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Health promotion is burdened by working within an “order of things” (Kickbusch, 2001, paragraph 6).

Mais quelle prison? Où suis-je recluse? Je ne vois rien qui m’enferme. C’est dedans que je suis maintenue, en moi que je suis prisonnière. Comment aller dehors? (Et l’une ne bouge pas sans l’autre).

[But what prison? Where am I cloistered? I see nothing confining me. The prison is within myself and it is I who am its captive. How to go outside?(And one does not move without the other) (Irigaray in Whitford, 1991, p.29 ).

Introduction: why and how should we look at Health Promotion discourse?

Philosophers and public health researchers with an interest in the development of the sociology of knowledge and philosophy of health promotion have argued that health promotion, as a discipline, has major difficulties in terms of contradictions within the discourse/s and the underlying philosophy which it utilises (Lupton, 1992; Kelly and Charlton, 1995; Grace, 1991; Nettleton and Bunton, 1995; Rawson, 1995; Thorogood, 1995, 1996).  It has been argued that contradictions in health promotion discourse and philosophical development are grounded in unresolved problems of a Modern philosophical perspective and the associated problems of Modernity, centring on notions of linear causality, instrumentality and progress (Flax, 1993).

In order to show to what extent these problems affect specific contributions to the present journal, this paper reports on a discourse analysis of eight reviews from the Reviews of Health Promotion and Education Online (RHPEO). These reviews are part of a special section in which prominent commentators in the field describe the five health promotion or education resources that they deemed to have had the most effect on their professional development. These eight contributions have been chosen because they were the ones available at the commencement of the present project. In addition, we decided to focus on RHPEO because it is an innovative journal aiming at providing health promotion and health education people all over the world with a discourse on resources that can help their practice (RHPEO, 2001).  It is in that spirit that our paper is presented, trusting that it may aid in maintaining RHPEO’s spirit of enquiry and reflexivity (Caplan, 1993).

Out of the eight texts selected for analysis here, six exemplify best some of the problems associated with Modernity outlined above, while the remaining two are examples of how these problems can be addressed. A type of implicit discourse, one we labelled “evolutionary transcendence” discourse, appears in the first six reviews. The discussion points to the consequence of this discourse to obscure the problems which Modern thinking (Flax, 1993) generates for health promotion practice and theory.

Health promotion practitioners endeavour to take account of the impact of socio-cultural experiences when designing health promotion interventions for improving the health of individuals, groups and communities. Some health promoters have also conducted research from a humanities-based perspective into these types of experiences and their impact on health and health promotion activities (Thorogood, 1995, 1996; Lupton, 1992; Nettleton and Bunton, 1995). This paper assumes a similar socio-cultural and political context to exist for health promoters themselves. Public health researchers have analysed this socio-cultural and political aspect of health promotion by analysing the discourse of health promotion professional practice (Grace, 1991). In particular, that literature argues for the need to address major instabilities and contradictions in health promotion discourse and underlying philosophy. It suggests making explicit their implicit ideology and discourses in theory and practice (Grace, 1991; Kelly and Charlton, 1995; Thorogood, 1995, 1996). The discourse analysis (deconstruction) utilized here is a research method which aims to do this (Lupton, 1992).

Broadly, discourse analysis functions to record patterns of meaning-making in both textual (documentary) and oral (spoken) communication. It also documents connections between such patterns and social patterns of change. Lupton notes that “unlike quantitative content analyses of texts, discourse analysis centers its attention upon the rhetorical devices and linguistic structure, the ‘style’ as well as the subject matter of verbal communications, and the manner in which ideology is reproduced in them.” (Lupton, 1992 p. 145)  The concepts of discourse and ideology are related, in so far as that many of the patterns inherent in discourse are often exterior to conscious manipulation and in that sense ‘ideological’.

Thus, ‘discourse’ itself is a “patterned system of texts, messages, talk, dialogue or conversation which can both be identified in these communications and located in social structures” (Lupton, 1992 p. 145) ‘Ideology’ is a concept which may be defined as “any system of ideas underlying and informing social and political action. More particularly, any system of ideas that justifies or legitimates the subordination of one group by another” (Jary, 1991, p.226). Ideology is able to be transmitted and legitimised, among other ways, through the discourse of texts. The underlying values or ‘truths’ of an ideology may also be known as  ‘common sense’. ‘Hegemony’ is another concept related to ‘ideology’, and is defined as the  “… power exercised by one social group over another…the ideological and cultural domination of one class by another achieved by ‘engineering consensus’ through controlling the content of cultural forms and major institutions” (Jary, 1991, p.207). Put in these terms, ideology functions to maintain and naturalise hegemony; the exercise of power over one entity by another through discourse.

Discourse analysis has been used here to analyse key practical and theoretical issues of professional health promotion practice. In addition to the present work, Grace, 1991 and Thorogood, 1995, 1996 are two public health researchers who have undertaken discourse analyses of health promotion professional practice. These researchers have analysed aspects of health promotion practice itself and argue that health education and health promotion discourse is constrained by internal contradictions and inconsistencies within their own discourses about empowerment and choice (Thorogood, 1995, 1996; Grace, 1991). We will briefly review these authors’ contributions before turning to our analysis of RHPEO contributions. In the same  spirit, Labonte and Feather (1996) have also  noted  that  it through  analysis  of  and dialogue  with  the stories  from  health  promotion practice that the discipline’s knowledge base may grow.

Some contradictions in Health Promotion discourse

In order to set the scene for our analysis below, we first turn to some of the contradictions and tensions identified in health promotion discourse by commentators such as Thorogood, 1995, 1996, Grace, 1991, Seedhouse (1997) and others. Thorogood notes the existence in health promotion and health education discourse of a contradictory relationship between empowering and controlling (Thorogood, 1996). Homing in on the issue of “choice” as the prime locus of this contradiction, she comments that were choices accepted in this discourse as truly being ‘equal’, health promotion would not be able to maintain the primacy it allocates to its own normative stance:

To acknowledge the possibility of choice within discourses other than health as equally valid would undermine health promotion’s claim to scientific rationality. If health promotion were truly to accept all choices as equally valid, the role of health promotion would be reduced to promoting access to and decision making about services and the dominance of the rational, medico-scientific paradigm would be challenged. (Thorogood, 1996 p.61)

In addition to highlighting this contradiction, Thorogood denounces health promotion’s practical use of rational, medical and scientific discourses to understand and regulate HIV/AIDS and sexual relations in the population for the same reasons. Here, too, empowerment is hard to disentangle from already established knowledges and the control that they embody.

For her part, Grace, 1991 analyses empowerment within health promotion discourse and argues that a contradiction exists in this domain in the information she gathered from health promotion professionals. She argues that health education and health promotion perpetuate the idea of health promoters being free of constraint or having free will, while at the same time they both tend to position oppressed groups as being constrained by deterministic influences. Grace notes that:

Two distinct themes emerged from the discourse analysis. There is  one theme of providing and serving, which exists alongside a second theme of planning, changing and controlling...On the one hand, the discourse is positioning the object of the discourse as being in control; on the other hand it is simultaneously articulating a controlling position on the part of the health promoters (Grace, 1991 p.334).

Grace’s and Thorogood’s work contribute to problematising these discursive contradictions, and show that they pose a challenge to the internal stability and congruency of health promotion discourse. Following on from this, in the next section we briefly look at how philosophers have also commented on similar contradictions in the philosophy of health education and health promotion, for reasons not unrelated to the ones just reviewed.

Health Promotion philosophy and discourse: Challenges for disciplinary growth

If health education and health promotion are indeed beset with the kinds of contradictions outlined above, then this is likely to have implications for the development of these endeavours as a discipline (Seedhouse 1997; Rawson, 1995; Kelly and Charlton, 1995).. Aiming to foreground the discipline’s assumptive dimension, Seedhouse’s contribution to health promotion has been to argue for reflection on the purpose, values, philosophy and theory of health promotion (Seedhouse 1997).  Seedhouse observes that whilst health promotion utilises a wide range of methods for problem solving from other disciplines, it has not developed a deeper level of theory (Seedhouse 1997). This deeper level of theory may be achieved through the use of reflection on why we do what we do and the associated dilemmas and problems encountered in this process of reflection. A point that is important to the argument that follows below, central to this mode of reflection is the acknowledgement that the discourses used to frame health promotional issues are not discontinuous with those used to frame the very identities of health promotional authors. This acknowledgement is central to making sure that issues of agency and health status are not bracketed off from the enabling discourses, practices, resources and contexts that co-constitute us as authors.

In the same line of reasoning, whilst  the critiques mounted by philosophers of science such as Kelly and Charlton (1995), may seem  to be hostile to  health promotion,  their criticisms emanate from a discipline and knowledge base, sociology, which is characterised by sustained  theoretical development and from their engagement with the aims and objectives of health promotion over  many decades. Critiques from these quarters may therefore well be worthy of consideration and investigation.

In essence, Kelly and Charlton (1995) propose that contradictions such as those outlined above may be due to theoretical and methodological assumptions of health education and health promotion not having been adequately understood or made explicit . They argue that both disciplines are grounded in a Modern philosophical perspective and that they have not taken the time to resolve or address the problems inherent in such perspective: a lack of recognition of the equally discursive constitution of both subjectivity (i.e. the authors of health discourses) and objectivity (the receivers of health discourses); inadequate (causal and linear) accounts of social, education and promotional effects; inability to factor in complexity and over-determination into health dissemination models, and so on. These authors argue that, as a result, health promotion and health education describe society, poverty, and disease as acting on people in a deterministic way:

...the social model is not, in our view, an alternative to a discredited medical model. It is a partner in crime and a very close modernist relative (Kelly and Charlton (1995), p.82).

Kelly and Charlton suggest that health education and health promotion have been criticised by proponents of both “right” and “left” political viewpoints because, in the final analysis, they are ultimately much less different than they claim to be: We have sympathy with both views and enjoy the apparent paradox that leftward and rightward thinkers should be so united in their scepticism...this is in fact no paradox…the central problem as we see it, is that the health promotion movement has become a political movement, without resolving the philosophical problems at the heart of both rightward and leftward thinking, namely the reconciliation of free will and determinism in determining human behaviour (Kelly and Charlton 1995, p.89).                         

This places health educators and health promoters in the following unenviable position: Whilst health education has to posit a linear-causal relationship between teaching and learning to anchor its own logic, health promotion simultaneously proposes that social structure acts deterministically upon people whilst facilitation and empowerment are held as a “guiding light” (Kelly and Charlton 1995). Moreover, they state that:

This becomes especially tortuous when describing the behaviour of oppressed groups.  Here the emphasis is on social determinism among the oppressed whilst maintaining a place for the idea of free will among non oppressed groups (such as health promoters). Empirically this may be the way the world seems to operate, and politically it may make considerable sense to construct things in this way. But theoretically and epistemologically it does not work. Either we are all free or are all socially determined. You (meaning health educators and health promoters) can’t have it both ways (Kelly and Charlton 1995, p.89; italics ours).

In the section that follows we will trace some of the contradictions and tensions highlighted so far in a number of RHPEO reviews, to highlight how pervasive and naturalised associated stances still are in recent health educational/promotional discourse.

Constraining or liberating: key contradictions in RHPEO discourse on health promotion and their consequences.

“Un discours peut empoisonner, entourer, cerner, emprisonner ou libérer, guérir, nourrir, féconder. (Parler n’est jamais neutre).”

[“A discourse may poison, surround, encircle, imprison or liberate, heal, nourish, fertilise. (Speaking is never neutral).”]  (Irigary in Whitford, 1991, p.9).

The discourse analysis we conducted for the present paper shows that the discursive contradictions around the themes of ‘providing and serving’, ‘planning, ‘controlling and changing’ and ‘controller and controlled’ unveiled by Grace, 1991 and Thorogood, 1995, 1996  are also present in the majority of the RHPEO material.

In the Rootman text, for example, ‘personal will power and taking control’ are juxtaposed with ‘empowerment’ (Rootman, 2001, paragraph 1). In this discourse, ‘power’ is a resource that is at one and the same time deployed by and dispensed by the health promoter. For Signal, too, instrumentality and functionality become the guiding principles of social action when saying that Indigenous people “seek their own understanding of health promotion and to ensure that health promotion addresses their needs in culturally appropriate ways” (Signal, 2002, paragraph 10). This discourse elides from view the contestations that might arise about defining people’s ‘needs’ and validating what is ‘culturally appropriate’. Essentially speaking from within the linear-causal assumptions of Modern discourse, Signal refers to the ‘goals and objectives’ of particular health promotional initiatives. A related set of linear-causal assumptions is present too in Rootman’s discourse, with the emphasis that is placed on “logical thinking and analysis” that serve to “[analyze] the essence of a situation and [reach] a sound and practical solution based on that analysis” (Rootman, 2001, paragraph 1).

A third RHPEO text, the one by Jan Ritchie, foregrounds the tension between people’s desire for self determination (free-will) and the authoritative stance of health education (authority). In doing so, Ritchie constructs health promotion as an enterprise that is sensitised to specific individuals’ positioning practices, noting “oddly enough…not all individuals want to retain power over their health outcomes. Some people take great comfort in relinquishing power, particularly less resourced individuals who have little power over other aspects of their life, and it is up to us to recognise when this is the case” (Rootman, 2001, paragraph 4). In view of Ritchie’s stated preference for health promotion over health education, however, the pragmatic resolution of the dichotomy between will and authority and the moral justification of this resolution still do not acknowledge the extent to which the health promoter him/herself remains immersed in a discourse of power.

To some extent acknowledging these tensions, Signal’s contribution states that “there are contradictions inherent in health promotion” (Signal, 2002). Signal then voices a subjective need for guidance for the practical handling of conflict in health promotion practice.  She suggests it is important to: …recognise the problems; talk honestly about the dilemmas in trying to put rhetoric into practice; discuss errors of practice; accept that conflict is necessary to achieve changes in an entrenched system and that you cannot, if you want to maintain integrity, pretend that values do not matter (Signal, 2002, paragraph 8).

This quote shows that Signal’s writing, much like Ritchie’s, ‘makes do’ and argues away the contradictions inherent in health promotion’s positioning, rather than drawing out their full consequences. Clearly, the health advocacy role of health promotion seems to us constructed, in the contributions from Signal and Ritchie, out of assumptions about scientific adequacy, educational efficacy and pastoral conviction whose logics fail to connect with the complexities and contradictions of ordinary people’s social and health discourses and practices, and with the way health promoters position themselves in relation to these.

The theme of the tension between free will and authority is continued in Rootman’s  text. Here, ‘personal will power’ and ‘taking control’ co-occur with ‘the people you are trying to help’:

I learned many things from Ron…One of them was the importance of logical thinking and analysis as he was a master at analysing the essence of a situation and reaching a sound and practical solution based on that analysis. At the same time he taught me how critical it was to keep the people you are trying to help in mind in health promotion. Although he seldom used the term “empowerment” he was a fan of the idea and exemplified it in his own example of overcoming severe handicaps through personal will power and through taking control. I marveled at the way in which he was able to follow a complex discussion in a meeting and summarize it in a cogent and clear manner at the end so that it was possible to move forward (Rootman, 2001, paragraph 1).

The free will versus authority theme reappears in a fourth contribution, the text by Green. Here, the author presents health promotion as concerned with individuals’ self-care as well as with the will to achieve social change:

We could hardly have foreseen the shape of health promotion to come, but Lowell’s self care orientation combined with Stuert’s community and social change orientation might well have defined it (Green, 2001, paragraph 10).

Other contributions are more circumspect about naturalising the tension between individual will and authority. Cardaci, for example, touches on the following disjunction in health promotion: “the contradiction between what we know we should do and what we really do” (Cardaci, 2001, paragraph 3), or the lag between espoused notions about health promotion and what transpires pragmatically between health promoters and their public. Moving still further towards inverting the ‘gaze’ of health promotion, Levin sees the greatest challenge as understanding health in such a way that it would give meaning to “the reason why, the individual or collective would invest in their health” (Levin, 2002 , paragraph 2). We will return to these alternative voices in the contributions studied further below, but first we will elaborate some of the implications that flow forth from not confronting tensions internal to health promotion discourse.

Most of the texts analysed above construct the ‘health education/health promotion’ subject as being, or being expected to be, ‘self governing’, and thereby willingly agreeing to be ‘naturally’ bound by the rules of what is normal, reasonable and explainable. This inscribes these texts into a neo-liberal discourse of self-governance, or an ethos that, according to Nikolas Rose, directs attention to the nature, problems, means, actions, manners, techniques and objects by which actors place themselves under the control, guidance, sway and mastery of others, or seek to place other actors, organisations, entities or events under their own sway (Rose, 1999 , p.16).

While he is concerned with state relations, Rose’s point is of relevance to what is at stake here. Where his argument is that “recent political strategies have attempted to govern neither through centrally controlled bureaucracies (hierarchies) nor through competitive interactions between producers and consumers (markets) but through self-organising networks” (Rose, 1999 , p.17), our position is that the increasing emphasis on self care and related neo-liberal strategies of engaging people are not independent from the changing status of the health promoter. Seen from this perspective, the analyses presented support Thorogood’s argument that “…public health represents the healthy choice, based on rational discourse. This is constructed as natural, neutral and objective” (Thorogood, 1996 p.247).

The “evolutionary transcendence” from health education to health promotion: an inappropriate discourse?

 

As shown with reference to textual examples from selected contributions, there are key tensions and dilemmas implicit in the Modernist discourses that populate them. Emblematic of the problem that is at stake here is what may be termed ‘evolutionary transcendence’ discourse. This discourse is evident from the emphasis placed on health promotion having moved ‘beyond’ the problems or ‘narrowness’ associated with health education. Thus the Green (Green, 2001), O’Neill (O'Neill, 2001) and Ritchie (Ritchie, 2001) contributions of the corpus analysed construct health promotion discourse and health education discourse in an oppositional, hierarchical and binary relationship to each other. For example, Ritchie observes that “As my focus moved from individual patient education to community-wide health promotion, I began absorbing public health principles for conveying health messages across whole populations” (Ritchie, 2001, paragraph 6). Green constructs a similar genealogy when he comments, “Though frequently criticised for its narrow focus on the belief structures and values of individuals, it continues to serve health educators in their construction of health messages. In any broader ecological approach to health promotion, a building block includes effective communication with individuals, either through mass media or more individualised channels” (Green, 2001 paragraph 7).

In a related fashion, O’Neill writes of the way in which, from 1975-1986, “Green and Kreuter exemplify perfectly the evolution of classical American health education (and due to the position of the USA in our field as in many others, of international health education) towards a broader vision of health promotion” (O'Neill, 2001 paragraph 7). Here, health education discourse is that which negatively signifies the ‘individual’, (a lack of) ‘education’, and a ‘narrowness’. At the same time, the above examples positively identify health promotion discourse as ‘social’, ‘structural’ and ‘broad’. This ‘binary opposition’ places health promotion discourse in a dominant position in this hierarchy of meaning. This, we contend, is at the heart of evolutionary transcendence discourse.

We can define ‘evolutionary transcendence discourse’ as discourse that renders unquestionable (‘transcendent’) a view of history whose unfolding (‘evolution’) is (relatively) seamless, rational, progressive and increasingly functional (or ‘healthy’) in orientation. Such an evolutionary stance contrasts with the post-modern perspective for which history is contested, over-determined, complex and unpredictable. Moreover, ‘history’ as tell-able narrative only becomes possible through discourse, and tends to conform to what is tell-able as history, as well as being structured according to the ‘genre’ of history writing.

The view that discursive convention governs much of the writing in question here also has implications for how we see the position of speaker or writer. A discourse perspective emphasises that the speaker or writer are implicated in their discourse, in the sense that s/he cannot stand outside the phenomena that are talked or written about even if the language gives us the impression that s/he can. The implications of this for health-promotional discourse are twofold. First, discourse in general effects the identification of those who are discoursed about through that of those who ‘do’ the discourse. This means that what we say or write re-presents what is, and therefore does not offer a transparent, self-evident vista on ‘the real’. Second, through ‘doing’ discourse, we identify ourselves; and this means that our sayings and writings constitute our selves as speakers and writers. This is not to say that ‘the real’ is not, or that we are ‘mere discourse’. Rather, we argue that what we say and write has a much more tenuous and problematic connection with both ourselves as observers and with what we say and write about than we tend to acknowledge. The importance of raising this point for the field of health promotion is that the ‘problem of representation’ is one that health promoters often dismiss (Seedhouse, 1997), at the risk of naturalising their academic positions as scholars, or framing their effectiveness as health promoters in cause-effect relationships that reduce the complexity of social life to narratives that strengthen the discipline of health promotion rather than confronting the complexity and over-determinedness of social life.

In essence, the ‘evolutionary transcendence’ discourse from health education to health promotion precludes the field from addressing the challenges and contradictions inherent in its evolutionary stance for its own practice and theory. The importance of highlighting the presence of this discourse is that it problematises the efficacy of the health promotional/educational thinking such as that which inhabits the contributions analysed here. Put more programmatically, problematising assumptions about progress and change also means calling into question notions of agency, effectiveness and social determination, all of which are central to the health promotional and health educational projects. Finally, calling the fundaments of health promotional and health educational writing into question enables us to outline the contours and the advantages of a more reflexive stance on health-oriented discourse, and proposes an alternative avenue for research and practice.

“A negative case”: The Kickbusch paper

Interestingly enough, the evolutionary transcendence discourse and its tensions and dilemmas appear not be present in the same way in the contribution by Kickbusch, nor in the Cardaci one already cited above. Kickbusch  (2001), and to less explicit degree Cardaci, (2001), differ in important ways from the other contributors in the way they construct health promotion and health education. In making explicit health promotion’s own conditions of possibility and discursive constitution, they move beyond the Modernist concerns and assumptions of the traditional health promotion and health education rhetoric critiqued above.

For example, when discussing perspectives which have impacted her, Kickbush writes that they taught her:

First and foremost to always question the ‘order of things’ and what we consider ‘normal’. Second, to aim to understand the implicit systems and patterns that structure everyday life and behavior. Third, to be very wary of any simplistic understanding of cause and effect. Fourth, to always remember that people are social actors and that the production of everyday life is a skilled performance. Fifth, to insist that public health is as much a political as a professional undertaking (Kickbusch, 2001, paragraph 4).

Kickbusch puts up a number of issues here that distinguish her contribution from the others seen so far. She emphasises, besides the more analytical aims of understanding the patterns of social life, the deeply political nature of public health, in addition to questioning “simplistic understandings of cause and effect”. This to some extent questions, if not deprivileges, health promotion as set of strategies aimed at bringing about better health. Kickbusch goes on to quote Giddens when advocating that health promotion and health are “not concerned with a  ‘pre-given’ universe of objects, but with one which is constituted or produced by the active doing of subjects … [hence] structures must not be conceptualised as simply placing constraints on human agency, but as enabling ... processes of structuration [that] involve the interplay of norms and power” (Giddens in Kickbusch, 2001, pp. 160-161). Here, Kickbusch leaves little doubt that for her health promotion is constituted in discourses and practices of power that deserve to be considered critically in what they claim and achieve.

Another notable difference is the way Kickbusch anticipates and refers explicitly to the problems of Modernist approaches to health and health promotion. In this way, she is determined to confront the potential incommensurability between empowerment and control:

With the codification of the Ottawa Charter health promotion ordered itself along a model of social interventions, subject to the ambiguities of empowerment and control, but far removed from the evidence framework of a clinical model (Kickbusch, 2001, paragraph 11; italics ours).

In addition to making these ‘ambiguities’ explicit, Kickbusch’s title, “The Map is not the territory: Five perspectives on how to interpret the world of health” (Kickbusch 2001), reveals a “textual awareness” of the tensions and issues generated by Modernist discourse, and by representation (speaking/writing) generally. In confronting her own rhetoric in this way, Kickbusch is able to dissociate the problematics and solutions constructed from within health promotion discourse and pit these against alternative ways of thinking about health and the dissemination and adoption of health practices. Our understanding of her title and her contribution generally is that for her ‘health promotion’ offers a multiplicity of ways of interpreting, seeing or experiencing health. 

Thus, Kickbusch elaborates on the discursive constitution of health promotion, and urges us to act in cognizance of this. Important for her is that we construct a ‘meta-discourse’ about the effects on us of our discourses as ‘implicit systems’. Only by confronting our own discourses and by thereby denaturalising them will we be able to see people’s health practices and appreciate them for what they are. To illustrate this point she quotes Foucault:

I try to understand the implicit systems which determine our everyday behaviour without our knowledge. I want to find their source, show their formation as well as the power they have over us. That is why I try to distance myself from them, in order to show how one can escape them (Foucault in Kickbusch, 2001, paragraph 15).

Here, the health promotional gaze has fully inverted itself, to reveal itself to itself. As a consequence, solutions, generalisations, and conclusions become problematised in ways that they could not before.

For her part, Cardaci uses vocabulary such as “passion”, “feeling” and “reflection”, erasing the boundary seen above between formal science and lived experience (Cardaci, 2001). Here, to some extent too, the integrity of health promotion as discipline is undermined and displaced by a radically different orientation to social life, to academia, to health promotion. In their own ways, both Kickbusch and Cardaci throw health promotional discourse back onto itself, revealing its own prerogatives and privileges, and the ways in which the authors’ own identities are tied up with the problems they choose to foreground and the solutions they promote. In doing so, we argue, they also reveal health promotion discourse’s limits and shortcomings, thereby opening the way for new ways of thinking about health and health practices.

Conclusion

This paper has presented a discourse analysis of a corpus of RHPEO contributions to investigate what kinds of philosophical and ideological problems are manifest in the material chosen. As shown, in six of the eight reviews there is evidence that health promotion philosophy and discourse are manifesting and are constrained by an implicit evolutionary transcendence discourse. This discourse blocks reflexivity as well as philosophical and theoretical responses to criticisms of health promotion, limiting its own ability to respond to key issues and tensions in its practice. Evolutionary transcendence discourse constructs an oppositional, evolutionary and thus binary relationship between health promotion and health education. This masks the shared origin of their issues and concerns, and naturalises tensions and contradictions as being part of any stance on health promotion.In contrast, we argued that the Kickbusch contribution, and to a lesser degree the Cardaci one, display a more reflexive stance and, with that, less reliance on the progressivism inherent in evolutionary transcendence discourse. Their work points to the problematic of health promoters’ own positioning in relation to the concerns, strategies and solutions that are the mainstays of the discipline. By inverting the gaze of health promotional discourse, these authors are able to critically examine their roles and contributions, and re-invent their principles of engagement.

We argue in closing that inverting our gaze in this way does not disable us from assuming meaningful social roles. On the contrary, doing so enhances our sensitivity to the discursive facets of not only our own backgrounds, knowledges and identities, but also those of the people health promotion seeks to target. And it is precisely here that the importance of this ‘gaze inversion’ will be registered: only the reflexivization of our discourses and practices will ultimately be able to engender reflexivization in others. Clearly, however, further research is needed on the practical and philosophical problems that the traditional evolutionary transcendence discourse generates for health promotion/health education in order to further sensitise the discipline to its own modalities of problem setting, knowledge production and solution creation.

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