Cogito e imaginación

discussed so far is a largely ‘heroic’ perspective of health promotion, presented in a relatively unproblematic manner. There are a number of issues raised to challenge the notion that all is not necessarily well and that health promotion is simply not able to be everything to everyone.

Kelly and Charlton (1995) contend that health promotion is a construct of post- modernism. They draw on Crook, Pakulski and Waters ’s (1992) work on

distinguishing post-modernism from modernism, which suggests that differentiation, rationalisation and commodification are the backbone of modernity and that

elaboration and exaggeration of these three areas is post-modernism. Kelly and Charlton overlay this framework onto health promotion. They argue that hyper- differentiation of health promotion is seen in the competing paradigms and practices arising out of public health, sociology, education and psychology, as well in the proliferation of varied occupational groups which are territorial about health. Hyper- rationalisation can be seen in the increasing privatisation of health, where people’s lives are being invaded and everyday living becomes a potential health issue. Hyper- commodification arises out of health becoming a consumer good. Health is linked with fashion, and can be bought and sold; it is about lifestyle and about consumption (Kelly & Charlton, 1995).

public health within broader policy changes has occurred because they fit into a neo- liberal policy environment. Health promotion is attractive because ‘modern medicine can only offer diminishing returns from ever-increasing rates of investment’ (Owen & Lennie, 1992, p.6) and because health promotion fits comfortably with notions of voluntarism, decentralisation and consumerism (Nettleton & Bunton, 1995). ‘The idea of positive health as the goal for health promotion is seductive. . . . To be healthy is a good thing, not because it means the absence of pain and suffering, but because it is a fundamental good. . . Health is defined as a great liberating force. It is linked to power and domination or to socioeconomic arrangements’ (Kelly & Charlton, 1995, pp.83⎯4).

The deconstruction of health promotion put forward by Nettleton and Bunton (1995) is one from a sociological perspective (and identifies) three broad categories of social critique: sociostructural, surveillance and consumption. Table 3.4 summarises the differences in how these three categories play through populations, identities, risk and environment. The table shows how the sociostructural critique is essentially about power. This critique asserts that any genuine attempt to promote health must first deal with the political economy as the producer of ill health. The surveillance critique centres on how health promotion monitors and regulates populations on the one hand and constructs new identities on the other. There is ‘more than a creation of healthy lifestyles and healthy bodies but also healthy minds and healthy subjectivities’ (p.47); health promotion is increasingly looking like social regulation. Considerations of consumption highlight the blurring between literature for health promotion and commercialisation of health, lifestyle and maintenance of body; they assert that self- responsibility for health serves interests beyond the individual - commercial

entrepreneurs and health promoters; and that health promotion is making

considerable use of social marketing, which involves symbolic communication and exchange of cultural goods.

Table 3.5 Critiques of health promotion and the foci of health promotion, Source: Nettleton and Bunton (1997 p.50)

Critiques Populations Identities Risk Environment Structural • Control of

‘problem’ groups

• Victim blaming • Material circumstances • Politics of pollution Surveillance • Technologies e.g. surveys, diaries • Health promoting self • Rational calculation/ probabilities • Human-made environmental dangers

Consumption • Social marketing • Consuming healthy lifestyles/images

• Buying security, e.g. Volvos, extra virgin olive oil

• Greening of commercial products

The rhetoric of health promotion makes considerable use of community

participation. Linking health promotion with the needs of a community should create a health promoting environment or setting; that is, infrastructure and political will are harnessed to meet what a community has deemed as being important in a way that is accessible and meaningful for that community. For this to occur, involvement of the community in planning, prioritising and evaluating is essential (Baum 1992).

The all-too-frequent reality is that the ‘community’ is left out of health promotion. Top-down policies, outcomes and indicators, projects and programs are the norm. Dominant political views prevail in determining what gets funding. Health promotion increasingly reflects management ideology ‘that it is possible to measure need and assess performance in a simple and easily quantified manner ‘(Baum 1992, p.77). ‘Health professionals can diagnose and measure pathology, but health in its positive sense is experienced by people themselves, and so often eludes simplistic quantitative measures favoured by management theory’ (Sindall 1992 p. 289).

The goal of individual empowerment in rhetoric is also not likely to equate with practice. Individual empowerment is more likely in middle and upper socioeconomic groupings. It is less likely to be an outcome for other social groupings such as

women, gays and ethnic minorities. ‘The current vogue for addressing women as consumers able to exercise personal choice over lifestyles and health care services is inappropriate, given the constraints on women’s lives’ (Daykin & Naidoo, 1995 p.69). Further, health issues detected in ethnic communities are more likely to be attributed to cultural differences and practices, whereas in Anglo Saxon populations the same health issue is more likely to be associated with living conditions and limited income such as poverty (Douglas 1995). According to Kelly and Charlton (1995) it would seem that ‘[C]ommunities remain marginalised and invisible ⎯ other than in the rhetoric (p81).

Behaviour change is a frequently presented aim of health promotion campaigns. Such campaigns are likely to be counter-productive because they are predicated on the belief that health-compromising behaviour is a lifestyle choice amenable to change through the provision of knowledge and education to enable the individual to make informed health choices. There is no recognition that such behaviour is embedded in a material and cultural framework and that the health goals or outcomes established in public health policy may have little or no meaning for individuals in their everyday lives (Daykin & Naidoo 1995; Douglas 1995).

Critiques of health promotion have a common theme. In spite of claims and attempts to be otherwise, health promotion is at risk of having much the same level of success as the biomedical model. Where health promotion fails to address fundamental causes of ill health, it simply fails. Health promotion has therefore been accused of

reinforcing current stereotyping and generating new stereotypes. It has been alleged that health promotion supports the hegemonic position of the biomedical model and that it can alienate those it purports to assist, such as those who undertake risk-taking behaviours ⎯ viewing them as being deviant from the common-sense position of medical behaviouralists and therefore possibly contributing to health inequities. Health promotion is at considerable risk of becoming yet another idea whose time had come but did not deliver on its self-touted health and wellbeing outcomes. The passing of an opportunity is becoming increasing evident in the literature where

reporting on HPS is from the (bio)medical perspectives, that are predominately about interventions to achieve behaviour change and therapeutic outcomes (WHO 2006).

Health promotion seeks to challenge the supreme position of the Western medical expert while acknowledging the ‘patient’s’ perspective and alternative medicines. It recognises the multiple factors that impact on an individual’s health ⎯ physical, social, psychological and environmental. There are many claims on health education in schools and the HPS model is an attempt to meld them into a workable whole while utilising its inherent potential to redirect the critical edge and democratic principles. However, the HPS model is also vulnerable to alternative uses ⎯ those that enable reproduction of both social determinants and health inequities.