Health promotion development: texts and textures

The invitation to choose my five favourite resources as well as being quite emotive turned out to be a healthy introspective exercise. Looking at my list of preferences I was able to take stock of the different beliefs, positions, expectations and desires that have shaped my personal and professional development.

I think that as the invitation is made as a shared exercise with other IUHPE colleagues- the pinpointing of the texts that underlie our formation and our practices allows us to get closer to an archaeology of health promotion knowledge. The epistemology of health promotion is a largely unfinished business in the consolidation of its scientific and discursive field.

Theoretical work and epistemological reflection on the objects and subjects at stake in the development of health promotion theory are essential to bring about the separation of health and medicine. Among other reasons owing to the fact that the latter does not place trust in theory –one can say it lacks theory-, and its knowledge is purely oriented by the rights and the wrongs of clinical practice. This is not the case of health promotion.

Health promotion evidence should not be sought through this type of casuistry (each social phenomenon typically has unique characteristics with outcomes that can only be “verified” on a case by case basis) but rather in relation to its adherence to what have been defined as guiding principles and characteristic goals for health promotion. If the results of our practice are limited and contradictory it is not so much because of the lack of supporting evidence but rather because of the limited and contradictory nature of the processes of social transformation that nourish and determine such practice.

Caveat: I am not as interested in identifying for this particular exercise an exact number of specific texts (which would run the risk of generating a list which would end up reading as a recipe). Instead I would like to include a blend of texts and authors whose combination, confrontation or conversation creates a network of references and provides the base from which I stand.

To start, I have chosen two authors whose vast works provide me with the lens through which to read other texts, a kind of ‘cosmo-vision’ in the old fashioned sense. And from that starting point, I have interwoven texts that are perhaps less primary but have fed my interest in community health because of their originality. In any case, reading and re-reading is always a pleasant and salutogenic activity that allows previous ideals and ideas to be recalled, recaptured, revived and revised.

To read and reread

First of all, Freud and Marx. Not so much regarding any one text in particular but because of what they have contributed to my standpoint and interest in public and community health, and to my conceptual baggage and perspective.

Of the various possible synergies that I find between the tools of analysis that Marx provides, and the work involved in health promotion, I want to highlight a shared interest in the causes, the question concerning the determinants of a phenomenon.

I believe that it is possible to identify a Marxist perspective in the emphasis the Ottawa Charter has regarding the importance of looking closely at health determinants and the political implications of addressing them. One of the principal tools of dialectic materialism is precisely that which defines the value of the determinants (in the final analysis, economic) to understand phenomena such as history, war or hunger.

In my opinion the scope of health promotion becomes ‘Marxist’ when it goes beyond the phenomenological interest that characterises medicine, exploring its determinants and defining itself as a strategy for society to address the structures that support these determinants.

The works of Freud were required reading during my training as a psychoanalyst but I have re-read and re-signified them since I have become involved in public and community health. It is true to say that there are no Freudian texts that refer to public health, just as there are no Freudian texts referring to education, social work or any other institution wherein the illusion of ‘controlling’ is distilled with that which psychoanalysis has defined as ‘impossible’: to cure, to govern, to educate. However, it is possible to pick out in Freud highly fertile material for our construction of the field of health promotion.

a. The definition of health as ‘the capability to love and work’. (It is worth highlighting that Freud does not attempt to offer a definition of mental health but just of health, which at first glance shows a holistic approach which set him apart from the predominant vision of his time.) Some of the questions that arise from this definition, seem to me to be consistent with those that we could raise in relation to health promotion: Is it possible to promote these “capacities”? Under what conditions? What type of environment, services, public policies make them possible? Are we talking about individual or collective capacities? To what extent do they express social processes or do they occur at the level of the individual?

b. The warning against ‘furor curandis’ and its unhelpful -and possibly iatrogenic- nature. The ‘super-hero’ approach to the control and triumph over disease is not uncommon in the health field and often becomes the primary obstacle to the person who is actually affected actively taking charge of their fate. The history of health education (which often finds its home in the overlap of ‘furor curandis’ and ‘furor educandis’) is littered with examples that illustrate this. Freud pinpoints a certain need to distribute power/knowledge/desire to cure (oneself). He alludes to a hunger (or desire) for health that needs to exist in the relationship between the patient and the health professional. In this way he emphasises that health is only possible if one (this ‘one’ could be individual or collective) takes responsibility for one’s own health. Such responsibility highlights the subjective dimensions of health, which can favour or prejudice its achievement.

To read and unearth

There is one text that possibly marks the first crossroads between my training as a psychologist and my interest in health policy, and reflects the richness of such interweaving of disciplines. “Razones de psicoanalistas en prácticas comunitarias” (1994) (which can be roughly translated as “Pyschoanalysts making sense of community practice”) is a compilation of articles on community health experiences in Rosario, Argentina (Argentina’s second-largest city) which illustrate a social and professional practice which bases itself in the notion of the “sujeto de derecho”. Two affirmations are at play in this notion:

a. That health is a human right
b. That its promotion can only be driven by an individual/collective subject, capable of taking responsibility for itself.

From this perspective, not only is health defined as a social good under construction but it also signals that everyone has a part to play in its construction.

The articles by Alvarez and Colvini on the concept of popular participation go deep into the fundamental ethical reflection that can be read as the ‘right to participate’ (together with the right to not participate). Aware that a political position can easily become a quasi-religious position (“similar to hypnosis”), the position of the psychoanalyst in community practice allows the permanent possibility of redrawing boundaries between popular participation initiatives and not infrequent paternalistic, authoritarian interventions resulting from submission and the absence of criticism.

Top-down social protectionist policies (too often the handmaidens of the powerful in Latin America) are characterised precisely for not discriminating between what is giving and what is promoting. If poverty leads to a deterioration in the affected community’s will and capacity (“animus societae”) to generate solutions, the health promoter must be aware of the necessity of restricting his or her role and promoting the perspective of empowerment, development from within and democracy. This book illustrates this warning, defining the health promotion field in the community beyond “furor participandis”.

To read and affirm

When I finished my community health studies I read a masters thesis that I have chosen as one of my favourite texts; it’s called “No longer fire fighting: intersectorial collaboration in health” (1996) by one of my fellow students at the University of Liverpool, Christianne Boeker. Through her experiences in the Northern Region of Ghana, Christianne outlines the connections and actions between the actors, sectors and processes that make up health, sickness and poverty in a context of reform and structural adjustment.

Having seen her work close-up, I was not only able to engage with the reading itself but also with the ethical standpoint from which Christianne undertook her research and writing even though she was aware that in the university context her viewpoint would be perceived as “more appropriate to a political manifesto than to a scientific work”. However, her will and sensitivity clearly manifested in the text the needs, dreams, hopes and nightmares of the communities with whom she worked. (Besides, if health promotion expects social change, is there not room in its discourse for a political manifesto?)

Of the various expressions and original ideas that Christianne includes, I choose the one that she uses when she dedicates her thesis to “those who are suffering from the disease Z.59.5 (ICD) –extreme poverty”.

To read and think again

“The Dictionary of Development: a guide to knowledge as power” (1995) is an exquisite selection of essays on the core concepts of development theory. If the objective that justifies a dictionary consists precisely in delimiting the polysemy of language and tightening the meaning of words to the closest degree, this looks like it is moving in a different direction: it examines the ambiguity that explains the uses and abuses of terms such as ‘international cooperation’, ‘poverty’, ‘development’ and ‘need’.

The essays by Mexican Gustavo Esteva on “Development from the inside”, Iranian Majid Rahnema on “Participation” and the beautiful text from German Marianne Gronemeyer on “Helping” which revises the different (historical, ethical and economic) meanings of the good and beautiful idea of ‘giving’ are all admirable.

It should be a periodic exercise - to question the jargon that tends to take centre stage in any disciplinary discussion. Only by doing this is it possible to keep the discussion alive and productive, and the discussion is itself transformed while at the same time it attempts to transform its object.

To read and enjoy

The Constitution of the World Health Organisation defines health as “not merely the absence of disease or infirmity” but “a state of complete physical, mental and social well-being”. This is “the sort of feeling ordinary people may achieve fleetingly during orgasm, or when high on drugs,” says Petr Skrabanek in “The death of humane medicine and the rise of cohersive healthism” (1994).

A Czechoslovakian refugee in Ireland at the end of the war, doctor, epidemiologist, professor in community health at Trinity College, Dublin, and one of the world’s only non-Irish experts on Joyce, Petr Skrabanek could perfectly well find himself number one on the list of ‘The Enemies of Health Promotion’. However, I cannot help but relish reading and rereading his provocative texts and endless examples of the ‘furor curandis’ of the public policy sector.

“The death of humane medicine” builds a tower of provocations, questions and examples which is hard to fault with in relation to the fundamentalist tendencies of ‘cohersive healthism’. With constant irony and a large dose of black humour, he knocks on the doors of public health (especially the pragmatic and commercialised western tradition, hegemonic since the 1970s) in order to make his denouncements: of epidemiology as an instrument of social control, of vertical and authoritarian vaccination-style prevention, that ‘health for all’ as declaimed in Alma Ata was “applauded.. [by] Leonid Brezhnev … Baby Doc .. Idi Amin, [and] scores of other murderous regimes, totalitarian states and military dictatorships”, of universal screening, of medical technology as a futuristic panacea, and (with foresight) of this modern-day Procrustean bed which is ‘evidence-based medicine’.

Skrabanek rings the bell and runs away, creased up with laughter. He does not intend his argument to be sophisticated, he just wants a ‘humane’ medicine that neither takes advantage of the propaganda that seeks to impose ‘healthy life styles’ nor abominates ‘risk behaviours’ nor excludes those who have their own idea regarding health or their own ways of dealing with life.