interpreted by human beings
making certain choices based on certain preferencesÐideological, political, philosophical, professional, etc. Research represents one kind of
interpretive activity, albeit more systematic than
other forms of inquiry, but rarely, as researchers,
do we make explicit which `commitments', as
Longino calls them, are being given preference
in our acts of interpretation.
A health promotion approach, based on a
critical social science perspective (Eakin et al.,
1996), attempts to be explicit about its epistemological commitments. By aligning itself with naturalistic inquiry (Lincoln and Guba, 1985; Guba,
1990; Labonte and Robertson, 1996), health promotion makes a commitment to a reflexive stance
on the part of the researcher. As a paradigm of
inquiry, naturalistic inquiry starts from the premise that, as researchers, we do not occupy some
privileged position outside of the social reality we
study, but rather that our beliefs and values
about the world, and who we are in it, influence
our inquiries about the world, and consequently
determine what we can say about it and ourselves.
In contrast, behind the notion that `data unite'
is an assumption that scientific inquiry not only
should be, but can be, neutral and autonomous.
From this position, knowledge `is supposed to be
stripped of value and present only facts. Truth
tells us how things work `naturally', not ideologically' (Gordon, 1988). Yet, it would appear
that the most powerfully ideological practices are
those which claim that their facts are non-ideological because they are scientific (Navarro,
1980). The point then, with a slight twist on
Tesh's (1990) argument, is not to get the ideology
out of science but to get the ideology out of
hiding.
In order to disclose its hidden ideology, this
paper now considers the theoretical underpinnings of population health.
U N DER LY IN G TH EO R ETI CA L
A SSU MP TI ON S OF PO PU LA TI O N
H EA LTH A ND H EA LTH PR O MO TI O N
As a result of its underlying epistemological
assumptions, revealed in the notion that `theory
divides, data unite', population health is, on the
surface at least, atheoretical. Grounded in an
apparently theoretically neutral epidemiological
account of health based on population-level morbidity and mortality rates, population health does
not appear to be based on any theory of society
and social change. This seems consistent with the
thinly veiled contempt of theory revealed in the
notion `theory divides, data unite'.
However, if we probe a little deeper into the
theoretical foundations of population health
what we find is an implicit theory that social
change is brought about by adjustments in the
economy. One of the recommendations of the
proponents of a population health discourse is to
shift resources out of the health care sector and
into the productive sector, the argument being
that the greater wealth which will be produced
will produce more health for everyone; this
appears to be a version of the `trickle-down'
theory of market-based capitalism as espoused
by conservative economic thinking which currently prevails. What is left out of this implicit
theoretical position is any consideration of how
capitalismÐand the power, privilege and structural inequity associated with this particular
mode of productionÐhas direct effects on
health (Navarro, 1976; Laurell, 1989; Navarro,
1990). In other words, we are left holding the
proverbial theoretical black box.
With the concept of `social determinants of
health', health promotion, on the other hand,
takes an explicit theoretical position with respect
to what it is that makes some people healthy and
others not: namely, that systematic and systemic
social and economic inequities (in terms of access
to a range of social and economic resources such
as money and power and esteem) are major
factors affecting the health of individuals and
certain social groups. For example, research
demonstrating the income gradient for all major
diseases indicates not only that the poor get more
diseases than those of us who are better off, but
also that when they get them they are sicker, and
they have poorer health outcomes in terms of
long-term morbidity or mortality (see the entire
20 April 1996 issue of the British Medical Journal); in other words, poverty is a major risk factor
Shifting discourses on health in Canada 161
for poor health. Research on hypertension
amongst African-American males (Klag et al.,
1991) and on the relative low-birth-weight rates
of African-American babies irrespective of
maternal socio-economic status (Wise and Pursley, 1992), indicates that it is not race but rather
racism that is and continues to be, a major risk
factor for poorer health status of African-Americans. Research like this tells us that there is
something about our current social, political
and economic arrangements which is bad for
people's health.
Proponents of population health might justifiably counter with the argument that `social determinants of health' is as much a theoretical black
box as the `trickle-down' theory of greater wealth
production. It behooves those of us who have a
commitment to the social determinants of health
explanation of health to take up this challenge, to
begin to unpack our own black box and to
propose theoretical frameworks which might
account for the dialectical relationships which
we claim exist between health and social phenomena, such as poverty and racism. Research on the
relationship between control and health (Rodin,
1986; Syme, 1986) begins to suggest how it is that
social facts may become biological facts.
PO LI TI CA L I MPLI C ATI O N S O F
PO PU LAT IO N H EA LTH AN D H EAL TH
PRO MO T IO N
What is politically problematic about population
health is a consequence of its epistemological and
theoretical limitations. Why this desire for the
unity which, it is assumed, data will deliver?
What is it that inclines us to privilege unity and
closure over difference and openness? I would
argue that the answers are linked to what political scientist Deborah Stone (1988) calls the `the
rationality project'. If the problem of human
needs can be framed as a technical problem
based on objective scientific knowledge, then we
can avoid the `messiness' of politics. And, I
would add, we can avoid the even more dreaded
messiness of moral reasoning. Inherent in the
notion that `theory divides, data unite' is the
assumption that knowledge and its production
are separate from politics or morality.
We knowÐand have known since the middle
of the last century (Szreter, 1988)Ðthat it is the
poorest amongst us who are the sickest; shouldn't
this tell us something? We also know that it is not
the absolute levels of wealth which determine a
country's overall level of healthfulness (at least,
as indicated by life expectancy); rather, it is the
relative levels of wealth, that is, the gap between
the richest and the poorest which is significantÐ
the bigger the gap, the lower the overall life
expectancy (Wilkinson, 1994). In other words,
economic inequities are bad for everybody's
health, rich and poor. We also know that the
countries with the highest GNPs do not necessarily have the smallest wealth gap between rich
and poor (Wilkinson, 1994). Doesn't this tell us
something more? Would this not seem to be an
argument for changing the way in which we
redistribute wealthÐexisting wealth, that isÐ
rather than simply producing more of it in the
context of current redistributive mechanisms?
This has less to do with economics and wealth,
or even science, and more to do with social values
and political will. Ironically, even though much
of the data linking overall health status to overall
economic well-being are provided by population
health advocates, with the exception of more
recent work by Wilkinson (1996) little of this
kind of political reasoning appears in the writings
on population health.
In contrast, health promotion, based on the
social determinants of health, is explicitly political.
Proponents of health promotion concur with the
population health analysis that health care does
not necessarily produce health. However, with its
emphasis on structural inequities, health promotion argues for a very different social agenda for
improving health than does population health. A
health promotion approach calls for a reallocation
of resources towards other sectors which affect
healthÐsuch as housing and employment. Health
promotion strategiesÐa significant component of
which is `healthy public policy' (Milio, 1981)Ð
also include such broad policy measures as local
economic development and the amendment of
taxation policy to effect more equitable income
distribution (Labonte, 1986).
It has become fashionable, ever since publication of Thomas McKeown's (1979) momentous
book, The Role of Medicine, to minimize the
contribution of health care to the improvement
in the health of the population. However, Simon
Szreter (1988), a history of medicine scholar at
Cambridge, reminds us that it was not simply
Adam Smith's `invisible hand' of wealth that
provided the key to health improvements. They
were, to a great extent, the result of the constellation of a number of factors, including: improved
162 A. Robertson
sanitation, nutrition, living and working conditions, and family planning. And, as Szreter
demonstrates, these did not occur `naturally',
but rather as the result of the efforts of a coalition
of public health reformers, labour activists, and
others working from reformist social and political agendas. These are the historical roots of the
current health promotion movement which,
unlike population health, is not only explicitly
political but also explicitly normative (Robertson, forthcoming). This is not to deny, however,
the usefulness of systematic scientific inquiry of
diverse kinds to illuminate the political and normative stands to be taken.
An underlying moral economy of health
promotion
This paper concludes with a discussion of the
normative aspect of health promotion. Because
of its commitment to a social justice agenda
(Labonte, 1986; Minkler, 1989; Robertson, forthcoming), health promotion is aligned with the
underlying moral economy of the welfare state.
The moral issue at the heart of the modern
welfare society is: when does need give people the
right to make a claim against the collective? Any
given society's answer to this question is embodied in its `moral economy'. Political scientist
Deborah Stone (1984, p. 19) characterizes the
concept of moral economy thus:
The moral economy of a society is its set of beliefs
about what constitutes just exchange: not only about
how economic exchange is to be conducted in normal
times but also . . . when poor individuals are entitled to
social aid, when better-off people are obligated to
provide aid, and what kinds of claims anyoneÐlandowners, employer, governmentsÐcan legitimately
make on the surplus product of anyone else.
Moral economy is, therefore, grounded in `the
collectively shared basic moral assumptions constituting a system of reciprocal relations' (Kohli,
1991, p. 275). E. P. Thompson (1966) originally
introduced the term `moral economy' to refer to
the principles of fairness and custom which
formed the moral underpinnings of the late eighteenth/early nineteenth century food riots that
occurred in England in reaction to increases in
the cost of bread. Despite the unease with which
many political economists consider the notion of
`moral economy', Kohli (1991, p. 274) argues that
speaking of moral economy shifts the emphasis from
individual motivations . . . to the system of reciprocal
relations . . . [and] allows us to extend the argument
beyond the political and economic sphere in a narrow
sense . . . squarely into an analysis of the moral
structure of the economy and polity themselves.
Recent discussions about the concept of `social
capital' also invoke moral economy notions of
reciprocity. Social capital `refers to features of
social organization, such as networks, norms,
and trust, that facilitate coordination and cooperation for mutual benefit' (Putnam, 1993,
pp. 35±36). In a recent analysis of the effects of
regionalization in Italy during the 1970s, it was
argued that the prosperous communities in
north-central Italy, which have a long history of
civic involvement and social solidarity, did not
become civic because they were rich; rather, `the
historical record suggests . . . [that] they became
rich because they were civic' (Putnam, 1993,
p. 37). The important thing about social capital
is that, as a public good and unlike physical
capital, it increases with use; additionally, `a
society that relies on generalized reciprocity is
more efficient than a distrustful one . . . [for] trust
lubricates social life' (Putnam, 1993, p. 37). It is
interesting to note that both the Jakarta Declaration and the UK Charter for Health Promotion
invoke this notion of `social capital'.
Political scientist Michael Walzer emphasizes
this essential relationship between a generalized
reciprocity and the life of the community when he
says that societies and communities come
together, in part, around the communal provision
of needs:
Political community for the sake of provision, provision for the sake of community: the process works both
ways and that is perhaps its crucial feature. (Walzer,
1983, p. 64)
It could be argued that any society or community is essentially characterized by the kinds of
needs it recognizes and collectively provides for,
and the extent to which it provides for those
needs. Stone (1988, p. 82) argues that `communal
provision . . . may be the most important force
holding communities together'. In a similar spirit,
and in opposition to the prevailing economic
view of human behaviour, historian Michael
Ignatieff says:
It is as common for us to need things on behalf of
others, to need good schools for the sake of our
children, safe streets for the sake of our neighbours,
decent old people's homes for the strangers at our
door, as it is for us to need them for ourselves. The
deepest motivational springs of political involvement are
Shifting discourses on health in Canada 163
to be located in this human capacity to feel needs for
others. (Ignatieff, 1984, p. 17; emphasis added)
For a relatively recent challenge to the neo-classical economics view of `economic man' as a
rational actor who makes individual rational
choices in the marketplace of goods and services
on the basis of endogenous preferences, see A
Quiet Revolution in Welfare Economics (Hahnel
and Albert, 1990).
The welfare state of many late-20th-century
Western nations, including Canada, represents
an institutionalized mechanism for communal
provision. One of the fundamental principles
underlying the moral economy of the welfare
state is the principle of universality. Richard
Titmuss, the late social policy analyst and defender of the British welfare state, has provided
some of the most eloquent moral economy arguments for the principle of universality:
The emphasis today on `welfare' and the `benefits of
welfare' often tends to obscure the fundamental fact
that for many consumers the services are not essentially
benefits or increments to welfare at all; they represent
partial compensation for disservices, for social costs
and social insecurities which are the product of a
rapidly changing industrial±urban society. They are
part of the price we pay to some people for bearing
part of the cost of other people's progress. (Titmuss,
1968, p. 119; emphasis added)
Titmuss believed in a `social theory of causality' of misfortune, that the disadvantaged are `the
social pathologies of other people's progress'
(Titmuss, 1968, p. 134), capturing this thinking
in the concept of `diswelfare'. Titmuss defends
the welfare state on the basis of its integrative
function and the positive effects on community
solidarity (Reisman, 1977, p. 69), and argues for
universal `social institutions that foster integration and discourage alienation' (Titmuss, 1968,
p. 133). Ignatieff (1984, p. 141), too, acknowledges the moral underpinnings of the welfare
state when he says, `the moral relations that exist
between my income and the needs of strangers at
my door pass through the arteries of the state'. In
other words, institutionalized redistribution, in
the form of the welfare state, acknowledges in a
profound way the moral basis of society.
With its emphasis on the relationship between
ill health and structurally based social and economic inequities, and on strategies such as
empowerment, community development and
healthy public policy, health promotion demonstrates its alignment with the underlying moral
economy of the welfare state (Robertson, forthcoming). It is in this sense that this paper argues
that health promotion gives a better account of
health and the kinds of social actions which are
necessary to assure and improve it than does
population health.
As indicated earlier, with a few exceptions
(Wilkinson, 1994, 1996), population health
lacks an explicit normative component. Producing more wealth overallÐa central health strategy of population healthÐmay not necessarily
improve the health of the most vulnerable
amongst us or, indeed, the general level of healthfulnessÐunless attention is paid explicitly to the
question `cui bono?', that is, `who benefits?'. This
necessitates a consideration of the net distributive
effect of this greater wealth generation, a fundamentally moral question, and one which is rarely
considered in the cost±benefit analyses which
now function as the anemic substitutes for political and moral reasoning.
C O NC LU SI O N
There is an increasing body of evidence that it is
wealth and social inequalities which create health
inequalities (see, for example, British Medical
Journal, 312, 20 April 1996). But as a recent article
puts it: `the growing gap between rich and poor
has not been ordained by extraterrestrial beings. It
has been created by the policies of governments'
(Montague, 1996). In these days of widespread
fiscal conservatism, based on the rhetoric of `fiscal
crisis', it should be no surprise that population
health appears to have gained considerable currency at all levels of government in Canada.
Unintended as it may be, population health provides powerful justification for major cutbacks in
health care, the Canadian version of health care
`reform'. Taking resources out of the health care
sector is precisely what politicians with neo-liberal
fiscal and social agendas want to hear. But we
have no guarantee that, in these mean-spirited
times, these resources will be reallocated in any
other way which will improve the lives and health
of the most disadvantaged amongst us. Seemingly
paradoxically, those of us who are committed to a
health promotion approach, based on the social
determinants of health, may find ourselves
arguing against cuts in funding for health care.
The removal of resources from the health care
sector, advocated by the proponents of population health, can only penalize further those whose
164 A. Robertson
health is already compromisd by underlying
structural inequities. And, if, as a society, we
are not prepared to do anything about those
underlying structural inequities, then ensuring
equitable access to health care, at the very least,
represents an acknowledgement that these inequities do exist. Universal publicly funded access to
health care stands as a powerful political symbol
of our commitment to the moral economy of
collective provision which lies at the heart of
what it means to be a community.
A fundamental conviction of this paper is that
words and ideasÐand the discourses which
convey themÐmatter. Words matter because
`what we cannot imagine and express in language
has little chance of becoming a sociological reality' (Bellah et al., 1991, p. 15) and because `the
way we name things and discuss them shapes our
feelings, judgments, choices, and actions, including political actions' (Glendon, 1991, p. 11). Ideas
matter because `our strongest bulwark against
demagoguery is the habit of critical discussion
about and self-conscious awareness of the public
ideas that envelop us' (Reich, 1988, p. 10). The
language and ideas of the market, corporatism
and globalization currently pervade public discourse and provide the rationale for the current
and near-universal rapid retreat of the welfare
state. As an explanation of health with particular
political and economic implications, population
health provides additional fuel to these prevailing
public ideas. Health promotion offers the possibility of a countervailing discourse (Baum and
Sanders, 1995; Robertson, forthcoming).
It matters that we speak of `inequities in health'
as health promotion does, thereby pointing to the
underlying structural causes of poor health,
rather than speaking, as population health does,
of `heterogeneities in health', a term with a thin
veneer of political neutrality. Heterogeneities in
health are an interesting topic of scientific investigation; inequities in health demand redress.
ACK N O WLED G EMEN TS
This paper was conceived and written in the
context of the stimulating and supportive group
discussions of the Critical Social Science in
Health Group at the University of Toronto.
This group includes (in alphabetical order):
David Coburn, Joan Eakin, Richard Edwards,
Lois Jackson, Rhonda Love, Patricia McKeever,
Michael Polanyi, Ann Pederson and Blake
Poland. The author also gratefully acknowledges
the helpful comments of anonymous reviewers on
an earlier version of this manuscript.
Address for correspondence:
Ann Robertson
Department of Public Health Sciences
McMurrich Building
University of Toronto
Toronto
Ontario M5S 1A8
Canada
R EFER EN CE S
Baird, P. A. (1994) The role of genetics in population health.
In Evans, R. G., Barer, M. L. and Marmor, T. R. (eds) Why
are Some People Healthy and Others Not? The Determinants
of Health of Populations. Aldine de Gruyter, New York.
Baum, F. and Sanders, D. (1995) Can health promotion and
primary prevention achieve Health for All without returning to their radical. Health Promotion International, 10,
149±160.
Bellah, R. N., Madsen, R., Sullivan, W. M., Swidler, A. and
Tipton, S. M. (1991) The Good Society. Alfred A. Knopf,
New York.
Coburn, D., Poland, B. with members of the Critical Social
Science in Health Group (1996) The CIAR vision of health:
a critique. Canadian Journal of Public Health, 87, 308±310.
Coronary Prevention Group (1997) UK Charter for Health
Promotion. Coronary Prevention Group, London.
Daedalus (1994) Health and wealth. Daedalus, 123(4).
Duhl, L. (1986) The healthy city: its function and its future.
Health Promotion, 1, 55±60.
Eakin, J., Robertson, A., Poland, B., Coburn, D. and
Edwards, R. (1996) Towards a critical social science perspective on health promotion research. Health Promotion
International, 11, 157±165.
Edwards, R. E. (1996) Conditions for a science of health
promotion: theory and research on the health of persons.
Unpublished PhD dissertation, University of Toronto.
Evans, R. G. (1995) Theory divides, data unite: health promotion meets population health. Rosenstadt Lectureship.
University of Toronto.
Evans, R. G. and Stoddart, G. L. (1990) Producing health,
consuming health care. Social Science and Medicine, 31,
1347±1363.
Evans, R. G., Barer, M. L. and Marmor, T. R. (eds) (1994a)
Why are Some People Healthy and Others Not? The Determinants of Health of Populations. Aldine de Gruyter, New
York.
Evans, R. G., Hodge, M. and Pless, I. B. (1994b) If not
genetics, then what? Biological pathways and population
health. In Evans, R. G., Barer, M. L. and Marmor, T. R.
(eds) Why are Some People Healthy and Others Not? The
Determinants of Health of Populations. Aldine de Gruyter,
New York.
Glendon, M. A. (1991) Rights Talk: The Impoverishment of
Political Discourse. The Free Press, New York.
Gordon, D. R. (1988) Tenacious assumptions in Western
medicine. In Lock, M. and Gordon, D. R. (eds) Biomedicine
Examined. Kluwer Academic, Dordrecht.
Shifting discourses on health in Canada 165
Guba, E. (ed.) (1990) The Paradigm Dialog. Sage, Newbury
Park, CA.
Hahnel, R. and Albert, M. (1990) A Quiet Revolution in Welfare
Economics. Princeton University Press, Princeton, NJ.
Hancock, T. (1986) Lalonde and beyond: looking back at `A
New Perspective on the Health of Canadians'. Health
Promotion, 1, 93±100.
Health and Welfare Canada (1969) Report of the Task Force
on the Costs of Health Care. Government of Canada,
Ottawa.
Health and Welfare Canada (1974) A New Perspective on the
Health of Canadians. Government of Canada, Ottawa.
Health and Welfare Canada (1986) Achieving Health for All:
A Framework for Health Promotion. Government of
Canada, Ottawa.
Hertzman, C., Frank, J. and Evans, R. G. (1994) Heterogeneities in health status and the determinants of population health. In Evans, R. G., Barer, M. L. and Marmor, T.
R. (eds) Why are Some People Healthy and Others Not? The
Determinants of Health of Populations. Aldine de Gruyter,
New York.
Ignatieff, M. (1984) The Needs of Strangers. Penguin Books,
Harmondsworth.
Kickbusch, I. (1994) Introduction: tell me a story. In Pederson, A., O'Neill, M. and Rootman, I. (eds) Health Promotion in Canada: Provincial, National and International
Perspectives. W. B. Saunders Canada, Toronto.
Klag, M., Whelton, P., Coresh, J., Grim, C. and Kuller, L.
(1991) The association of skin color with blood pressure in
U.S. blacks with low socio-economic status. Journal of the
American Medical Association, 256, 599±602.
Kohli, M. (1991) Retirement and the moral economy: an
historical interpretation of the German Case. In Minkler,
M. and Estes, C. L. (eds) Critical Perspectives on Aging: The
Political and Moral Economy of Growing Old. Baywood,
Amityville, NY.
Kuhn, T. (1970) The Structure of Scientific Revolutions. University of Chicago Press, Chicago, IL.
Labonte, R. (1986) Social inequality and healthy public
policy. Health Promotion, 1, 341±351.
Labonte, R. (1995) Population health and health promotion:
what do they have to say to each other? Canadian Journal of
Public Health, 86, 165±168.
Labonte, R. and Penfold, S. (1981) Health Promotion Philosophy: From Victim-blaming to Social Responsibility. Health
Promotion Directorate, Western Regional Office, Vancouver.
Labonte, R. and Robertson, A. (1996) Delivering the goods,
showing our stuff: the case for a constructivist paradigm for
health promotion research. Health Education Quarterly, 23,
431±447.
Laurell, A. C. (1989) Social analysis of collective health in
Latin America. Social Science and Medicine, 28, 1183±1191.
Lincoln, Y. and Guba, E. (1985) Naturalistic Inquiry. Sage,
Beverly Hills, CA.
Lock, M. and Gordon, D. R. (eds) (1988) Biomedicine Examined. Kluwer Academic, Dordrecht.
Longino, H. E. (1990) Science as Social Knowledge. Princeton
University Press, Princeton, NJ.
Manga, P. (1987) Equality of access and inequalities in health
status: policy implications of a paradox. In Coburn, D. (ed.)
Health and Canadian Society. Fitzhenry & Whiteside, Toronto.
McKeown, T. (1979) The Role of Medicine: Dream, Mirage or
Nemesis?, 2nd edn. Basil Blackwell, Oxford.
Milio, N. (1981) Promoting Health Through Public Policy. F.
A. Davis, Philadelphia, PA.
Minkler, M. (1989) Health education, health promotion and
the open society: an historical perspective. Health Education
Quarterly, 16, 17±30.
Montague, P. (1996) Economic inequality and health.
Rachel's Environment and Health, 497 (6 June).
Navarro, V. (1976) Medicine under Capitalism. Prodist, New
York.
Navarro, V. (1980) Work, ideology, and science: the case of
medicine. Social Science and Medicine, 14C, 191±205.
Navarro, V. (1990) Race or class versus race and class:
mortality differentials in the United States. Lancet, 336,
1238±1240.
Nord, E. (1989) The significance of contextual factors in
valuing health status. Health Policy, 13, 189±198.
O'Neill, M. and Pederson, A. (1994) Two analytic paths for
understanding Canadian developments in health promotion.
In Pederson, A., O'Neill, M. and Rootman, I. (eds) Health
Promotion in Canada: Provincial, National and International
Perspectives. W. B. Saunders Canada, Toronto.
Pederson, A., O'Neill, M. and Rootman, I. (eds) (1994)
Health Promotion in Canada: Provincial, National and
International Perspectives. W. B. Saunders Canada, Toronto.
Poland, B., Coburn, D., Robertson, A. and Eakin, J. (forthcoming) Wealth, equity and health care: a critique of a
population health perspective on the determinants of
health. Social Science and Medicine.
Putnam, R. D. (1993) The prosperous community: social
capital and public life. The American Prospect, 13
(Spring), 35±43.
Raeburn, J. and Rootman, I. (1997) People Centred Health
Promotion. John Wiley & Sons, London.
Reich, R. B. (ed.) (1988) The Power of Public Ideas. Ballinger,
Cambridge, MA.
Reisman, D. (1977) Richard Titmuss: Welfare and Society.
Heinemann, London.
Robertson, A. (forthcoming) Health promotion and the
common good: reflections on the politics of need. In Callahan, D. (ed.) Ethical Issues in Health Promotion and
Disease Prevention. Georgetown University Press, Georgetown, DC.
Robertson, A. and Minkler, M. (1994) New health promotion
movement: a critical examination. Health Education Quarterly, 21, 295±312.
Rodin, J. (1986) Health, control, and aging. In Baltes, M. M.
and Baltes, P. B. (eds) The Psychology of Control and Aging.
Lawrence Erlbaum Associates, Hillsdale, NJ, pp. 139±165.
Ryan, W. (1976) Blaming the Victim, 2nd edn. Random
House, New York.
Stone, D. A. (1984) The Disabled State. Temple University
Press, Philadelphia, PA.
Stone, D. A. (1988) Policy Paradox and Political Reason. Scott,
Foresman/Little, Brown College Division, Glenview, IL.
Syme, S. L. (1986) Social determinants of health and disease.
In Last, J. M. (ed.) Public Health and Preventive Medicine.
Appleton±Century±Crofts, Norwalk, CT.
Szreter, S. (1988) The importance of social intervention in
Britain's mortality decline c. 1850±1914: a re-interpretation
of the role of public health. The Society for the Social
History of Medicine, 1, 1±41.
Tesh, S. (1990) Hidden Arguments: Political Ideology and
Disease Prevention Policy. Rutgers University Press, New
Brunswick, NJ and London.
166 A. Robertson
Thompson, E. P. (1966) The Making of the English Working
Classes. Vintage Books, New York.
Titmuss, R. M. (1968) Commitment to Welfare. George Allen
& Unwin, London.
US Surgeon General (1979) Healthy People: The Surgeon
General's Report on Health Promotion and Disease Prevention. Department of Health, Education and Welfare,
Washington, DC.
Walzer, M. (1983) Spheres of Justice. Basic Books, New York.
Wilkinson, R. G. (1990) Income distribution and mortality: a
`natural' experiment. Sociology of Health and Illness, 12,
391±411.
Wilkinson, R. G. (1992) Income distribution and life expectancy. British Medical Journal, 304, 165±168.
Wilkinson, R. G. (1993) The impact of income inequality on
life expectancy. In Platt, S., Thomas, H., Scott, S. and
Williams, G. (eds) Locating Health: Sociological and Historical Explorations. Avebury, Aldershot.
Wilkinson, R. G. (1994) The epidemiological transition: from
material scarcity to social disadvantage. Daedalus, 123, 61±
77.
Wilkinson, R. G. (1996) Unhealthy Societies: The Afflictions
of Inequality. Routledge, London.
Wise, P. H. and Pursley, D. M. (1992) Infant mortality as a
social mirror. New England Journal of Medicine, 326, 1558.
World Health Organization (1984) Report of the Working
Group on the Concept and Principles of Health Promotion.
WHO, Copenhagen.
World Health Organization (1986a) A discussion document
on the concept and principles of health promotion. Health
Promotion, 1, 73±78.
World Health Organization (1986b) Ottawa Charter for
Health Promotion. WHO, Copenhagen.
World Health Organization (1997) The Jakarta Declaration
on Health Promotion into the 21st Century. WHO,
Geneva.