The dynamics of health promotion: from Ottawa to Bangkok

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The fact, that WHO together with the Thai organizers of the Bangkok Conference has signaled the intention to produce “a Bangkok Charter on health promotion” has sent storms, waves and ripples through the health promotion community. Suddenly, the uniqueness of the Ottawa Charter - a warm blanket that we had come to live with – was questioned. Various options emerged: it could be dismantled, it could be updated and even – as some implied – improved, or Bangkok could lead us to a new vision of public health in the 21^st century. Meanwhile the first draft is available for commentary.

I like the fact that the World Health Organization is beginning to take health promotion seriously again and that the process of the Bangkok Conference engages the health promotion community in a dialogue over the value of the Ottawa Charter and any new approaches and innovations that may be necessary. And I am delighted to have been asked to be a part of this process. This is indeed a rare opportunity in a professional career.

Twenty years have passed since those cold days of creation in a conference hotel in Ottawa in 1986 and in looking back I am proud of what we achieved. WHO showed clear leadership and the Charter contributed significantly towards a new public health. The Charter has held up incredibly well in these twenty years – partly because it reflected the many changes that were in the air, partly because it was based on sound research, partly because it was clear about its values and partly because it was very participative in its production.  But there is a new world and a new policy environment out there and a new generation of health professionals needs to take over the torch from the Ottawa pioneers in order to move the field forward.

I would like to comment on five issues that I feel we must consider in this process:

Developed – developing countries

Much has been made of the fact that the Ottawa Charter (OC) was for the developed world only and that we now need “something global”. Yet the challenge thrown out by Dr. Halfdan Mahler, the then Director General of the WHO, was to make the principles of the Alma Ata Declaration applicable to the developed world – in particular the notion of empowerment. Indeed that concept came as much out of the experiences of the developing countries – Paolo Freire’s approach to conscientization to name one of the most influential – as it mirrored the global social movements of the times.  That has also been reinforced through that fact that it was easier to gain understanding for health promotion and its strategies in many developing countries and with indigenous societies than in the medicalized developed world.

The deliberations at Bangkok could help free the OC and health promotion from this misconception and false dichotomy. In a global world there is no us and them – only us.

Integration – specific areas of action

Others like to indicate that there are big chunks missing from the Ottawa Charter – an area that is mentioned frequently is mental health. Yet the challenge of the OC was to provide an integrative strategy for ALL the dimensions of the WHO definition of health (physical, mental and social – in the debate there was also frequent reference to the spiritual) and to recognize that in real life the three are hardly separable. A simple case in point was the heart disease research of the day which showed that the mental health effects of exercise groups were as important as the physical. Another key influence on the OC was the research on social support and health, which, given the medicalized mental health approach of the day, needed to find a strategic home as far away from mental health as possible. Even though the OC did all it could to suggest that its five action areas could be applied to more or less any health problem in any part of the world it seems there is a deep psychological need to find “my health issue or problem” or “my vulnerable population group”  in policy documents.

I hope the deliberations in Bangkok will be able to steer clear of long lists and reinforce the clear strategic directions of the OC.

The essential core

Health promotion practice has faced many difficult challenges, last not least to find recognition and funding for the kind of approaches it stands for. In consequence many deals have been made pragmatically along the way. The OC became the mantra while practice was something toned down to fit reality. Increasingly the evidence that the OC took from the knowledge base in the social sciences has arrived in the health arena through the research on social determinants, social capital and even macroeconomics. I hardly dare mention that health promotion spoke about investment in health even before the 1993 World Bank report was published. 

The deliberations at Bangkok could help clear the air a bit again and bring us back to the essentials: the focus on health not disease, on resources not problems, on social determinants not symptoms, on people not professionals. This includes those new determinants that are now global in reach and need new strategies of response.

The WHO role

WHO has not always been a reliable champion and partner in health promotion. Despite World Health Assembly resolutions as to its importance the organization has had problems with assigning it the importance and budget that the policy documents would indicate and ensuring an organization wide commitment. Changes in staffing and outlook as well as personal preferences (based on the Not-invented-here Syndrome) have led to many up and downs – the most far reaching being the near equation (and at times replacement) of health promotion with non-communicable disease control.

I hope the deliberations in Bangkok can give a clear message to the WHO as to the relevance and scope of health promotion and the very strong contribution it can give to the WHO Commission on Social Determinants. It is a core function of public health and health policy and should be a core function of every government and of a global health organization.

The other partners

The OC is very “nation-state focused” in its approach because it wanted to underline that governments have a responsibility for the health of their people – particularly in the then new area of “lifestyles”. The challenge of healthy public policy is now becoming increasingly recognized within governments and in the global arena. Health promotion has also frequently been at the cutting edge of public health thinking beyond the state – for example in relation to civil society involvement in health or public private partnerships. This has not always been well received initially. Health promotion developed this capacity for innovation through its work in the community with people – in short the untidy processes of real life. It remains true that “health is everybody’s business” and that we should make “the healthy choice the easier choice” – finally it seems that this message is reaching more and more policy makers and is being turned into concrete strategies – witness the actions on tobacco or on obesity as well as some of the new health policy initiatives in countries.  Finally many strategic approaches heralded by famous management gurus have – for example – been practiced every day in the “settings projects”.   Indeed health promotion has been a great social laboratory, not only of health but of participation and democracy.

I hope the deliberations in Bangkok will include many of these other partners – from the public, the private and the NGO sector – and that any document that emerges will reflect their commitment to health and health promotion.

Finally:

In my view there is no need to dismantle, revise or improve the Ottawa Charter – it is a living document with deep vision and practical orientation. We should let it stand.

But at the same time we should look forward. Let us work towards a conference outcome that is both as visionary and as resilient as the Ottawa Charter and complements it in important dimensions.  What is should be called is part of the democratic process at the conference.

Beyond a document I hope that a group of committed partners will come together to support the WHO in its work on health promotion – so as to ensure continuity of effort. Many of the disease specific areas have seen the forging of important focused alliances with a good funding base – health promotion should aim to create a global partnership that will support the results of the conference and the implementation of whatever the key action areas of a Bangkok Charter might be.

I hope that by the time we then come together at the IUHPE Conference in Vancouver in 2007 the first policy impacts of such a partnership can be reported.

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