What would the Nutbeam Charter look like if it were written with my editing?

By Lawrence W. Green, Visiting Professor, University of California at Berkeley School of Public Health, USA

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Don Nutbeam's very nicely crafted and cogent commentary (2005) on the Ottawa Charter leads with the stage-setting observation that the Charter process was highly consultative, but within a relatively small group. One could add that most of those present from developing or developed countries were not necessarily representing their governments or the leading professional associations or other stakeholders in their countries. They were the people who could attend, among those who were invited. If my invitation was typical, it is easy to appreciate the issue Prof Nutbeam raises concerning the representativeness of consultative process. The other part of Nutbeam’s implicit concern here is with the representation of the developing world at the Ottawa conference. In response to this frequent criticism, Ilona Kickbusch pointed out in her commentary in February (2005) that this was the very “challenge thrown out by Dr. Halfdan Mahler, the then Director General of the WHO, …to make the principles of the Alma Ata Declaration applicable to the developed world…” If Ottawa was the tilting of the balance back toward developed countries, Bangkok may be expected to be the pendulum swing back toward the emphasis of the Alma Ata Declaration on developing countries, but with a greater emphasis on the health promotion issues raised in Ottawa. Or, as Kickbusch suggests, it could be the end of this “false dichotomy.”

Nutbeam’s section on "Healthy Public Policy" accurately reflects the origins of the concept, its limitations for certain developing countries, and the needs for updating it to give greater weight to decentralized policy-making, the needs of developing countries, and globalization. I would embellish his decentralization to emphasize organizational and institutional policies within communities, because community has such varied geographic meaning across the globe, as witnessed by the need to rename the "Healthy Cities" initiative of Western Europe "Healthy Communities" in North America, "Healthy Shires" in Australia, and "Healthy Villages," “Healthy Towns,” or "Healthy Counties,” in some places. What also concerned me with the naming of these things as "healthy" is that the real intent was to make them healthful so that people living in them could be healthy. Living things can be healthy. Inanimate or nonliving objects can, at best, be healthful. This is not just a grammatical point, but also a concern that the redirection of focus from the health of people to the "health" of policies, cities, and communities could have the effect of diluting the concern with health outcomes for people. It might have had the effect of reinventing policies, cities, communities, etc in the possibly romanticized or utopian image of what some people (e.g., those attending the Ottawa conference) would hold for an ideal community life or political orientation of policy, but which would not be guaranteed to improve the health of people. What it did contribute toward was the growing interest in reviving ecological approaches to health promotion.

Some of the foregoing issues are addressed in the Nutbeam’s following section on "Healthy Environments." Here Nutbeam seems to shift the spotlight onto the physical environment and "settings," which became the "more subtle" way of expressing health promotion's particular interests in social environments. Some reference might be in order here to the shift in emphasis from physical environment in public health history to social environments in the Ottawa Charter's health promotion, to the current emphasis on "social determinants of health" which places less emphasis on settings and more on social inequalities and early childhood or lifetime exposures to socioeconomic conditions harmful to health. Whether health promotion needs to take this additional step toward social inequalities or away from “settings” as a focal concern for the Bangkok Charter needs to be debated. Such a shift, however, must not abrogate the traditional (and now growing) responsibility of public health for the protection of people from exposures to toxins and other threats of the physical environment, which is deteriorating in many places.

Nutbeam's point about the over-reaction of the Charter to simplistic behavioral and individualistic approaches is very important and worthy of a prominent place in this debate leading up to the Bangkok meeting. It was expressed by some during the Ottawa Charter era as disdain for the historical roots in health education and disparagement of those continuing to develop the theoretical and empirical grounding of educational and behavioral components of more ecologically layered, more comprehensive programs. The subsequent maturing of both levels--individual and social--expressed in part in the Ottawa Charter, might give the Charter a different tone, emphasizing the reciprocal determinism of behavior and environment, a central tenet of ecology, if written today. Nutbeam’s casting this section of his commentary in the context of health literacy puts a particular spin on one aspect of the issue that for those with a narrow understanding of health literacy could miss the larger ecological context in which the individual-community, behavioral-environmental interplay and dialectic have played out. This would be, ironically, the same fate of those who held a narrow understanding of health education at the time of the Ottawa Charter.

Nutbeam's observation in the next paragraph that governments have tended to invest in the IEC components of the more comprehensive efforts needed to get at the social determinants and other ecological forces recovers the important point that the combination of both is needed to achieve the goals of health promotion. One could add, perhaps more cynically, that governmental focus on IEC components gives them publicity and visibility when they are doing little to address the determinants over which individuals can exert minimal control, so that IEC sometimes becomes public relations rather than public health education.

In his section on community development, I would add a plea for more participatory research with professionals and other indigenous practitioners, community policy makers, and grass roots residents. This is a concrete example of the point Professor Nutbeam makes here about the richness of experience and literature from developing countries that is only beginning to be reflected in mainstream health promotion literature. Participatory research was not a concept developed in the Ottawa Charter, but one whose time has come.

In short, if Don Nutbeam and I were co-authoring a draft of the next charter, it would likely have (1) a built-in consultative process to assure wider representation of key stakeholders; (2) a more systematic tracing of causal links from population health outcomes to the policies, regulations, and organizational structures that could achieve them, rather than “healthy polices” and “healthy cities” as apparent ends in themselves; (3) a blending of physical and social environmental issues; (4) a rehabilitation of health education (perhaps in the new clothes of health literacy) with its recognition of individual agency and reciprocal determinism between behavior and the environment; (5) recommendations to strike a better balance in the distribution of expenditures of governments on information, education and communications, such that government officials could not misdirect such funds toward their own public relations purposes; and (6) an underpinning of the health promotion enterprise with the development of a science that grows as much out of participatory research on existing needs and local practices as from highly controlled, hypothesis-driven trials in artificially contrived experiments.

These features, of course, would depend on Professor Nutbeam’s acceptance or further rewriting of my edits on his virtual, hypothetical, updated redrafting of the Ottawa Charter. It was his prospectus for such an update that inspired me to sign on. We both “retain a strong attachment to the basic concepts and principles of the Ottawa Charter,” and we both seem to come back to it with the benefit of our respective revolving-door careers in and out of academia and government service. 

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