RHP&EO is the electronic journal of the International Union for Health Promotion and Education

The welfare of the future: A Swedish case study

Lennart Levi
WHO Collaborating Research and Training Centre on Psychosocial Factors and Health,
Karolinska Institute, Stockholm, Sweden

1. Introduction

This paper is based on the philosophy of "Investment for Health". According to a common dictionary the verb "invest" is defined as a commitment (of money or capital, technology, human resources, etc.) in order to gain a return, to spend or devote for future advantage or benefit". Consequently, an investment for health refers to a commitment of resources in order to gain a health and social return. Seen in such a way, the investment does not constitute a burden, but an opportunity for increasing returns.

"Investment for health refers to resources which are explicitly dedicated to the production of health and health gain. They may be invested by public and private agencies as well as by people as individuals and groups. Investment for health strategies are based on knowledge about the determinants of health and seek to gain political commitment to healthy public policies."

In the area of working life, an important ILO (1975) resolution states that "work should not only respect workers´ lives and health and leave them free time for rest and leisure, but also allow them to serve society and achieve self-fulfillment by developing their personal capabilities". Given these prerequisites, it is easy to motivate both full employment and "healthy work". A good job is good for health, in its broadest sense, as defined by WHO (1946) as "not only the absence of disease and infirmity but also a state of complete physical, mental and social wellbeing". Unfortunately, a sizeable proportion of all people of working age are, and are likely to remain, unemployed or underemployed, while another sizeable minority is exposed to overemployment and/or other conditions of work not conducive to good health.

2. The Actual Unemployment Rate

In a special Parliamentary sitting which took place in July 1996, the proposals of the Swedish Government and the Centre Party for unemployment measures up until the year 2000 and the counter proposals of the opposition, were discussed.

The level of ambition in all of the proposals was universally cautious. All aimed to cut both 'open' and 'total' unemployment by half. This would have meant a reduction from 8% to 4% in the 'open' unemployment rate, and from 13% to 6.5% in the 'total' unemployment rate.

All parties were careful, however, not to mention the actual unemployment rate. During the summer of 1996, no less than 26.7% of the population of working age (Berg 1996) were more or less permanently excluded from the labour market. Even the most optimistic of the Government's and the Opposition's various scenarios would still mean that between a quarter and a fifth of Sweden´s population of working age would be permanently excluded from the labour market at the turn of the millennium.

A good job (cf. Jahoda, 1979) helps to give life purpose and meaning. It provides the day, week, year and lifetime with structure and content. The worker gains identity and self-esteem and is able to give and receive social support in social networks. In addition, a job provides material advantages and a reasonable living.

A person excluded from the labour market risks losing or perhaps never even accessing all of these things (except perhaps the latter).

At the same time, the remaining workforce is put under an ever greater strain as fewer workers have to carry out the same or an even greater amount of work, and large numbers of individuals not in the workforce have to be provided for.

3. Stressors At Work

All this contributes to conditions of work that are reported to be highly stressful in a number of respects and potentially pathogenic even in our Swedish welfare state (ASS and SCB, 1996 and 1997):

• too heavy a burden of work;
• insufficient time to complete one’s job to one’s own satisfaction;
• too much responsibility in relation to one´s authority and rights;
• unclear work instructions and work role;
• unclear goals and meaning;
• no or insufficient support from one's supervisor and fellow workers;
• no reward for a job well done; and lack of feedback;
• lack of decision latitude, influence and control over one's own work situation;
• exposure to violence or threath of violence;
• exposure to discrimination, mobbing, offence;
• unsatisfactory conditions in one’s physical work environment;
• underutilization of one's capacity and knowledge;
• conditions in whom one’s mistakes or failures induce high costs or risk other people's health and life;
• risk of losing one's job.

Many of the stressors listed above can be summarized in three major dimensions, as proposed in a model by Karasek, Theorell and Johnson (Karasek and Theorell, 1990; Johnson, 1986).

Figure 1. A 3-dimensional model of the relation between the social environment and health (Karasek and Theorell, 1990; Johnson, 1986)

These are:

• environmental demands
• the control exercised by the individual on his/her situation
• the degree of social support available to the individual.

As hypothetized, the most pathogenic combination turns out to be the one characterized by high load, low control and low support. In contrast, high load combined with high control and high support is considered to constitute a "positive stress". Here, the situation becomes a challenge and not a burden.

4. Over- And Unemployment

Briefly, Sweden is facing a combination of over- and unemployment. Out of 5.3 million people in working age, only 3.9 million are gainfully employed. At least

500 000 unemployed are fully fit for work; and another 500 000 are conditionally fit for work, yet unemployed.

As the unemployed pay little or no tax, this leads to a strong decrease in total revenue basis and a corresponding increase in belttightening. The total fiscal costs of unemployment in Sweden have been estimated to 153 billion SEK (Behrenz and Delander, 1997).

At the same time, 53% of those still at work report "far too much to do" (not "lean" but "anorectic" production). Similarly, there is a widespread fear of: quitting; reporting industrial injury; or register and/or ask economic compensation for overtime worked. In addition, a type of captivity in unsuitable jobs is created - employees do not dare to quit jobs they do not like or are unsuited for, because it seems better to have a bad job with tenure than a better one that one may loose at any time due to the practice - last hired, first fired.

All of these situations can be detrimental to health and well-being. Overemployment, unemployment and unsatisfactory conditions of work, all cause stress (Levi, 1972, 1981, 1984; Kompier and Levi, 1994, Levi and Lunde-Jensen 1997; Dooley et al., 1996) and stress can lead to ill-health (see below) as well as reduced physical, mental and social well-being - the contrary of welfare. This is where we are heading. The question is whether we have already reached this point. And there are no signs of any real improvement.

The above example concerning some important social determinants of health illustrates the changes taking place in one of our most important social environments and the effects that these changes might have on the health and well-being of the population and subsequently on its welfare.

5. Childhood, Family Life

Another area highly relevant to welfare is the social environment of children and young persons (Levi, 1975, 1978).

In Sweden, the situation for families with children has improved in many respects. There are better opportunities for parents to stay at home with sick children. Parents of young children have a better entitlement to shorter working hours and childcare facilities have been extended.

One might expect, then, to find a corresponding psychosocially related improvement in the state of health of Swedish children and young persons. However, no such improvement has been observed. One in three Swedish children or young persons suffers from mental or psychosomatic problems. Psychosomatic symptoms such as irritability, nervousness and sleeping problems are especially - and increasingly - common (Marklund, 1997; Public Health Report, 1997). According to statistics compiled by UNICEF (1997)

• 90% of Sweden´s municipalities have cut their staff for childcare (1994);
• every year 40-50,000 children and adolescents experience their parents divorce;
• 16% of all children live together with a single parent;
• 48% of the single mothers of the country have difficulties to sustain themselves and their children;
• in 1993, 221,000 children lived in families who depended on social welfare;
• one out of ten 11-16 years old lives with at least one parent who is unemployed;
• the proportion of pupils in the ninth grade, reporting psychosomatic problems is 80% higher among those who often or always worry about their family’s economy in comparison to those who do this rarely or never;
• suicidal actions among young people have doubled since the 50s.

According to Andersson and Hibell (1996), 30% of the boys and 20% of the girls in the ninth grade in Sweden consume at least 5 cans of beer, or 60 cl of wine, or 37 cl of liquor at a time at least once a month. 39% of both sexes report getting drunk every or almost every time they consume alcohol. 8 % of the boys and 7% of the girls report having used illicit drugs.

Needless to say, one of the main objectives in the work for the welfare of the future generations is to remedy these and similar phenomena, their causes and consequences.

This should be another crucially important component in a well structured and comprehensive investment for health approach.

6. Stress - what is it?

German pathologist Rudolf Virchow (1821-1902) formulated a die-hard dogma stating that every disease is conditioned by a single specific and clearly defined cause - for example, the tubercle bacillus in the case of tuberculosis. The 'father' of the biological stress concept, the Canadian biologist Hans Selye, in turn, proved that exposure to a wide variety of stressors could lead to similar patterns of changes in the functioning and structure of organs and organ systems. His findings lay the foundations of today's more complex ecological view of aetiology and pathogenesis.

The notion that physical and chemical environmental influences - for example, nuclear radiation, short asbestos fibres, lead, mercury and organic solvents - can damage health and well-being is widely established and accepted. However, it is harder to demonstrate and to find acceptance for the notion that psychosocial influences brought about by social conditions and conveyed by processes within the central nervous system can have similar effects (Levi, 1979; Kompier and Levi, 1994).

The kind of questions which have been raised are: Can stress make you ill, for example by causing blood pressure to rise to unhealthy levels or by causing heart attacks (myocardial infarction)? Does the fact of whether or not we have a stimulating, evolving and satisfying job have any effect on our health? Do people living in the relative slums of mass housing programs remain as healthy as those living in well-designed residential districts?

Fortunately, more and more people today are beginning to realise we cannot look to biomedicine alone to find the answers to these questions. We need to look further afield and to take into consideration both the conditions of life, the ways people cope with these conditions and the resulting stress effects - the combination of discomfort and the organism's subsequent 'step into overdrive' - which can damage health and well-being.

Needless to say, an investment for health approach should draw heavily on this knowledge.

This awareness has been summarized some 14 years ago in the Swedish Government's "Public Health Service (Lines of Development) Bill", No. 1984/85:181, approved by the Parliament of Sweden on March 21, 1985. Some excerpts:

"Our health is determined in large measure by our living conditions and lifestyle."

"The health risks in contemporary society take the form of, for instance, work, traffic and living environments that are physically and socially deficient, unemployment and the threat of unemployment, abuse of alcohol and narcotics, consumption of tobacco, unsuitable dietary habits, as well as psychological and social strains associated with our relationships - and lack of relationships - with our fellow beings."

"These health risks ... are now a major determinant of our possibilities of living a healthy life. This is true of practically all the health risks which give rise to today´s most common diseases, e.g. cardiovascular disorders, mental ill health, tumours and allergies, as well as accidents."

"... Care must start from a holistic approach ... By a holistic approach we mean that people´s symptoms and illnesses, their causes and consequences, are appraised in both a medical and a psychological and social perspective."

7. Pathogenic Mechanisms

Research carried out in recent decades has widened our knowledge on the subject. Social epidemiological methods have shown that certain individuals and groups, in certain types of socio-economic situations, exhibit a higher (or lower) degree of poor health and/or mortality than other groups in other situations. (cf. Swedish Public Health Report, 1997; British Government´s Green Paper "Our Healthier Nation", 1998). The mechanisms which mediate such effects on health have also been studied experimentally, both in animals and humans, in laboratory settings and in field studies.

Four different types of pathogenic (disease-provoking) mechanisms have been identified (cf. Levi, 1979).

Emotional reactions. When we have problems at home or at work for example, we may react emotionally with anxiety, worry, depression, fatigue, insecurity, feelings of hopelessness and helplessness. Some become hypochondriacal by interpreting normal proprioceptive impulses as "symptoms" and beginning to suffer from all sorts of strange sensations, aches and pains. All this adds to an increasing strain on the overburdened health services and rising costs of social welfare.

Cognitive reactions can lead to our finding it harder to remember things, to learn new things, to concentrate on our tasks and to make decisions. Thus, as a result of the stressors we are exposed to, we risk losing part of our intellectual capacity in situations when we need it the most.

Behavioural reactions. The stressors we are exposed to can also change those aspects of our behaviour which influence our health. We start to use alcohol as 'self-medication' to ease worry, anxiety and depression. We smoke more to stimulate ourselves, to comfort ourselves or to relax. We think less about healthy eating - this normally results in consuming more fat and less fibre. Separately or combined, all this can produce a severe impact on morbidity and mortality.

In addition, our behaviour may become more passive and/or self-destructive. We do not comply with instructions provided by health care workers. Or we do not even care to report our problems and ask for professional help. Some aspects of directly self-destructive behaviour lead to major public health problems. In Sweden, 1 800 people commit suicide every year (in a population of 8.8 million), and 18 000 attempt to do so. Suicide is the most common cause of death in Swedish males aged 25-44 and second most common in Swedish females of the same age.

Physiological stress reactions. A further category of pathogenic mechanisms comprises the physiological stress reactions. Primary ones occur in the nervous, hormonal and immunological defence systems which secondarily affect the function and structure of cardiovascular, gastrointestinal, skeletomuscular, urogenital, pulmonary and other organs and organ systems.

An estimate made in a WHO teleconference (October 12, 1990) indicates that such "diseases of lifestyle" are the cause of 70 - 80% of premature deaths in industrialized countries.

This insight was expressed about one decade earlier by the U.S. Secretary of Health, Education and Welfare (Califano, 1979) in three summarizing sentences about these "modern killers":

• We are killing ourselves by our own careless habits
• We are killing ourselves by carelessly polluting the environment
• We are killing ourselves by permitting harmful social conditions to persist.

To sum up: every organ and system of organs can be affected, by psychosocial and physicochemical stressors. The type and degree of the outcomes of such an influence depend on the type, intensity and duration of stimuli, the 'programming' of the organism and the conditions under which the exposure occurs. The negative effects that need to be identified and prevented are due to components in the person-environment ecosystem that are

• necessary,
• sufficient, or
• contributory, in

• causing disease
• accelerating its course
• triggering its symptoms.

It is, of course, equally important to identify and promote corresponding components that are necessary, sufficient, or contributory in causing or promoting health and wellbeing.

8. Health Outcomes

Some examples: one of the major causes of death is cardiovascular diseases. Research in recent years has shown strong links between heart disease and lifestyles which are characterised by stress, melancholy, low decision latitude and loneliness. (Karasek and Theorell, 1990; Theorell and Johnson, 1998).

Corresponding findings have been made with regard to cancer. The main causes of cancer are neither industrial effluent nor pesticides from agriculture, but rather two aspects of human behaviour. People eat too much fat and too little fibre, and they smoke too much. Not primarily to obstruct public health policies, but possibly as a

reaction to "the slings and arrows of outrageous fortune" to which they are exposed.

Many of these maladaptive reactions are the same type of reactions that enabled primeval man's survival in his fight for existence in the forests and on the savannahs of those times. Faced with threats and other pressing demands of its environment, the human organism reacted by preparing to fight, to flee, to use its muscles. This generally promoted the survival of both the individual and the species. Since then, our biological programming has remained largely unchanged. The environment around us, on the other hand, has undergone very drastic changes and thus our stone-age reaction patterns have become increasingly inadequate and obsolete (cf. Levi, 1971).

Furthermore, the man-made conditions governing our lives are changing at an ever increasing rate, without taking into account our biological heredity and the boundaries that this sets on our ability to adapt. This has subsequently lead to a dramatic change in the overall spectrum of diseases. Neither social policy nor medical training and research have taken these rapid changes into consideration and adapted to them.

One major obstacle to all such attempts is the extreme complexity of the systems under consideration. Ideally, diagnosis, therapy, and prevention should take this complexity into account by applying a systems approach. Instead, both political and professional approaches are usually simplistic - either as fragmented, ad hoc actions, or, worse, as a search for, or belief in, a "silver bullet" that is expected to solve all problems, in all respects.

As already emphasized, the situations, their causes, effects, and interrelationships, are extremely complex. Therefore, according to James Grier Miller, "one should simplify as much as possible - but not more". An attempt to do this is presented by Kagan and Levi (1975), with minor modifications (Levi, 1997):

Figure 2. Human ecological system. Human element detailed (Kagan & Levi, 1975)

According to this model, we are surrounded by nature (box 1, fig. 2), whose influences on us we modify and adjust by social arrangements, i.e. social structures and processes (box 2). These reach us through our senses. Their actions are experienced, filtered and appraised by the brain, resulting in psychosocial stimuli (box 3). These act on a human organism characterized by a psychobiological programme (box 4), conditioned by earlier environmental influences and genetic factors. The interaction between all before mentioned factors makes the organism react. Some of these reactions are related to health, while others are not. In this context we focus on the former. Some of these mechanisms (box 5) are specific in the sense that they are related to one individual stressor or to certain individual characteristics of the organism, or lead to a specific type of morbidity or mortality. Others are non-specific in the sense that they are triggered by many conditions, in many types of individuals and relate to many types of morbidity and mortality. The latter have been defined as stress (Selye, 1936).

 These mechanisms might lead to precursors of disease (box 6) and to disease or lack of well-being (box 7). This sequence of events is not a one-way flow but takes place in a system with many feedback loops. What occurs in "box" 5 through 7 acts back on the social structures and processes, their appraisal, the resulting stimuli and the psychobiological programme, sometimes creating vicious circles. This flow of events is modified by interacting variables (box 8), the most important ones being the presence or absence of social support and its utilization, and the coping repertoire of the individual in terms of problem or emotion oriented approaches.

What we need to identify is

• the content of each "box"
• the interaction between the "boxes", and
• the dynamics of the entire system.

Once this has been achieved, we can try to prevent disease and promote health by addressing

• social structures and processes
• the way people appraise these social structures and processes
• the resulting stimuli
• the psychobiological programme
• other pathogenic emotional, cognitive, behavioural and physiological mechanisms
• the precursors of disease
• the diseases and the lack of well-being and
• the interacting variables (by improving social support and coping repertoire).

Needless to say, to become more effective, these approaches could and should be combined and integrated.

The above description obviously has a bias towards prevention of pathogenesis. However, it could, and should, be complemented by a corresponding promotion of salutogenesis.

9. Salutogenes

Needless to say, not all (or even most) psychosocial (or physical, or chemical) stimuli act pathogenetically. Some have no effects on health, whilst others do counteract disease, or even promote health and well-being.

In medicine, the emphasis is, and has always been, on negative outcomes and what may lead to them - on pathogenesis, morbidity and mortality, i.e., on pathology. The latter is the scientific study of the nature of disease and its causes. It comes from the prefix 'patho', from Latin and Greek 'pathos', suffering. Genesis, the origin, the coming into being of something, comes from Latin and Greek. Accordingly, pathogenesis may be defined as "the development of a diseased condition".

In contrast, something can be salutary, i.e., favourable to health, wholesome. The term is derived from old French 'salutaire' from Latin 'salutaris', from 'salus', health.

Analogously, salutogenesis (cf. Antonovsky, 1987) could be defined as "the development of a condition of health".

According to the founding fathers of WHO (1946), health could be characterized as "not only the absence of disease or infirmity but also a state of complete physical, mental and social well-being".

How, then, can disease be prevented (and health promoted)? Theoretically, this can be done in accordance with principles spelled out in the EU Framework Directive (89/391/EEC), according to which employers have a "duty to ensure the safety and health of workers in every aspect related to the work, on the basis of the following general principles of prevention:

• avoiding risks;
• evaluating the risks which cannot be avoided;
• combating the risks at source;
• adapting the work to the individual, especially as regards the

design of workplaces, the choices of work equipment and the choice of working and production methods, with a view, in particular, to alleviating monotonous work and work at a predetermined work rate and to reducing their effects on health;

• developing a coherent overall prevention policy (my italics)

which covers technology, organization of work, working conditions, social relationships and the influence of factors related to the working environment."

Related approaches to disease prevention and investment for health should, of course, be considered also for non-work aspects of human life, including level of living areas such as

• education and training
• economic resources
• housing
• transports and communication
• leisure and recreation
• social relations
• political resources
• safety and security
• health and medical services
• equality and equity.

The EU Framework Directive restricts itself to conditions of work, thereby limiting itself to an "8-hours-a-day approach". The remaining 16 hours should, of course, also be considered.

Swedish developments in this field do, of course, not occur in a vacuum. They are influenced by, and influence, corresponding processes in other countries and in international organizations. Some examples of such developments are given below.

10. Influences From Other Countries

As early as in the beginning of the 1970s, WHO began to develop an understanding of these issues. The Director-General of WHO wrote to the ministers of health in all member states asking them for their view on the significance of psychosocial factors for health and healthcare. The replies were so positive that the 27th World Health Assembly (1974) came to be focused on these questions and resolved to give priority to such issues with regard to research, education/training and policies.

A special sector within this framework has been the psychosocial working environment and how it can influence the health and well-being of the labour force. Two UN bodies, WHO and the International Labour Office (ILO) addressed these issues, first independently and then together, and agreed on a joint report, which was approved in 1986 by both WHO's Executive Board and by ILO's Governing Body. The report thereby became the joint policy document of these two UN bodies, with recommendations to the government and the parties on the labour market in each of the Member States (ILO, 1986).

The report defines the concept of psychosocial factors at work and describes these factors and their positive and negative impact on workers’ health. It reviews current knowledge of the methods of measuring and monitoring psychosocial factors at work and proposes various means of prevention, such as education, workers’ participation and practically oriented research. The subject matter of this report has subsequently been updated by both WHO (Kalimo et al, 1987) and ILO (1992). Related issues were discussed and a Declaration adopted at the UN Social Summit (1995).

This largest gathering yet of world leaders - 117 heads of State or Government - pledged to make the conquest of poverty, the goal of full employment and the fostering of stable, safe and just societies their overriding objectives. These objectives, in turn, constitute basic investments for health, although they were not explicitly classified as such.

Among the agreements made by the world’s leaders in the Declaration are commitments to:

• eradicate absolute poverty;
• support full employment;
• promote social integration;
• achieve equality and equity;
• accelerate the development of the least developed countries;
• ensure that structural adjustment programmes include social development goals;
• increase resources allocated to social development;
• create "an economic, political, social, cultural and legal environment that will enable people to achieve social development";
• attain universal and equitable access to education and primary health care; and
• strengthen cooperation for social development through the UN.

A comprehensive analysis of socio-economic and health problems in Russia and their interrelationships was published by UNICEF (Cornia, 1994) and is also an input of the 1988 Verona Initiative. An updated version of it is part of the input for the first Arena meeting. The Russian Ministry of Health (1995) has also published an analysis of the entire problem area - "Towards a Healthy Russia" (1995). Ways to cope with these multiple and complex clusters of problems were further discussed at international conferences in Moscow (1996) and St. Petersburg (1997), (Cullen et al., under preparation).

In the United States, psychosocial aspects of preventive medicine were discussed in one of the background papers for the Surgeon General’s Report on Health Promotion and Disease Prevention (Levi, 1979), and, again, in the National Academy of Sciences Institute of Medicine report on Stress (Elliot & Eisdorfer, 1982) and in its chapter on working life (Levi, Frankenhaeuser and Gardell, 1982). Subsequently, the American Psychological Association, in collaboration with the U.S. National Institute of Occupational Safety and Health (NIOSH) has organized three major conferences and published their proceedings (Keita and Sauter, 1992; Quick et al., 1992; Keita and Hurrell, 1994; Murphy et al., 1995; Sauter and Murphy, 1995; Gowing et al., 1998.)

In the beginning of the 1990's, an EU body, the European Foundation for the Improvement of Living and Working Conditions conducted a large-scale survey on a representative sample of the labour force in the then twelve member states of the EU (Paoli, 1992). It was found that the conventional components in working environments, industrial welfare and occupational medicine had increasingly given way to 'stress problems in working life'. Based on this awareness, and on the initiative of the European Commission, an EU Conference was held in Brussels in November 1993. The conclusions formulated at the conference (EU, 1994) were completely in line with the above mentioned ones from WHO and ILO.

A few years later, the European Foundation carried out its second large-scale survey, sending out its questionnaire to a random selection of the 147 million employees in the EU's presently 15 Member States (Paoli, 1997). Again, the impressive extent of psychosocial and welfare problems and their key significance on the health of the population was highlighted. Now aware of this, the European Commission appointed an 'Ad-Hoc Group' whose function was to propose measures to combat 'Work Related Stress'. The group's report was issued in the autumn of 1996, and soon after endorsed by the EU Advisory Committee for Safety, Hygiene and Health Protection at Work (CEC, 1997). Its unanimous recommendations concern the need for

• support for research;
• preparation of a guidance note for national guidelines;
• exchange of information on work-related stress; and
• education, training and information.

Again, to be effective, this requires a systems approach.

According to a common dictionary, a "system" can be seen as "a group of interacting, interrelated, or interdependant elements forming a complex whole". A systems analysis accordingly implies "the study of an activity or a procedure to determine the desired end and the most efficient method (s) of obtaining this end". The term is derived from late Latin "systema", from Greek "sustema" - to combine.

11. Our Healthier Nation - A Contract For Health

A most interesting initiative along these lines has been made recently by the British Government, who has presented its Green Paper on "Our Healthier Nation - A Contract For Health" to the British Parliament in February 1998. In essence, this paper spells out five types of factors affecting health. The first cathegory is referred to as "fixed". It includes genes, sex and ageing, and is accordingly difficult to influence in a disease preventing and/or health promoting manner. In contrast, the other four cathegories could and should be approached:

• social and economic (such as employment, poverty, social exclusion)
• environment (such as air and water quality, housing, and social environment)
• lifestyle (such as physical activity, diet, smoking, alcohol, sexual behaviour, drugs) and
• access to services (such as education, health and social services, transport, and leisure).

All these and related factors can be dealt with in a coordinated, systems approach, across sectors and societal levels, in a Contract for Health. The three groups of partners in such a contract are

• central government and national players
• local players and communities, and
• all citizens.

Examples of what these three cathegories of players can do are given below.

A Contract for Health

Government and National Players can:	Local Players and Communities can:	People can:
Provide national coordination and leadership. Ensure that policy making across Government takes full account of health and is well informed by research and the best expertise available. Work with other countries for international cooperation to improve health. Assess risks and communicate those risks clearly to the public. Ensure that the public and others have the information they need to improve their health. Regulate and legislate where necessary. Tackle the root causes of ill health.	Provide leadership for local health strategies by developing and implementing Health Improvement Programmes. Work in partnerships to improve the health of local people and tackle the root causes of ill health. Plan and provide high quality services to everyone who needs them.	Take responsibility for their own health and make healthier choices about their lifestyle. Ensure their own actions do not harm the health of others. Take opportunities to better their lives and their families’ lives, through education, training and employment.

Figure 3. A Contract for Health (British Government, 1998).

As pointed out by Kickbusch (1997), the Investment for Health approach has far-reaching implications. Quoting the Human Development Report (1997) she points out that eradicating world poverty would cost only 1% of global income, and no more than 2-3% of the respective national incomes and that this investment would also eliminate a significant part of the global disease burden.

It is likely that the benefits, not only in human but also in economic terms, would far exceed the necessary investment. As support for such a view, she quotes the report on "Health, Nutrition and Population" by the World Bank (1997), according to which

• global health spending amounted to USD 2,330 billion, i.e. 9% of global GDP (1994);
• USD 250 billion, i.e. 11% of this, concerned middle and low income countries;
• 84% of the world´s population live in these countries;
• they carry 93% of the world´s disease burden;
• their health expenditure is expected to increase by USD 9 billion annually;
• this would suffice to cover the preventive and curative services for the 900 million world poor who still lacksuch services.

Kickbusch (1997) further draws attention to and makes a distinction between "traditional hazards", related to poverty and insufficient development, and "modern hazards", related to rapid development that lacks safeguards, and to unsustainable consumption. She considers health promotion to be "a theory based process of social change contributing to the goal of human development, building on many disciplines and applying interdisciplinary knowledge in a professional, methodical and creative way". In her view, "health promotion outcome" can be determined by an organized, partnership-based community effort contributing to health, quality of life and social capital of a society.

Thus, there is a growing awareness - nationally and internationally - of the problems that people are experiencing both with regard to their social situation and to their health, well-being and quality of life as well as of ways to prevent ill health and promote health and well-being. However, there still seems to be a long way to go before effective measures are taken to deal with existing problems, to prevent other ones from occurring, and to the promotion of positive health. There is a wide science-policy gap. The high unemployment in Sweden and in most of the other 14 EU Member States serves as an example of this inability.

12. Continued High Unemployment?

EU seasonally-adjusted unemployment at end-December 1997 fell slightly to 10.5% (Eurostat). This compares with 10.6% at end-November and 10.8% at end of both 1996 and 1995.

Spain’s 21.0% was still by far the EU’s highest rate. Lowest was Luxembourg’s 3.6%. Next lowest was Austria with 4.4%.

EU average for men was 9.1%, 0.4% percentage points down on the year. For women it was 12.5%, same as at end of ‘96 and ‘95. Lowest EU-wide rate was 7.7% for men 25 and over - a fall on 8.0% at end of the two previous years.

Under-25s remained hardest hit - 18.7% for young men and 22.2% for young women at the year-end, but down on the 20.2% and 23.2% respectively seen at end of both ‘96 and ‘95. Spanish under-25 rates were still 33.5% for men and 46.9% for women, little changed.

Eurostat estimates 17.7 million men and women were unemployed in the EU in December 1997. This seasonally-adjusted figure in line with ILO criteria is 370,000 fewer than in December 1996.

In comparison, US and Japanese unemployment stood at 4,7% and 3.4% respectively (October, 1997).

The EU's Social Commissioner, Mr. P. Flynn, has bluntly pointed out that these European figures are ‘intolerable’. Part of their intolerability lies in the fact that unemployment within the EU costs as much as ECU 200 billion (SEK 1,800 billion) annually. This is much more than the entire Swedish national debt and as much as the total gross national product of Belgium. It is indeed intolerable - from both public health, welfare and financial perspectives.

The fact that it is also financially intolerable perhaps gives us cause for hope that the labour market's three parties - the employers, the employees and the Governments - will eventually realise that it is in their common interest to increase employment and productivity without increasing wear (cf. Cooper et al, 1996; Levi and Lunde-Jensen, 1996). If wear is also increased, the longer term results are both lower productivity and higher social and health costs - which of course is beneficial to no-one.

 The international competitiveness of Sweden and other industrial countries depends on people having jobs, the jobs being good jobs, people working hard and feeling well. There are thus many reasons to work towards achieving full employment and at the same time to attempt to humanise the organisation and content of working life (and of our living conditions as a whole!). This means not putting too much pressure on people but at the same time not excluding them from various forms of fellowship, including a sense of community at work.

 As already emphasized, at least half a million people in Sweden today (out of a working age population of 5.3 million) have a full working capacity which is not being utilized. About the same number have at least a partial working capacity which they probably could put to good use but are denied the opportunity to do so.

This can have a detrimental impact both on health and wellbeing of large segments of the population and on the social and economic development of the entire country.

Unemployment is also a terrible waste of resources.

At the request of the European Commision, Behrenz and Delander (1997) have recently estimated the total fiscal costs to the public sector of unemployment in Sweden. In addition, they present their estimates of real resource costs to the society as a whole, and economic costs to the unemployed.

Their results are summarised in the specification below (rounded figures in billion SEK; 1 ECU = 8.67 SEK):

Fiscal cost and loss of revenue for the public sector caused by open unemployment and unemployment-related early retirement	95.0
Fiscal costs to the public sector of active labour market policy measures	58.0
Total fiscal costs	153.0
Real resource costs to society caused by open unemployment and unemployment-related early retirement	105.2
Real resource costs to society of active labour market policy measures	60.5
Total real resource costs to the society as a whole	165.7
Income losses for the unemployed, early-retirement pensioners, and participants of labour market programmes	12.7

The authors have also assessed the relationship in Sweden between changes in unemployment and in GDP. The results of the calculations indicate that reductions in open and total unemployment by 2.3 and 3.5 percentage points, respectively (from 7.7% and 11.1% in 1995), would have the following effects (rounded figures in billion SEK):

Reduction in fiscal costs - a benefit to the public sector	88.0
Increase in GDP - a benefit to society as a whole	115.0
Increase in disposable income - a benefit to individuals associated with improved labour market status	27.0

Beherenz and Delander (1997) conclude that there are large rewards to the society, the public sector, and, of course, to the unemployed associated with an improvement of the employment situation.

Furthermore, huge sums of money are added to public expenditure at national, county and municipal levels as a result of ill-health - physical, mental and social - brought about by the unemployment of one sector of the population and the overemployment of another. This amount is as yet unknown but certainly runs into many billion SEK.

Part of these costs are due to attempts to buffer at least some of the ill effects of medium and longterm exclusion from the labour market. In all probability this support is well intended. However, it is worth considering to make more rational use of these enormous resources as help for self-help and as support for active ways to promote a reentrance into working life of these populations. Such a change in strategy is likely to promote both the health and wellbeing of our population and the social and economic development of our nation, thereby being a true investment for health.

13. A Path Forward

Developing entrepreneurship, improving employability, encouraging the adaptability of businesses and their employees, and strengthening the policies for equal opportunities are the core conclusions of the extraordinary European Council meeting on employment (1997). The summit launched a coordinated strategy for national employment policies defining guidelines for employment at EU level (Eur-Op News, No.4, 1997):

1. Entrepreneurship means creating a new culture of employability in the EU by:

• facilitating the starting up and management of companies by setting in place clear and reliable regulations,
• developing venture capital markets, mainly on the basis of EIB initatives, in order to
• mobilize Europe’s wealth behind entrepreneurs and innovators, and
• making the tax system more favourable to employment.

2. Creating a new culture of employability means:

• combating long-term and youth unemployment,
• ensuring at national levels that every unemployed young person, before being unemployed for six months, is offered a new start in the form of training, work practice, a job or some other employment measure,
• offering unemployed adults similar possibilities before being unemployed for 12 months;
• facilitating the transition from school to work - Member States must endeavour to reduce the proportion of those who leave school early by half within five years,
• abandoning passive measures in favour of active measures, in particular improving training schemes, and
• developing a partnership approach by associating social partners and companies.

3. Encouraging adaptability is the notion of enabling both businesses and the workforce to embrace new technologies and new market conditions. This means modernizing work organization, including flexible working arrangements, and supporting companies’ abilities to adapt to structural changes in the economy. Member States will, for example, re-examine prevailing obstacles, in particular taxation, to investment in human resources.

4. Improving equal opportunities for women and men is vital to developing the full growth capacity of EU economies.

According to the Council, these guidelines will have to be inserted into national plans for employment, drawn up by the Member States. Each year, the Council will report to the summit on the way the guidelines have been transposed into national policies, and the Council will decide on policies for setting the guidelines for the following year.

The objective of these measures is to arrive at a significant, long-lasting improvement in employment rates in Europe. The main challenge arising from these guidelines is that of bringing the EU gradually closer to an employment rate of over 70% of the active population, in line with Japan and the US for instance, instead of only 60.4% at present in the EU.

This first special summit focusing entirely on employment is an outcome of the Amsterdam Summit, when the Council decided to make certain provisions of the new chapter on employment in the treaty immediately effective.

- Still lacking is the complementary application of such approaches for investment for health in other important sectors of human existence.

14. Top-Down And Bottom-Up Approaches

The approaches advocated by the Summit are based on a necessary but probably insufficient top-down strategy, a new variety of what is usually referred to as social engineering. What seems to be forgotten is the necessary complement to this of a bottom-up approach, an attempt to mobilise the millions of European unemployed to consider mutual help and self-help and to remove obstacles to their initiatives to do so.

One key - in fact the skeleton key - which is all too often forgotten in the discussions is that over a million people outside the Swedish labour market (and the corresponding army at least 18 million of unemployed in the EU) are in fact not merely a burden. They can also be an excellent asset, that is if they are empowered by being allowed and encouraged to actuate their wealth of ideas and initiatives.

It is imperative for an investment in health to activate and implement policy makers so that these potential assets for health are mobilized and sustained.

At the same time, we must break down the structural barriers that hinder such efforts, thereby allowing people to 'nose out' all existing available jobs and/or start up their own business or, even better, to start up cooperative enterprises. In order for this to work, people will have to empower themselves, regain faith in themselves and in their abilities. ‘Learnt helplessness’ (Seligman, 1975) will need to be converted to ‘learnt resourcefulness’ (Rosenbaum, 1983; Johnsson et al, 1994). People will have to cooperate with one another, support and receive support from one another in similar situations - carry each others’ burden. Assistance from the public sector should focus on the wording of the Charter of the United Nations but also of the Swedish constitution which states that 'it is especially incumbent upon the public to safeguard the right to work'.

It is thus a matter of converting a problem and a burden - the unemployed - into an asset, a resource.

Similar approaches could and should be considered in other health-relevant societal sectors.

In addition, the path forward must be characterised by a systems approach, long-term planning and cross-sector cooperation (IPM et al, 1994). On a central level, the governments should lead the way, establishing broad cross-ministerial cooperation with directives and objectives to set up a corresponding cooperation at central and local authority and administrative levels. It is also a matter of breaking down structural barriers and implementing joint solutions to problems - with regard to planning, and allocation of funds and personnel. A system of 'communicating vessels' should be set up between local authorities - i.e., a cooperation between employment offices, social insurance offices, social services, primary health care, the educational establishments, companies, trade unions, voluntary organisations and the unemployed themselves. An important step in this direction has been made recently in Sweden (Swedish Government Bill 1996/97:63).

15. Collaboration Across Sectors And Societal Levels

This bill has its focus on concerted action in the field of rehabilitation - of bringing unemployed people with physical, mental and/or social handicaps back to gainful employment. One may hope that the general principles spelt out in this bill will be applied to many other societal problem areas as well.

The bill states that "the Government’s official documents to the authorities should contain objectives, missions and financial requirements which are both specific to the authority concerned, and common to those of other authorities."

"It is of the greatest importance that joint policy documents be drawn up at local or national level."

"The cooperation which is currently being pursued in the form of projects in numerous directions should be modified and widened to form part of established practices throughout the country. Cooperation between sectors is needed in order to be more effective in getting people with complex problems to provide for themselves."

"Joint action plans should be drawn up at central administrative and regional level, as well as a programme for joint training."

Even more recently, these strategies are followed up in the Swedish Government’s Budget Proposal 1997/98 to the Parliament. According to the latter bill, "as of 1st January 1998, the Regional Social Insurance Office will be able to conclude agreements with local authorities, County Councils and County Employment Boards in order to take part in joint projects with a view to achieving more efficient use of available resources."

Similarly, "local authorities and County Councils will be able to conclude agreements with each other and with the Regional Social Insurance Office and County Employment Boards ... within the framework of the jurisdiction of social services and health care."

"The Swedish National Labour Market Board, the National Social Insurance Office and the National Swedish Board of Health and Welfare have the common objective of achieving more efficient use of available resources by promoting cooperation in the field of rehabilitation, with a view to making it easier for the individual to provide for him/herself through his/her own work."

According to this Bill, "joint, overlapping (inter-sectoral) objectives need to be formulated. The government budget appropriation documents to the authorities should contain objectives, missions and financial requirements which are both specific to the authority concerned and common to those of other authorities."

Briefly, then, the two bills emphasise the need for collaboration both across sectors (such as health care, labour exchange, social welfare, and social insurance) and across public sector levels (central government, counties, municipalities). Still lacking is the integration also of education and training policies regarding elementary and secondary schools but also colleges and universities into such a systems approach. It is further likely that such integrative initiatives will have to overcome very considerable amounts of intrasectoral "territoriality" thinking and bureaucratic inertia.

16. Action for Full Employment

In more concrete terms, this top-down approach, to which this paper has tried to add some necessary bottom-up complements, can be summarised in the following matrix:

ACTORS/METHODS

Figure 4. A matrix summarizing coordinated goals, actors and actions to secure full employment (cf. IPM et al., 1994).

The left column of this matrix indicates six major goals:

• to save and/or develop good jobs, and to abolish obsolete ones;
• to find those vacant jobs that already exist;
• to create new jobs;
• to develop individual professional and social competence (life skills), and to empower the "grassroots";
• to improve community climate, in terms of awareness, empathy support, and involvement (i.e., social capital); and
• to protect and/or promote health and functional ability of the individual to enable him or her to fill a new position once it has been offered, found, or created.

Social action to promote the achievement of these goals is possible on eight levels, namely:

• supranationally, e.g. through the United Nations and its specialized agencies, the European Union etc;
• nationally, through governmental bills and parliamentary acts concerning laws and regulations, taxes and allowances, administered through various ministries and civil service;
• regionally, through County Councils, County Administrative Boards, County Labour Market Boards etc.
• municipally, through Local Social Insurance Offices, Employment Exchange Offices, Social Welfare Offices, the school system, and units for adult education;
• through the parties on the labour market and their collective bargaining and agreements;
• through voluntary organizations, including self-help groups, religious and charity organizations etc;
• through local cooperative approaches; and
• individually, through initiatives and actions from each individual in conjunction with his or her close network, and their mutual help and self-help.

The challenge here is to design and implement a coordinated approach of many concerted actions in such a way, that the various actions facilitate and reinforce rather than counteract or obstruct each other.

For all actors to have a reasonable chance to achieve this difficult goal, approaches need to make use of a set of socio-political "tools", which can be applied synergistically to each sector and its problems, as well as across sectors.

17. Social Policy Matrix

As shown in the matrix below, major areas for both sectoral and intersectoral, preventive, curative and health promoting action (top of matrix) include:

• children and family life;
• education and training;
• work and unemployment;
• housing and segregation; and
• elderly and handicapped.

Strategic tools to be applied to these areas of action include:

• coordination of approaches across sectors, disciplines and societal levels;
• pooling of resources from appropriate sources;
• promotion of professional and social competence in all actors, combined with empowerment of the grassroots;
• promotion of social support - its availability and utilization; and
• promotion of sense of coherence in all concerned (Antonovsky, 1987), including their feelings of understandability, manageability and, meaningfulness.

Figure 5. A social policy matrix providing a basis for coordinated approaches for "investment for health".

Again, to be cost-effective, these approaches should not be applied as one-shot affairs, on an ad hoc basis. They must be coordinated, across "tools" and across sectors in a mix adapted to the prevailing or forseen target situation(s), and the sociopolitical setting, to which they are applied.

As already emphasized, these measures should not be intended as a replacement for the various conventional measures already applied or planned but should act as a complement to them.

I have a dream - of the prime ministers (and of the corresponding decision-makers at county or municipal level) setting up a series of complementary objectives. For example, to cut unemployment by a certain percentage, and at the same time to increase life-long learning, and to improve public health to a given degree - preferably also stating the estimated, specific gains for welfare and for the national economy. Then I would like to see the Ministries of Labour, of Health and Social Affairs, of Education, of the Interior, and the Ministry of Industry and Commerce (and corresponding bodies at county or municipal level) receive or appropriate a joint portion of the total budget in order to achieve these objectives, with promises of 'rewards' for effective goal achievement and 'penalties' for unsatisfactory results. But also to empower all citizens to add their own initiatives to such a joint programme. Briefly, to combine top-down and bottom-up approaches into a systems approach.

18. Education And Training - Necessary Qualifications For Life

Almost one in five Swedes is 'functionally illiterate' at the end of his/her compulsory 9-year schooling. He or she is unable, or barely able to read, write and do simple arithmetic sufficiently for everyday occupational purposes. Not surprisingly, these young persons have considerable and increasing difficulties entering the labour market and managing to stay in it. The routine jobs in mass production industries which the generation of their parents had access to have been increasingly rationalised or made redundant as a result of technical development (computerisation and robotisation) and global competition.

Even those educated to upper secondary level but with incomplete, poor or mediocre grades can be faced with these kinds of difficulties.

The problems are intensified by the fact that many upper secondary and post upper secondary education programs fail in their task to train the pupil's capacity for abstract thinking - to detect patterns and purpose, to think analogously, in models, pictures and categories. Nor is the education system effective in teaching the pupils to think in systems, to view things holistically, to discover cross-disciplinary and cross-sectoral causes and relationships, to work experimentally and to work together with others to solve problems (cf. Reich, 1993).

Bert-Olof Svanholm, the late MD, of the ASEA Brown Bovery Group (ABB), maintained that his company could not promise its employees life-long employment - but it could offer life-long employability, by offering them continuous professional development, thereby maintaining and increasing their attractiveness on the labour market.

The Swedish government has realised the importance of developing professional skills both as a measure against unemployment and in order to maintain and increase the international competitiveness of the Swedish workforce, by offering continued education for more than 100,000 adults considered to be in need of it.

However, skills mean more than just professional expertise. Life skills are just as important - the ability to manage one's life both in prosperity and adversity.

19. Skills For Life

Nowadays, many unemployed are so downhearted, helpless and have such low self-confidence that they give up, feel defeated, stop looking for new solutions. In such situations, vocational education and training, however ambitious and necessary, is not going to be sufficient. A person with low self-confidence will find it hard to profit from such options. Furthermore, the person will subsequently find it hard to apply for and to get, or create a good job.

WHO, in good cooperation with the European Commission and the Council of Europe, has attracted attention to this problem, based on a broader health perspective. One of WHO's ideas is to improve school-age children's 'introduction to life' by providing them with opportunities to live in a way which promotes health and well-being. 500 schools in 40 countries in Europe have entered the "European Network of Health promoting Schools" (WHO, European Commission, Council of Europe, 1997). These schools are fully committed to:

• create socio-educational settings which support health;
• strengthen collaboration between schools and their communities;
• develop and sustain the school as a healthy physical environment;
• build personal health skills among pupils, teachers and parents.

The health-promoting schools’ complementary curriculum includes increasing the pupils’ knowledge and understanding of a number of lifestyles known to be hazardous - smoking, drinking, drugs, unhealthy diets, lack of exercise etc., in order to promote healthy life-styles. In addition, the programme attempts to promote ‘social skills’ or ‘skills for life’. These pupils have learning opportunities, for example, to:

• communicate effectively,
• make decisions,
• solve problems,
• think critically,
• hold their own,
• resist peer pressure,
• manage their own worry, depression and stress,
• adapt to new environmental demands, and
• get to know themselves.

Anybody possessing such 'skills for life' - related to but not identical with emotional intelligence (cf. Stone and Dillehunt, 1978; Grant Consortium, 1992; Goleman, 1995) - will not remain unemployed for long. Nor will they remain in a bad job. They will improve their job or find another.

The notion of ‘skills for life’ is very similar to the notion of 'self-power' which was introduced by Karl-Petter Thorwaldsson, former president of the Social-Democratic Youth of Sweden. 'Self-power' is having power and influence over your own everyday life. This can be gained partly through life skills and partly by society not hindering individual and cooperative bottom-up efforts to solve problems but rather promoting and encouraging such efforts, as a complement to society's own central and regional top-down resolution of problems. In this way we could get popular movements against unemployment and other large-scale social and health problems.

20. Social Support

Sweden has a long and honourable tradition of solidarity between people - a solidarity not only expressed in readiness to pay progressive taxes, but also in a will to 'carry each other's burdens', a mutual consideration for other people, not only those within a given circle of family and friends.

Gunnar Nilsson, former president of the Swedish Trade Union Confederation coined a good term for such mutual consideration - comrade support. It could equally well be referred to as social capital.

Alone is not strong. It is crucial for our welfare and our health that we have someone to 'hold our hand' in the storm. Someone who cares. Who gives us support and appreciation, helps us to orientate ourselves in our surroundings and to interpret them, to encourage, to listen, to comfort, even to lend us a practical hand. It may be a close relative or a good friend. It may be a colleague at work. Or a neighbour. We feel better and can tolerate more if we have somebody to stand up for us. But also when we ourselves have somebody to stand up for. When we do not only receive - but also give - social support, i.e., "carry each other’s burden’.

This support can be applied to both our own and other's self-esteem, for example, through receiving and giving appreciation and praise. We can get help to interpret a social situation correctly - to realise that what is causing us problems is perhaps an annoyance rather than a catastrophe. We can get, and give, a feeling of solidarity. Or practical advice.

A person who has access to all of this and can take advantage of it will feel better and will become more resistant to life's various trials (cf. Johnson, 1986). Welfare will be improved along with health. It is, in fact, another option for "investment for health".

21. Sense Of Coherence

When you are 'navigating on the ocean of life' it is good to have nautical charts and a compass with you. To have an idea of where you are heading and how and why. To have a salutogenic 'sense of coherence' (Antonovsky, 1987). This consists of three components.

• Understandability. - People want to understand what is happening to them.. Why aren't I getting a new job? Does the employer dislike me? Is there something I have done? Is it due to the indifference of the trade unions? Or to the recession in the entire region?
• Manageability. - People want to be able to manage their current situation, to cope with it.
• Meaningfulness. - People want to find a meaning in their present situations.

All of this can be taught to people in various problem scenarios, or to all people as a step towards improving their life skills.

22. Wisdom Of The People

I strongly believe in the wisdom and power of initiative of the individual, not instead of, but as a complement to the top-down approach, to social engineering. But I also believe that an activation of the 'grass roots' not only demands clear political signals but also requires that the competence and self-power of the individual be increased, and the structural barriers preventing it be stripped away.

All of this cannot be achieved overnight. It must be based on arduous, long-term efforts. It will not be possible to achieve without clear-cut political signals from all relevant levels, complementing a popular movement both centrally and locally.

Isn't this all very difficult? Of course it is, it's very difficult, complicated and hard to master.

But do we really have any alternative?

23. Some Challenges For You, The Participant At The 1st Arena Meeting

• How would you promote full employment?
• How do you empower ordinary citizens to contribute to problem solving?
• How do you promote "skills for life" in yourself, your children, your fellow workers?
• How do you overcome bureaucratic, political and/or academc "territoriality"?
• How do you pursue life-long learning?
• How do you protect vulnerable groups during restructuring?
• How do you increase awareness in the medical profession, and among decision makers?
• How do you promote a long-term, systems approach in politicians elected for rather short mandate periods?
• How do you promote evidence based social policy making?

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