A synthesis of the INPES forum on the preparation of the Bangkok Charter

Pierre Arwidson, director of scientific affairs, INPES, France

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Initiation of the forum

Catherine Le Galès-Camus[1] and Desmond O’Byrne[2] of WHO have proposed to the French Institut national de prevention et d’éducation pour la santé (INPES) to open a debate within the international Francophone community about the Bangkok Charter project. In reaction to this proposal, the INPES has opened an online discussion forum on its site February 1^st 2005. This forum was initially supposed to be stopped on the 11^th of February but was extended up to the Kobe meeting of February 21-22-23 and will be open up to the Bangkok conference taking place August 7 to 11 2005. The second version of the Bangkok Charter was added to the site as soon as it was received as well the links leading to the official conference preparation site. The first and second versions of the Bangkok Charter have been freely translated from English to French via a two-column presentation.

Although anyone who has the URL can sign up and participate, the forum isn’t open (there is no link on the INPES homepage leading directly to the forum); monitoring is a posteriori (no contributions filtering is in place but the possibility exists  to eliminate a contribution if it generates a problem).

The publicity for the forum was made via several online lists containing approximately 5000 addresses. The members of these lists received the first draft of the Bangkok Charter as well as a link enabling them to access the home page of the forum http://www.inpes.sante.fr/Forum_eps/indexForum.asp?page=login.asp . They also received a valid password: global.

• The addresses lists used to advertise the forum included:
• the French-speaking community within the IUHPE file.
• the REFIPS (The international French-speaking network for health promotion; www.refips.org; the original message was sent to 15 correspondents who are responsible for 1500 members)
• the French national Federation for Health Promotion
• the French Society for Public Health, including foreign correspondents
• a certain number of addresses picked within the interested French-speaking people from Africa and Asia (Vietnam, Laos)

Between the 1st and the 20th of February, the forum received 35 contributions, which are the ones synthesized below[3]. Contributions continue to arrive since then. The technique utilised to the spread out the word worked, well since many of the contributors were not included in the initial mailing list. Even though there were not a lot of responses, health promotion leading names out of Quebec, Belgium and France made their voices heard. A majority of contributions came out of Belgium. There have been two contributions from black Africa, none from the Maghreb and none from French-speaking Asia. Humanitarian and popular education organizations, as well as the alternative globalization movement, participated in the debate; the involvement of those organizations was not initially planned.

Summary of the forum

Critics made about the forum

Since the forum was put online in a confidential manner, the access was rather complicated for some people. The short time frame in which the forum was opened seemingly didn’t permit a democratic exchange and has be seen denounced by some as allowing a certain type of manipulation. The motives leading to the writing of the new Charter were not clearly exposed.

Most of the remarks made about the forum concerned the bad French translation. The English and French versions of the 6^th paragraph didn’t concord[4]. The French version was constantly described as weaker than its English counterpart. There are a couple of errors in the translation and in the English utilized.

For one of the contributors, the translation problems were overshadowing a bigger, more cultural problem: the Anglo-Saxon concepts aren’t always transposable hence the suggestion of writing a French Charter based on the French-speaking community cultural background.

How to initiate the transition between Ottawa and Bangkok?

Numbers of contributions have questioned the opportunity of creating a new Charter. Why should the Ottawa Charter be questioned? Why the need for a new Charter when the Ottawa one is not even being implemented  ? What about the evaluation of the Ottawa Charter ? Why a new Charter by the WHO when a discussion about it’s future was planned at the IUPHE international conference in Vancouver in 2007 ?

The Ottawa Charter received significant attention in its time and it was probably caused by some favorable historical and political circumstances. The subsequent declarations didn’t generate a large impact. How will the Bangkok Charter be received in those circumstances?

For some, the evaluation process of the Ottawa Charter remains unknown. For others, the Ottawa Charter did not cause major changes in the French and international public health policies.

Why did the goals of Health for all 2000 fail? First, it is important to take a closer look at the report on the non-application of the process initiated at the Ottawa Charter.

The reference made towards the Ottawa Charter is insufficient: the health prerequisites resulting from Ottawa were not considered in Bangkok’s. The concern of addressing the current new challenges mustn’t come at the price of erasing 20 years worth of hard work.

A constant is noticed between the two texts: the absence of the term prevention. Health promotion (centered on the person and aiming the well-being) is fundamentally different than prevention (centered on the risk and aiming the absence of illness).

Communities and participation

There is a lack of reference to communities and community health in the Bangkok Charter when compared to the Ottawa Charter. Is it ethically correct to encourage vulnerable populations to participate while they don’t even have the necessary health prerequisites (a home, food, etc.)? In this draft, the populations do not sufficiently appear as masters of their own destiny. The consultation process concerning the Charter shows that the approach is more technocratic than participative. When are the populations involved in the revision of this proposal ?

The role of the WHO and international organizations

The world has changed a lot since 1986: globalization, the ever-growing influence of neo-conservatism, etc.. We can also observe a decline in the moral authority of important international organizations such as WHO or the UN. Should the WHO be more influential with regard to countries policies ? Should it influence decisions made in Davos and participate in Porto Alegre? How should it act so that the Charter is debated truly in national assemblies (like the WHO anti-tobacco convention[5] and in the process of the national adaptation of the millennium goals[6]). ?It would be desirable for the WTO to work with the Charter or at least be informed of its existence .

Implementation

The Bangkok Charter states easily accepted general principles: human rights, respect of diversity, the concern of acting on the health determinants, social justice, equity , collective implication in local, national and international actions, health promotion at the core of governmental policy…. But in fact, nothing happens. Health may not be the best entry point to motivate socio-economic decision-makers who have the real impact on the determinants of health. The people to whom WHO speaks to shouldn’t be the health ministers but those who make the policies and those who undergo their effects. Laws that increase social justice, and consequently health need to be enacted.

Equity of equality

We must be very attentive to the difference between equity, social justice and equality. Actions made with a justice and social equity intent can lead to social health inequalities and ultimately, it is the latter that count. References to handicapped and vulnerable persons are missing in the Bangkok Charter. The Charter should indicate that handicapped persons be mostly maintained in regular life settings rather than being confined to specialized places.

Private sector and health in Southern countries

Is the Charter project a sign indicating a new orientation of WHO towards economic liberalism ? Are references made to the market and the role of the companies a signal of that orientation ? The most active health promoter is the pharmaceutical industry using aggressive marketing policies aimed towards physicians and the general population. This leads to increases in health expenditures as well as generates new consumption needs in this area (ex: Prozac or Ritalin). The pharmaceutical industry makes record profits while the Southern countries are still searching a way to sufficiently supply drugs to all. Generally, the cost and bad quality of the medical treatments are major problems in these countries.

Health education and the new information technologies

Two contributions highlight the Charter’s role on the potential impact of new technologies but at the same time, forget the health education role of these technologies. Why? It was one the leading themes of the Ottawa Charter.