The politics of health promotion: channelling our anger and our hope for the wellbeing of people, place and planet

ABSTRACT

With the Institute of Health Promotion and Education turning 60, it is timely to reflect on health promotion’s journey. While health promotion can celebrate many advances, much remains to be done. This paper considers the enormous challenges we face and how we might move forward by working not only within, but beyond, the five action areas of the Ottawa Charter: engaging creatively with the opportunities offered by the changing contexts in which we operate, for example in relation to integrated care systems and place-based partnerships; learning from our experience of COVID-19 to ensure joined-up whole system responses that nurture the transformative change necessary to ‘build back better’ for a sustainable and healthy future; and advocating a new economic vision and model that rejects economic growth as an end in itself and refutes the assumption that such growth will automatically result in improved population and planetary health. Health promotion is inherently political. Reflecting on the UK’s current situation – with spiralling child, food and fuel poverty, flatlined/reduced life expectancy, increased inequalities, and the ongoing failure of government to take on powerful vested interests through legislative, regulatory and fiscal measures – we face a crisis. However, a crisis represents not only danger, but also a potential turning point. This should motivate the health promotion workforce to harness and channel its righteous anger; and give space for active hope that we – as citizens, professionals and members of families and communities – can envision, advocate and fight to secure the wellbeing of people, places and the planet.

KEYWORDS:

• Politics of health
• inequalities
• health determinants
• settings
• planetary health

With the Institute of Health Promotion and Education celebrating its 60^th anniversary, it is salient to reflect on health promotion’s journey. Looking back, there have been significant developments and advances:

• We’ve seen a consensus that health promotion must be driven by core values focused on addressing inequalities, working in partnership across sectors and facilitating the meaningful participation of citizens and communities.

• We’ve seen a widening acceptance that multiple professionals and community members – with or without roles labelled ‘health’ – can make a valuable contribution to health promotion.

• We’ve seen a growing critique of individualistic approaches to compartmentalised health issues, which can so quickly spiral into victim-blaming.

• We’ve seen increased advocacy for approaches that create settings actively supportive to health, thereby providing contexts and infrastructures within which behavioural and educational interventions have more potency and validity (Kokko and Baybutt 2022).

• We’ve seen growing calls for approaches that tackle the social determinants by embedding an understanding of and commitment to health and wellbeing within and across multiple sectors.

• And we’ve seen an appreciation that the health of people, the health of places and the health of the planet are intrinsically interconnected, with key milestones being Agenda 21 (United Nations 1992) and the Sustainable Development Goals, which formed part of Transforming Our World: The 2030 Agenda for Sustainable Development (United Nations 2015).

So far, so good. But against that hopeful backdrop, where are we now? At global and European levels, the new millennium saw the aspiration of Health for All by the year 2000 (World Health Organization 1981, 1991) morph into Health for All for the 21^st Century (World Health Organization 1999). And at a national level, the Marmot Review, Fair Society Healthy Lives (Marmot et al. 2010) was published in 2010. Like the Black Report (Department of Health and Social Security 1980) and Acheson Report (Department of Health 1998) before it, the Marmot Review clearly highlighted the unacceptable health inequalities undermining the public’s health and called for wide ranging cross-policy and cross-sector action to tackle the underlying inequalities in society. Yet, more than a decade on, things have got worse – with life expectancy flatlining and more recently declining, and inequalities widening (Marmot et al. 2020; Raleigh 2022).

Looking forward, it’s important to celebrate our successes and applaud the excellent work being undertaken across the breadth of the health promotion workforce. However, we also need to recognise that – if we are to realise the impact of this work and do more than ‘tinker round the edges’ – we need bold and assertive action that dares to engage with the ‘politics of health’ and moves outside of what would often be viewed as the remit of health promotion. In framing this, the Ottawa Charter (World Health Organization 1986) – the key output from WHO’s first Global Health Promotion Conference in 1986 – continues to provide an invaluable guide. Below, I illustrate this by focusing on how we can advocate, mediate and enable within each of its five action areas:

With regard to Reorienting Health Services, we need to focus attention on the reviews that have, over many years, called for health services to focus more on prevention and health improvement (see for example: British Medical Association 2018, 2019; Elwell-Sutton et al. 2019; Wanless 2002, 2004) – but at the same time reflect critically on the interrelated political, economic and other reasons that go towards explaining why recommendations have not been fully realised. We need also to counter myths about being unable to afford a publicly funded health service and speak out on the Government’s chronic underinvestment of the NHS. As the King’s Fund concludes (Wickens 2023):

Compared to other countries, the UK does not spend a particularly high proportion of its national wealth on health care, while a decade of historically low funding increases has left services facing huge pressures and a workforce crisis. Like levels of taxation and public spending more generally, how much is spent on health is a political choice.

In relation to Developing Personal Skills, we need to learn from and move beyond Health Promotion’s well-established track record in lifestyle education, asking what skills are needed to enable people to navigate and build the resilience necessary to function successfully in the complex 21^st century circumstances in which we live (Nutbeam and Lloyd 2021)? This can be illustrated by highlighting two key areas. First, people need the skills, literacy and motivation to decipher and critically assess health-related information against the backdrop of artificial intelligence and in the context of infodemics and other post-truth narratives nurtured by both social and traditional media (Bin Naeem and Kamel Boulos 2021). Second, health literacy needs to embrace Paolo Freire’s notion of conscientization (Freire 1972), building critical consciousness and understanding of the upstream determinants of health, and empowering people with the skills and courage to advocate for corporate policy change, to lobby governments and to mobilise community activism.

This leads onto the Charter’s third action area, Strengthening Community Action. We need to build on health promotion’s strong history of community participation and development by learning from and collaborating with social movements focused on human and planetary health and highly experienced in empowering individuals and communities (de León et al. 2021). While the radical fringes of health promotion have previously engaged with direct action linked to issues such as tobacco and HIV, through subverting corporate advertising and wider culture jamming (Winters 2020), there is today understandable caution about aligning with organisations explicitly rooted in activism, particularly given this Government’s draconian public order act (Government 2023). However, it’s crucial that health promotion shows courage in moving into this space: we need to stand alongside the UN Human Rights Commissioner who has condemned the act, saying (United Nations Office of the High Commissioner for Human Rights 2023):

I am … concerned that the law appears to target in particular peaceful actions used by those protesting about human rights and environmental issues. As the world faces the triple planetary crises of climate change, loss of biodiversity and pollution, governments should be protecting and facilitating peaceful protests on such existential topics, not hindering and blocking them.

Focusing on the fourth action area, Supportive Environments for Health, alongside our strong focus on the social determinants, we need to highlight and act on the ecological determinants of physical and mental health, such as those highlighted by the UN Commissioner. The planet provides our life support system and we are increasingly seeing tangible examples of how our failure to respect and care for the earth impacts human wellbeing, particularly for the poor and vulnerable (Poland, Dooris, and Haluza-Delay 2011). I’d suggest that we also need to strengthen our focus on the settings of everyday life – where people are born, grow, learn, live, love, age and die – drawing inspiration from the fantastic work that has been practised in programmes such as Healthy Schools, Healthy Universities, Health Promoting Hospitals, Health Promoting Prisons and Healthy Cities (Kokko and Baybutt, 2022, 2014). This means prioritising whole system approaches to tackle complex 21^st century challenges and enable individuals and populations to flourish (Dooris, Kokko, and Baybutt 2022). However, the settings approach not only highlights that it is inappropriate to focus on lifestyle education without ensuring we have organisational and geographical contexts that enable people to engage with their health and facilitate shifts in behaviour; it also looks upwards and outwards – informed by the Ottawa Charter’s focus on ‘ensuring that the society one lives in creates conditions that allow the attainment of health by all its members’ (World Health Organization 1986, 4).

This leads onto the fifth of the Ottawa Charter’s action areas, Healthy Public Policy, now widely expanded to embrace ‘health and health equity in all policies’ (World Health Organisation, 2014). This advocates whole of government and whole of society approaches to addressing the drivers of inequality and injustice; and focuses on the upstream determinants of human and planetary health within and across multiple domains. Nationally, an ongoing frustration is the short-term nature of government policy, operating as it does within the constraints of our ‘first-past-the-post’ electoral system and five-year electoral cycle (Ilott et al. 2016). Locally, it’s valuable to reflect on what’s happened in England since public health returned to local government in 2013. This move was seen by many as an important opportunity for a renewed and invigorated cross-local government approach – and while the reforms have widely been viewed as successful, with multiple examples of innovative and impactful work, it is very clear that the decimation of public health and wider local government funding has made it severely challenging for directors of public health and their teams to take a comprehensive approach to embedding health within multiple policy areas (Buck 2020). In pursuing health in all policies, it is increasingly evident that – alongside focusing on social, economic, ecological and political determinants – we need explicitly to name and tackle the commercial determinants of health – and to take on, rather than pander to, the multi-nationals that wield power over so many aspects of public health. One key example is the current UK Government’s failure to envision and advance a truly holistic and systemic food strategy. Not only has it delayed its own plans to tackle unhealthy diets by curbing advertising and banning ‘buy one get one free’ offers, it has chosen to ignore many of the recommendations made by its Food Tsar, Henry Dimbleby, who has subsequently resigned in order to be free to critique the Government and its obsession with what he terms ‘ultra-free-market ideology’ (The Guardian 2023). These recommendations include a sugar and salt tax aimed at breaking the junk food cycle; expanding free school meals; introducing greater environment and welfare standards in farming; and working towards a 30% reduction in meat and dairy consumption (Dimbleby 2021, 2020).

As we look ahead, it’s also important to recognise that the world has changed significantly since the Ottawa Charter was published. It’s crucial, therefore, that we add into our framing new and emerging insights, such as those profiled below:

First, we need to identify opportunities offered by the changing contexts in which we operate – for example within England, focusing on integrated care systems. As they take shape, integrated care boards are increasingly using the language of ‘place-based partnerships’ (NHS England and NHS Improvement/Local Government Association 2021). While this focus on fostering cross-sector collaboration at multiple levels is far from new, it does offer an important entry point for health promotion to contribute its experience of and expertise in settings-based work. It is particularly important to encourage place-based approaches to connect between and harness the health potential of different settings within a geographical area; and to move beyond a simplistic focus on place-based service delivery to embrace more holistic and systemic thinking that is better equipped to deal with complexity (Dooris, Kokko, and Baybutt 2022).

Second, as we move forward from COVID-19, it’s crucial that we learn from that experience. In preparing for the future, we need to appreciate that the threat posed by zoonoses is symptomatic of humans’ exploitation of nature, driven by an unsustainable food system and lack of respect for the earth (de León et al. 2021), and that the impacts of this pandemic in large part amplified and were mediated by existing health and societal inequalities (Baybutt and Dooris 2020). We also need to reflect on the key role that organisational and geographical settings played in mitigating the impacts of COVID-19 through joined-up whole system responses (Dooris and Baybutt 2021) and we need urgently to consider how health promotion can join forces with other voices to demand that the disruption caused by the pandemic serves as a catalyst to the transformative change necessary to build back better (de León et al. 2021): How can we combat isolation and loneliness by building on the sense of community and reciprocal support that was engendered? And how can we use the hopeful glimpses we saw – of reduced pollution, decreased road and air traffic, increased walking and cycling, and renewed connectivity with nature – as a springboard to a new future that is both sustainable and healthy?

Third, whereas the Ottawa Charter merely referred to the influence of economic factors on health, I’d suggest that we need to think much bigger than this and articulate and advocate a new economic vision and model – one that rejects economic growth as an end in itself and refutes the assumption that such growth will automatically result in improved population health. This doesn’t mean that everyone in health promotion needs to gain a PhD in economics, but it does mean being bold enough:

• to critique discredited notions such as trickle-down theory (Chancel et al. 2022)

• to highlight the unacceptability of excessive wealth being concentrated in the hands of the ‘one per cent’ and question successive governments’ failure to tackle wealth inequality as a key component of a progressive economic strategy that seeks to raise revenue and tackle poverty (Chancel et al. 2022; Tippett 2021)

• to provoke debate about the public health impacts of commodifying and commercialising water (Buse and Bayliss 2022), energy and transport

• to call out the UN’s SDGs for upholding Gross Domestic Product (GDP) as a dominant measure of progress and for failing to challenge consumerism as a driver of environmental degradation (Baum 2021).

I think it also means embracing Doughnut Economics (Raworth 2017) and other progressive frameworks that position economic development as a means to promote community, societal and ecological wellbeing. Doughnut Economics is concerned to enable people to thrive within the means of the planet and views the economy as nested within, and dependent on, society and the living world (in contrast to the more traditional ‘overlapping circles’ model of sustainable development). The visual representation proposes a ‘safe and just space for humanity’ between what’s termed the social foundation and the ecological ceiling. Drawing on the Sustainable Development Goals (United Nations 2015), the social foundation comprises 12 essential needs that no one should be without – water, food, energy, housing, education, income/work, social and information networks, health, peace/justice, a political voice, social equity and gender equality. Informed by the work of the Stockholm Resilience Institute (Rockström et al. 2009; Steffen et al. 2015), the ecological ceiling presents the nine planetary boundaries that must stay intact in order to protect the life support systems on which life depends – biodiversity loss, climate change, ocean acidification, land conversion, nitrogen & phosphorus loading, air pollution, chemical pollution, ozone layer depletion and freshwater withdrawals. The framework applies regenerative or ‘circular’ thinking to safeguard resource use and prioritises ‘distributive’ approaches to ensure that wealth and prosperity are distributed rather than concentrated in the hands of a small elite.

To conclude, I’ve reflected on the history of health promotion, taken stock of where we are now and used the Ottawa Charter and recent insights to frame priorities going forward. Health promotion is inherently political. Reflecting on our current situation in the UK – with recent years having seen a spiralling in child, food and fuel poverty, a reduction in life expectancy, a widening in inequalities, and the continuing failure of government to take on powerful vested interests through legislative, regulatory and fiscal measures – it doesn’t seem an over-statement to call this point in time a crisis. However, a crisis is defined not only as a time of intense difficulty or danger, but also as a potential turning point when an important decision must be made. This gives space for us to be angry – questioning why we, in one of the world’s richest nations, we are in the state we are in; and it gives us space for optimism and hope. Although the upstream nature of many of the causes of health and ill health means that much of what needs to be done lies outside the hands of the health promotion community per se, we all – as citizens, as professionals and as members of families and communities – have a critical role in to play in envisioning, advocating and fighting for the future we need in order to secure the wellbeing of people, places and the planet.

Disclosure statement

No potential conflict of interest was reported by the author(s).