40 years of health promotion at Leeds Met

We have just celebrated forty years of health promotion at Leeds Metropolitan University. We gathered together previous and current students and staff and Emeritus Professor Sylvia Tilford talked about the early development of the course at Leeds Met, whilst Emeritus Professor Jackie Green joined us in a pre-recorded piece, as she was overseas on the day. Professor Jane South talked about her current work on healthy communities and I talked about some of the global dimensions of our work.

I need to qualify the description ‘forty years of health promotion at Leeds Metropolitan University’ though, as when the course started in 1972, we were still Leeds Polytechnic and only became a University in 1992, when all polytechnics in England became universities. (For anyone unfamiliar, we haev two universities in Leeds - Leeds Met and Leeds University). Also, we started as a health education course, as ‘health promotion’, as we all know, didn’t really take off as a term until the mid 1980s. But – our achievements are significant whatever we call them. In 1972, we were one of three higher education institutions in England asked by the government to develop and deliver health education training for health education officers. Keith Tones was responsible for this development; he of course went on to contribute so many papers and books outlining the principles and practice of health promotion, and commented in the early days about the importance of empowerment (Tones 2001).

Shortly after, Sylvia Tilford joined the department, along with John Hubley and Faith Delaney. Sylvia and Keith, along with Yvonne Robinson produced the key textbook ‘Health Education: Effectiveness and Efficiency’ in 1990, one of the first texts aimed at Masters’ level study. It went through a number of revised editions and was later simply referred to, when we were recommending books, as ‘Tones and Tilford - Health Promotion’.

The course in its earlier days concentrated on the Postgraduate Diploma, as this was the qualifying course to become a health promotion officer. The course was closely tied to practice and students were only accepted with several years of work experience. The primary aim was to provide the theoretical underpinnings to professional practice. In the 1980s and 1990s it was not difficult for students to find work. UK students were employed by local authorities and health services, and those many students who came to us from Africa and Asia were employed in a variety of roles within health and social care, community work and education.

By the time I arrived in 1991, after a decade or so of developing health promotion schools and working in Africa, the course had both health promotion and health education in its title. Keith, Sylvia, Faith, John and I taught the course but we were also developing a research profile and John in particular was doing consultancy work overseas. He contributed mainly in the international sphere, and was a master at producing accessible books aimed at practitioners. He wanted to improve the practice of front line workers. For many years we ran a one-year diploma course at undergraduate level for such workers, which attracted students from all over the world. Some later went on to our Masters’ course. His book ‘Communicating Health’ remains a practical and useful book used in the field, and he went on to produce, with June Copeman, the book ‘Practical Health Promotion’. Tragically, he died at the age of 58 just before this book was published. A second edition has just been produced, being brought up to date and joined as an author by James Woodall.

A couple of years after I joined the team, Jackie Green came to work with us, having been a practitioner at Leeds Health Promotion Service. She went on to

produce another useful book with Keith Tones, (Tones and Green) which in its second edition became Green and Tones (2010).

A major development occurred in 1997, when we set up the Centre for Health Promotion Research, and Sylvia Tilford, who up to that point was the head of the team, took a sideways move to head up the Centre, and I was promoted to head the staff team. The creation of a formal research centre enabled us to house the burgeoning research activity taking place. One of the first major contributions was a piece of research which took forward understanding of the processes of intersectoral collaboration, and one of the papers from that study is still used as  seminal piece today (Delaney 1994). Faith moved on in the 1990s.

The course was popular, and went through a series of name changes to reflect developments in the field. We would spend hours debating what to call the course! In the 1990 and early part of the 21^st century, health promotion was being renamed and ‘rebranded’ variously as ‘health improvement’, ‘health development’ and ‘public health’. There was criticism that health promotion had no delivered its intended promises (French and Milner 1993). Several Masters courses in England changed their names at this point but we felt we wanted to keep the term ‘health promotion’. We did however bend to market demands and call the course ‘Public health – Health Promotion’ – clumsy perhaps, but students were demanding that public health appear in the title, as government ideology had swung away from health promotion and towards retrenching health promotion within the broader (and less radical) public health function. The current fortunes of health promotion in England are described in chapter 6 of the book I mention below (Dixey 2012).

Whilst I was head of the team (1997- 2011), we appointed Mima Cattan, who produced a key book on mental health promotion with Sylvia Tilford, and who drew attention to the issue of loneliness in old age through her PhD studies. Mima is now a Professor at Northumbria University. We also appointed John Barron, a practitioner in young people and schools. Sadly John died suddenly at the age of 48 from a congenital heart condition.  He was passionate about the neglected issue of the mental health of young people, supporting a charity called ‘Young Minds’. Mary Green was another appointment at that time, and she was to prove so instrumental in setting up, with me, the delivery of our Masters’ course in Zambia.

We had become aware that it was proving expensive to study in the UK for students from developing countries. Mary already had a partnership with Chainama College in Lusaka and so we set about seeing if we could deliver the course there. This proved possible when we were awarded scholarships from the Commonwealth Scholarships Commission through their new distance learning committee. We therefore developed a separate course, suitable for Zambia, which we delivered by relays of staff from Leeds going out to Zambia for two-week teaching blocks several times a year (Dixey and Green 2009). We saw this as a way to develop a sustainable workforce in Zambia and since it started in 2004, we have educated successive cohorts, with the seventh cohort about to start in January 2013. Later we also took the course to The Gambia, again on the request of our alumni. We have educated three cohorts there, with the second about to graduate. We again had the welcome scholarships from the Commonwealth and also the generous support of the National AIDS Secretariat in The Gambia which meant that we could educate larger groups (e.g. 37 and 32 in the second and third groups). This way of delivering course is a creative solution to the lack of higher education infrastructure in Africa, and is also, through capacity building, contributing to the development of that infrastructure, as well as building up the health promotion workforce (Dixey 2012). During the time the course has been running in The Gambia, health promotion has been more firmly embedded as a separate unit within the Ministry (Dixey and Njai in press).  Mary Green retired three years ago, leaving a wonderful legacy, as our partnership with Chainama College remains strong.

During the late 1990s and into the 2000s, a number of staff joined the team. Joy Walker was with us for a few years, and Jane South, Ruth Cross, Diane Lowcock, Ivy O’Neil, James Woodall all joined and stayed. Sally Foster has been an essential part of the team since before I arrived, but as a sociologist and health promotion graduate, she was located in social sciences; she and Louise Warwick Booth (a social policy and sociology expert) and Chris Spoor (a health economist) only formally joined the health promotion group in the early part of the 2000s.  Two very experienced practitioners also joined us - Judy White from years of practice in health promotion in Bradford, and Skye Hughes from working for NGOS and at Universities in Kenya and Botswana. Skye left in 2012.  James originally did his PhD with us, one of a large number of PhD students in our thriving research student community.

My initial expertise was in development and I had worked in Africa, as had Mary, John Hubley, Sally, Ruth and Skye. We were also joined in this African work by Zac Mwanje, a Zambian based in Leeds. The opportunity to deliver our course in two African countries has been a highlight of my career and it’s something I feel especially proud of. We have all gained hugely from experiencing the warmth of people in these very two different countries, working with colleagues in Zambia and The Gambia and enjoying developing additional collaborations and projects (Foster et al 2012).  We are planning to deliver our Masters’ course in Ghana, which will begin in 2013. 

The Centre for Health Promotion Research went from strength to strength, firstly under Sylvia’s leadership, then under Jackie Green’s once Sylvia semi-retired. Jackie and Jane South wrote a useful book on evaluation (Green and South 2006), and many of the projects the Centre has undertaken have been evaluations of health promotion initiatives. After Jackie left us, the Centre was co-directed by Jane South and Mima Cattan, and once Mima left, has been very ably led by Jane South. She has developed special strengths in community engagement and in people-centred public health, ideas formulated into a recently published book with Judy White and Mark Gamsu,  our visiting professor (South, White and Gamsu 2012). We have contributed a lot to the development of empowerment approaches, through a series of reports commissioned by Altogether Better (see for example, Woodall et al 2010). Gianfranco Giuntoli, Anne-Marie Bagnall and Karina Kinsella work with us in various research roles, delivering the work of the Centre alongside the rest of the team, all of whom also teach. Our output can be seen through these pages: http://www.leedsmet.ac.uk/hss/research_centre_for_health_promotion_research.htm

Louise, Ruth and Diane have made important contributions to the health studies literature (Warwick Booth et al 2012 and Warwick Booth et al forthcoming), and since 1990 when it was established, we have all contributed to the degree in Health Studies run at Leeds Met.

Our main UK based Masters remains the MSc Public Health – Health Promotion, and the current course leader is James Woodall. In the past, the course has been led by Sylvia, myself, Mary Green, Ruth Cross and Ivy O’Neil. We have been fortunate to have had a number of external examiners attached to the course, all large figures within the epistemic health promotion community – Amanda Amos, David Stears, Jane Wills, Angela Scriven, and currently, Peter Duncan.

Our recent book (Dixey 2012) comes out of our experience of running the course, comprises an overview of all our ideas about health promotion and is designed to be applicable globally. It reasserts the radical intention of health promotion, seeing it as a social movement to bring about health justice. In the introduction, we say:

“What our book does aim to do is to set out some of the key principles and ideas, or in more academic terms, to explore the discourse surrounding health promotion in the twenty first century. It not only attempts to explore what health promotion is, but also to ask some uncomfortable questions about health promotion – in short, to be critical of it. Being critical, according to some, is what defines our age (Jencks, 2007) – being sceptical and asking questions…As such then, this book does aim to be a guide to ‘how to think about health promotion’.”

At the end of chapter one, we write:

“For now, distilling the key points from this discussion, we propose (in no particular order), that health promotion therefore should:

1.     Resist biomedical models of health and advocate for the broader social model of health to be adopted at policy making levels;

2.      Place empowerment and the redistribution of power at the centre, so as to bring transformation to individuals, communities, organizations and societies with the aim of produce greater health;

3.     Involve collaborative working and strong partnerships;

4.     Take a salutogenic approach and promote the importance of ‘good health’;

5.     Take an assets perspective (rather than a deficits one), with a stress on capability;

6.     Prioritize the most vulnerable and disadvantaged communities, thus tackling areas facing the worst inequities;

7.     Start with where people are, use ‘constructionist epistemologies’, respect and value local knowledge and lay epidemiologies;

8.     Use ethical change processes;

9.     Have capable, skilled health promotion workers working alongside communities as allies;

10.  Adopt anti-oppressive practices, challenge racism, sexism, disablism and any other practices and institutions which oppress people;

11.  Adopt ecological principles, sustainability and a concern for the environment;

12.  Invest in the capabilities of the health promotion workforce (both professional and lay), paying attention to life-long learning;

13.  Use evidence-based practice, ‘real world’ evaluation methods.

14.  Produce ‘big picture’ change at the societal level and also ‘small picture’ change, working with communities and individuals.”

Whether the book ‘works’ as a guide to health promotion in the 21st century and is applicable to all countries, no matter what state of ‘development’ remains to be seen. Please let us know!

(You can get in touch through the comment facility of this blog, or email us r.dixey@leedsemt.ac.uk)

We remain passionate about tackling health inequalities and we believe that we put our principles into practice, making sure that in our research we are inclusive, use participative methodologies, such as working with lay researchers; and in our teaching we are empowering another generation of health promotion workers. Our concern with marginalized communities can be seen in our work with, among other things, health promoting prisons and with waste collectors. We also have a major initiative called Health Together: Evidence, Policy and practice for Community Engagement. (leedsmet.ac.uk/healthtogether). 

This round up of health promotion at Leeds Met is inevitably personal and partial, so I’m sorry if I’ve missed anything out. It’s been a fabulous journey for me and I’m proud to have been a part of health promotion at this University. I stepped down from managing the team in 2011 so that I could concentrate more on writing and other projects and also on the professorship that I was given in 2008. (My inaugural lecture is on youtube, as will be Jane South’s later in 2013). There are not many professors in health promotion, but we have two – myself and Jane South. I think it’s fair to say too, that we are one of the largest specialist academic health promotion departments anywhere. The research centre has become a part of the Institute of Health and Wellbeing, enabling us to gain synergies from a wider research community through collaborating with other Centres in the University. Just recently I have been given a part time role in the University as Director of Postgraduate Students which means I have a responsibility for the 650 PhD students across the University. Playing this role I can see that there is all sorts of health promotion research and teaching going on other parts of the University – in the Carnegie Faculty for example, focusing on physical activity, lifestyle and weight management. And as the Arts, sustainable building, healthy cities, politics and social policy and so many other disciplines all have a bearing on health, we are at the centre of a huge amount of creativity as far as health promotion and wellbeing are concerned.

References:

Cattan, M. & Tilford, S. (2006) Mental Health Promotion: A lifespan approach, McGraw Hill International, Maidenhead

Delaney, F. (1994) Muddling through the middle ground: theoretical concerns in intersectoral collaboration and health promotion, Health Promotion International. 9(3), 217-225

Dixey, R, (2012) Health Promotion: Global Principles and Practice. Wallingford: CABI Press

Dixey, R. and Green, M. (2009) Sustainability of the Health Care Workforce in Africa: A Way Forward in Zambia, The International Journal of Environmental, Cultural, Economic and Social Sustainability, 5(5), 301-310

Dixey, R. and Njai, M. (2012) The Call to Action: Health Promotion in The Gambia - Closing the Implementation Gap? Global Health Promotion (in press)

Foster, S., Dixey, R., Oberlin, A. and Nkhama, E. (2012) ‘Sweeping is women's work’: employment and empowerment opportunities for women through engagement in solid waste management in Tanzania and Zambia. International Journal of Health Promotion and Education. 50 (4) July, pp.203-217.

French, J. & Milner, S. (1993) Should we accept the status quo?, Health Education Journal, 52(2), 98-101

Green, J. & South, J. (2006) Evaluation, Open University Press, Maindenhead

Green, J. & Tones, K. (2010) Health Promotion: Planning and Strategies 2^nd edition, Sage, London

Hubley, J. (1993) Health Communication: An action guide to health promotion and health education. MacMillan

Hubley, J., Copeman, J., and Woodall, J., (2012) Practical Health Promotion. Polity Press, Second edition.

South, J., White, J., and Gamsu, M. (2012) People Centred Public Health: Policy and Practice. Polity press.

Tones, K. (2001) Health promotion: the empowerment imperative, in Scriven, A. & Orme, J. (eds.) Health promotion: professional perspectives 2nd edition, Palgrave, London

Tones, K. & Tilford, S. (1991, 2001) Health Promotion, effectiveness, efficiency and equity, Nelson Thornes, Cheltenham

Tones, K. & Green, J. (2004)  Health promotion: Planning and Strategies, Sage, London

Warwick- Booth, L., Cross, R. and Lowcock, D. (2012) Health Studies: An Overview Of Contemporary Perspectives, Polity Press,  Cambridge

Warwick-Booth, L., Cross, R., & Lowcock, D. (forthcoming) Health Studies: A Contemporary Overview, Polity Press, Cambridge

Woodall, J., Raine, G., South, J. & Warwick-Booth, L. (2010) Empowerment & health and well-being: evidence review, Leeds, Centre for Health Promotion Research, Leeds Metropolitan University

Women, leadership and peace

I often wonder what the world would look like if women were in power. Maybe you do too.

By power, I mean in formal positions of power, prominent in public life – if there were, for example, 502 women and 145 men in the UK Parliament. (There are 502 men and 145 women by the way…) Would childcare be so expensive? Would, across the water in Ireland, women die for lack of abortion (as happened recently)? How would priorities be different?

A recently published report, From the Ground Up, produced by the Institute of Development Studies and funded by ActionAid and Womankind Worldwide, shows how perspectives on peace are different from women’s point of view. Peace, as I’ve said before in this blog, is the first prerequisite for health. The Ottawa Charter points out this fact -  it should be obvious, but it isn’t always given its due.

The From the Ground Up report suggests that women define peace more broadly than men, and did not consider that their lives were peaceful, even if there was no civil conflict occurring, because their lives were not free from violence, harassment and abuse. Men viewed peace as the opposite of formal conflict, and the gender difference is summed up by an Afghani woman: “we’re not talking about big war, but peace for us also means no domestic violence”.  Afghanistan was one of the countries surveyed, along with Sierra Leone, Liberia, Nepal, and Pakistan. It’s well known that conflict and lack of peace affects men and women differently but what the report also points out is how women are largely absent from high level negotiations at national or international level, despite a UN security council resolution in 2000 which called for more equal participation of women in maintaining and promoting sustainable peace worldwide. In 17 out of 24 recent major peace treaties, there were no women involved in signing agreements; there have been no female chief mediators in UN-mediated peace talks. Women are renowned peacemakers in homes and communities, and some feminists would argue that if there were more women heads of state, there would be fewer wars.  Women as a peace-keeping resource is thus being under-used, but also the prominence of men in peace negotiations means that women’s and girls’ needs are not emphasized.

Women have been prominent in local peace movements, from Asha Amin and Starlin Abdi Arush in Somalia, Ana Guadalupe Martinez in El Salvador, Luz Mendez in Guatemala, Martha Karua in Kenya, plus all the women in the Northern Ireland peace coalitions such as Monica McWilliams. It was marvelous to see Fatou Bensouda appointed as the chief prosecutor of the international criminal court but this prominence at the top of a key international agency is rare. Women are more likely to be involved in peace making at the informal stages, forming local coalitions and peace groups, or brokering peace in their neighbourhoods and communities. These grassroots activities receive no funding very often, and women’s skills as bridge-builders, conflict resolvers, in dialogue and building trust, is often devalued.

The report From the Ground Up recommends that 30% of those involved in all local, national and international peace negotiation processes are women.  It also calls for 15% of peace building aid to be directed at aid to address women’s needs.  Some of the report’s findings however, also echo some of the UN and WHO’s declarations about peace, that it is not merely the absence of war, (just as health is not merely the absence of disease) – peace must also mean an absence of the structural violence caused by the unequal distribution of wealth, resources and other ‘goods’ within societies. This structural violence is often reified into patterns of discrimination, such as under apartheid in the ‘old’ South Africa, or into systematic oppression on the basis of gender, sexual orientation, age and so on.

It has been claimed that investing in health is investing in peace. See http://www.who.int/hac/techguidance/hbp/Conflict.pdf

Many of these high-blown and well-intentioned statements emanating from summits can be found in UN and WHO documents. Implementing their content so as to enable people to live in greater peace is another matter, and doesn’t appear to be happening. As the From the Ground Up report suggests, unless women are represented at all levels of decisions making, peace is less likely.

Navi Pillay, UN commissioner for human rights is one prominent woman calling attention to global conflict. Recently she has written about the upsurge of violence in the Democratic Republic of Congo. Last week, Goma fell again into the hands of armed men, the M23 movement. One of its leaders is Bosco Ntanganda, who has been indicted by the international criminal court for the mass killings in 2008 in the DRC. Navi Pillay was one of those compiling a report documenting 617 violent incidents in the DCR from 1993 to 2003, all of them involving gross violations of basic human rights. The Congolese army, let alone the rebel groups have perpetrated acts including extreme sexual violence, mass rapes, violent dismantling of refugee camps, using forced child soldiers, and murder of civilians. The UN expert panel report published last week shows that the rebel groups have received assistance form neighbouring countries, such as Rwanda. I often use Rwanda as an example of a country where more than half of the MPs are women – 52% - yet in this specific case, they do not appear to be helping to bring peace to their larger neighbour. These neighbouring countries are essential to brokering peace.

I have just returned from contributing to a symposium on empowerment and health promotion in Germany, as along with Glenn Laverack and Mark Dooris and a few other invited speakers, we were helping German colleagues to establish the idea of empowerment in German public health discourse. I went along to a mass in Regensburg cathedral on Sunday to hear the famous boys’ choir. Speaking as an atheist, I was struck by the display of white male privilege, all the priests and officiates men, and the opulence in this wealthiest of European countries was very clear. I have no idea how it all relates to the message of Christ in the new testament (and I do know my new testament) but no matter. What was clear was that women did not have a place here except in the congregation and of course this is in the same week that the Anglican Church in England has decided not to allow women to become bishops. I know that male leaders of the church – many bishops – were devastated, and that women in the laity were amongst those leading the no vote. It does seem extraordinary and a missed opportunity for women to play leadership roles in the church, to make it more relevant to the 21^st century, and to have a voice in peace-making. If the church cannot do this, what is it for? The tiny African country of Swaziland already has a woman bishop, and if the vote had gone through in England, Rose Hudson-Wilkin, a woman of black African descent might have become the first bishop. Wouldn’t that have been great? I am at a loss to understand why anyone would not think that women have a role to play at the highest levels.

Shakespeare wrote 788 parts for men and 141 for women. I’m not changing the subject here – I’m still talking about women as peacemakers. Phyllida Lloyd, the successful feminist film and theatre director is currently directing a production of Shakespeare’s Julius Caesar, a play all about male power, conflict and war. This production is different as it’s all female cast. A play about fallen dictators, regime change, war and peace clearly has modern relevance. Harriet Walters will play Brutus, and as she says, “There is something in… the ‘alienating’ effect of seeing women paly these parts. The play is essentially about the power vacuum after a dictator falls, and how you tend to fill it using the template of what has gone before. And there’s something about an all-women cast doing that”. Showing women making war points out how odd it is for them to do so – and conversely, how ‘normal’ it is for (some) men to do so.

Austerity Kills

Bradley Wiggins’ high profile accident has brought attention to cycle safety and the government has used it to publicise the £30 million it has set aside for improvements to road junctions with cyclists in mind. We now that the danger of cycling is the major factor putting more people off using this as a healthier way to get around, or for leisure. In fact, the £30 million is about the same amount that the Mayor of London, Boris Johnson, has cut from the capital’s road safety budget and also amounts to £64,000 per council in the UK – not enough to improve even one dangerous junction.  Last year London alone had a 23% increase in cycling casualties and there was also an increase in pedestrian casualties after a decade of seeing reduced numbers.  In the cycling mecca of Holland, the government spends £25 per person per year on cycling infrastructure. Our government spends £1.  The impetus created by the Olympics and the success of the cycling team did start to get more people on their bikes. Now though it looks as if people will weigh up the odds and decide that the risks are too great, so any putative health benefits will go. And it looks as though dedicated cyclists will be at greater risk of death or injury in the future.

These kinds of cuts are happening in many sectors of public life. However, the austerity measures being endured by the population of the UK are being disproportionately administered across the country – to the extent that Hilary Benn, the shadow secretary for local government has said the cuts are “politically motivated”. He has stated that of the 50 worst hit councils, 43 are Labour and of the 50 least hit, 42 are Tory. The 50 councils least affected are seeing cuts of £16 per head, many of them in more affluent parts of the south of England. The 50 worst affected are seeing cuts of £160 per head and are predominantly northern, in Liverpool, Rochdale, South Tyneside, or in inner London such as Hackney.  Haringey in London, often cited as a deprived local authority (and is indeed the 11^th most deprived in Britain) has £84 million of budget cuts, amounting to £170 per head.

Some of the things happening at the moment are not likely to be captured by the conventional methods of measures of deprivation. The Carstairs deprivation scores for example, which are based on adult unemployment, car ownership, social class composition and overcrowding, show how one area can differ from another in terms of relative deprivation, but does not take into account aspects of personal behaviour such as drug use, smoking or poor diet. It’s acknowledged the Carstairs measure no longer captures relative deprivation as effectively in the 21^st century compared to the 1980s.

Whilst academics are clearly extremely concerned about the effects of austerity and poverty on health, there will be a time lag before data are collected to demonstrate the effect and also before robust measures are developed to measure the effect. In the meantime, some journalists are doing an excellent job in showing the impact of austerity. Amelia Hill for example, in this weeks’ Guardian newspaper (19/11/12) shows the pernicious rise of food poverty. She reports research from the Joseph Rowntree Trust which shows that food price have risen by 32% since 2007, twice the EU average. FareShare, a charity which feeds 36,500 people every day is seeing people coming for help who are living on “what were once regarded as reasonable salaries” but who “can no longer afford to eat enough”.  A Save the Children report shows that of 5,000 families in the UK earning £30,000 a year, two thirds had to go into debt, avoid paying bills, not replace worn out clothing and for the parents to skip meals, in order for the children to have enough to eat. A survey of teachers shows that four out of five teachers see children who are hungry in the morning.

The government’s own statistics show that eating healthily has become more expensive, with the price of vegetables rising by 22% since 2007 and fruit by 34%. Between 2007 and 2010, low-income households cut the amount of food they buy by 11%. If you believe, as many health promoters do, and as I certainly do, that the food we eat – the stuff we put into our bodies – is one of the very most important determinants of health, then these effects of austerity are potentially the most worrying. Already the UK has the highest rates of obesity after the USA and rates of liver diseases associated with it are suddenly in the media. The lack of micronutrients and other essentials in the diet are likely to affect immunity and store up health problems. What’s as depressing to me is that those on poverty incomes and poverty diets no longer enjoy food. Food is one of the great joys of life – there’s a celebration of good food in the UK and we seem to have caught up with some of our continental neighbours in enjoying good food, grown and cooked carefully. Amelia Hill’s article though, sadly ends with one of those she interviewed saying, of the food he’d been forced to buy due to his low income, “it all looks so cheap and nasty. To be honest, just looking at it takes my appetite away”.

Austerity not only kills, it also kills quality of life and takes away any joy.

Empowerment and President Obama

We were teaching about empowerment today on our Masters course in Public Health – Health Promotion here at Leeds Met. My colleague Dr. James Woodall was, as part of the session, asking students to critique a paper he and two other colleagues had written. The paper questions whether ‘empowerment’ has lost its radical roots and is now used too casually and without precise definition. (Woodall et al 2011)

Power is a key concept that we dissect when we discuss empowerment, and this inevitably leads to a discussion of powerlessness. Powerlessness, according to Solomon (1976) comes from three potential sources: firstly there are systems which systematically deny powerless groups opportunities to take action; secondly there are the negative images which oppressed people have of themselves, a form of self-oppression, and thirdly there are the negative experiences which oppressed people undergo in their everyday interactions with systems, institutions or the media.

In this week where Barack Obama has been re-elected (Hurrah!) it’s interesting to think about the effect of such an election on power structures and empowerment. When he was elected first time around, black people all over the world were delighted – what a message – to see a black man as the President of the world’s most powerful country, meaning that for the first time, a black man was the most powerful person in the world. (That depends, of course, on how much power you think a President can have, given the forces of capitalism and conservatism in the USA). In terms of the second of Solomon’s sources of powerlessness, Obama’s victories have had a huge impact on positive images and thus on dismantling self-oppression.

Marginalized people – and health promotion is principally concerned with those who are marginalized – have been able to use the election system to their advantage. This doesn’t happen often. In the election that took place this week, for once, the white, male majority did not get their candidate of choice. Exit polls show that 45% of men and 55% of women voted for Obama; of white men, 35% voted for him and 42% of white women. 87% of black men and 96% of black women and 65% of Latino men and 76% of Latino women voted for Obama. In terms of ‘race’ alone, 39% of white voters voted for Obama, 93% of African Americans, 71% of Latinos and 73% of Asians. Those earning less than $50,000 were more likely to vote for Obama – 60% as opposed to 44% of those earning over $100,000.

So all in all, poorer, female, black, Hispanic and Asian people were able to make their vote count and to elect someone who they felt would represent their interests. This is essential if one of the key outcomes of empowerment – systems change – is to happen. It also resonates with the first of Solomon’s points about sources of powerlessness, that systems operate to exclude certain groups in a systematic way. There is a good chance, with a second term, that Obama will be able to bring about permanent systems change. The implementation of the reform of health services must be a major plank of this systems change. One thing which seemed to make a difference this time around was persuading those who don’t normally vote, to get out and make sure they did.  They stopped Mitt Romney doing what he had pledged to do in cutting after school programmes, job training programmes, Head Start, Planned Parenthood and other social projects which primarily target the marginalized. Now, we have a President who has pledged to invest in education, tackle climate change, reform immigration policy; this means for example, that the eleven million undocumented immigrants might be able to gain a path to citizenship. I don’t agree with all aspects of America’s foreign policy but I’m certain it will be a lot more enlightened than it would have been if a Republican had got into the White House.

No doubt Obama will not be able to be as radical as he’d like, given the opposition of Republicans, but in terms of empowerment, it’s a great stride forward.

The change of leadership in China, also happening this week, gives hope that the two most influential countries in the world could take us into a different era of politics.

References:

Solomon, B.B. (1976) Black Empowerment: Social Work in Oppressed Communities, Columbia University Press, New York

Woodall, J., Warwick-Booth, L., Cross. R. (2012) Has empowerment lost its power? Health Education Research. 27 (4), 742-745.

Starting out on a health promotion course....

The start of the new academic year is always exciting, and we have been welcoming our new intake of students on the MSc Public Health- Health Promotion. Their initial module builds the Foundations of public health and health promotion and is an introduction to the Leeds Met philosophy. As we have written in our forthcoming book, Health Promotion: Global Principles and Practice (see reference below), we regard health promotion as a broad social movement centred on health justice. We adopt a social model of health, and this is a major challenge to some students, coming as they do, from a medical model mindset. Others are already in tune with a salutogenic as opposed to a pathogenic model. We pose this statement for discussion early on, though we broaden it to say that it could apply to any country: “The most confounding factor to health promotion development in Africa emanates from the fact that health promotion activities are in most cases, planned, managed and controlled exclusively by health staff, mostly from within the ministry of health. The main actors are health workers whose concept of health is based on the conventional public health model and whose focus is on interventions revolving around curative services. “(Nyamwaya and Amunyunzu-Nyamong, 2009:21). For some, it seems logical that health promotion is dominated by health staff, but for us, this is detrimental, as suggested by David Nyamwaya and Mary Amunyunzu-Nyamong.

Realising that health is created outside the health (or sickness) service, and that health care is but a small part of our thinking, is new to many students.  As such, we need to talk about key ‘threshold’ concepts. The threshold in many homes is the line you cross from the outside to the inside, or from one room to another, but in popular expression it’s a line that once crossed, you cannot go back. In educational terms, it means a concept that opens up a new world, a new way of thinking and often too, means an idea that you have to understand before you can progress to the next idea. Understanding what we mean by a ‘social model’ is such a concept, as too are ‘upstream thinking’ and ‘salutogenesis’.  At this stage in the course, many students have not crossed this threshold but the module guides them through the complexity of principles, theories, approaches and concepts that make up health promotion based on the Ottawa Charter.  Our first formative assignment is to ask students to consider whether the Ottawa Charter still provides a solid foundation for health promotion in the 21^st century – quite a difficult task!

The layers of health promotion are illustrated, for me, by the phrase ‘sugar in the blood’. To someone steeped in a medical model, sugar in the blood evokes the idea that we have high rates of diabetes in both developed and developing countries, and that this increasing trend needs to be addressed. Individuals need to address their diet and increase exercise, which will require top-down exhortation. At the other end of a political spectrum and of analytical complexity, we could see how the idea of sugar is infused throughout our lives.  The Tate galleries in London are famous for their role in cultural life, but the links with Tate and Lyle, the sugar manufacturers, is perhaps less prominent today.  The Tate family made their fortunes in the sugar planantions, which themselves were made possible by the slave trade. Many large stately homes, including our local Harewood House, near Leeds, are based on money derived from the plantations that used slaves.  Andrea Stuart, in her book, Sugar in the Blood: A Family's Story of Slavery and Empire, documents the history of her family. One of her ancestors went to the West Indies in the 1640s and made a fortune in sugar. This sweet stuff fuelled the industrial revolution in Europe as well as the Enlightenment, and created a new diet. It also of course, created the shamefully inhumane relationship between Africans and Europeans that still resonates today. Stuart’s book grapples with this legacy. 

So sugar is highly symbolic.

The health consequences of sugar have also become political issues. It was Professor John Yudkin in London who first questioned in the 1970s, whether sugar, rather than fat, was behind the problem of heart disease. His work was systematically discredited by lobbyists from the food industry, and especially the sugar industry. In an era when low fat items were being developed, the fat was replaced by sugar, to make the food palatable. The leading nutritional scientist Professor Phillip James began to question why people were getting fatter, even those who ate a ‘low fat’ diet. Simultaneously, researchers were looking at the effects of eating modern processed foods, and this showed that in both rats and people, the more sugar was eaten, the more hungrier those rats and people became, setting up a needy cycle. It seems that the stomach sends messages back to the brain asking for more sugar, as it becomes conditioned to want more. And in obese people, leptin, which is a hormone produced to tell you that you are full, becomes so depleted that it no longer serves its function. Eating lots of sugar is the mechanism causing this depletion. The food industry funds, and is involved in, much of the research looking at the links between diet and health. Moreover, the food industry is a powerful lobby, and is behind, for example, the failure of the WHO to recommend global limits on sugar intake in 1990.

I was once involved in developing healthy eating guidelines for schools across the then 15 members of the European Union. We held one of our meetings in the FAO offices in Rome. We were unexpectedly joined for this meeting by an organization called EUFIC who described themselves as an advisory body, and said they would fund publication of materials – with certain provisos. It turned out that they were a front group for the food industry. It amazed us that they knew about our work and also were prepared to fly people in for a meeting from all over the world, and were also prepared to fund nutrition related activities. A powerful lobby indeed.

The effects of sugar on the body are now well known, but governments do not appear to be tackling the food industry – it’s far too contentious,  jobs are at stake, and the food industry is lucrative and  entwined with other industries. The tobacco industry has been somewhat curbed but it looks like the food industry will not be, even if causes health damage.

The example of ‘sugar in the blood’ shows how a political issue is literally embodied in the individual. But tackling it at an individual level is not going to work. It would be a ‘downstream’ action to try to influence the diets of individuals who are already overweight or obese, and anyway it is not individuals who are putting the sugar or high fructose corn syrup into the foods we buy. As so obvious from the Ottawa Charter, policy action is needed from the highest levels to look at how our food is produced.

Some of our new students thought that their role would be to help these overweight and obese individuals to change their lifestyles – and maybe that is the case. What we also want them to do, however, is to think how they can effect change much further upstream.

Dixey, R, and others (2013) Health Promotion: Global Principles and Practice: Wallingford: CABI Press. Text book for postgraduates: http://bookshop.cabi.org/default.aspx?site=191&page=2633&pid=2454

London 2012 Olympics

I have to say that I loved every minute of the London 2012 Olympics. I cheered, whooped, shed tears and jumped up and down as much as everyone else. It was wonderful to see so many athletes doing amazing things and of course I was delighted at Team GB successes.  I’m a great sports fan anyway and this Games has been fantastic. For me though, the whole experience has thrown up contradictions, confusions and the need to analyse just what has happened over these momentous few weeks.  Sport is so commercialized, male, privileged, elitist, and nationalist – isn’t it? – so how is it that those of a feminist, leftist, peace-loving persuasion can find it so compelling? Well, I guess the fact that we can both critique it and find it compelling shows how complex humans are.  Half of me is astounded and fascinated by what humans can do with their bodies and part of me is saddened and puzzled that sane people can spend so much time, energy, money and make so many sacrifices just to shave 0.008 seconds off someone else’s time…..

But, back to the beginning - Danny Boyle’s opening ceremony was astonishing, dramatically showing how the opening says something implicit and explicit about the host nation. Before the perfectly honed bodies of the athletes were paraded, we were treated to human touches so different from the Beijing opening, with the experiences of everyday people, vulnerable, funny, brave, on show. Seemingly small touches spoke volumes – Doreen Lawrence, the mother of the murdered Stephen Lawrence holding the Olympic flag as it came into the stadium, for example, along with notaries like Ban Ki-Moon.  Another flag carrier was a human rights activist, a category of person, as many have pointed out, locked up before the Beijing Games.  The NHS had a starring role, the suffragettes made an appearance, and the 1993 Brookside first lesbian kiss popped up in a montage celebrating the film industry, a kind of snub to the 150 countries still banning openly gay athletes from competing.

These Olympics smashed the idea of sport existing in a separate bubble. The sport literally spilled out on to the streets, but it also raised key questions about diversity and equality. The opening ceremony was a celebration of the history and diversity of modern Britain.  The backgrounds and stories of the athletes showed they were connected to the real world, with all its messy complexity.

The Games have been good for women. For the first time, all 204 countries taking part sent women, with Saudi Arabia, Qatar and Burundi sending women for the first time. Team GB’s women had extraordinary success. This doesn’t mean that women are equal though. In the UK, the Women’s Sport and Fitness Foundation reports that women’s sport in general receives only 5% of total media coverage and only 0.5% of corporate sponsorship.  Some Olympic Sports were only open to one sex – synchronized swimming is female-only, but more sports are male-only, with canoeing a good example of discrimination, and overall there being 30 more medals available to men than women in the 2012 games.  In Saudi Arabia, girls and women are not allowed to do PE at school, join a sports club or even go to sporting events. The International Olympics Committee put pressure on the country to send women, and Wojdan Shaherkani made history by being their first woman from Saudi to compete, in the judo. She only knew three weeks before the games that she was to compete, and she didn’t meet the qualifying standard – but that wasn’t the point. She was one of 4,847 women competing in London, 44% of the total.  Not only was it great to see these women enjoying what they could achieve with their bodies, they have provided a set of role models for all the other girls and women out there. 

The achievements of athletes like Mo Farah highlight how Europe offers possibilities denied to many from poorer countries; Mo came to Britain aged 8, his parents hoping for a better life. His twin remained behind and although then a promising athlete, he has not gone on to develop this talent. Britain is a country of migrants, and Britain is happy to claim Mo, but it has also given a boost to Somalis and the Somalian diaspora – he is the first ethnic Somali to win gold. Sadly, a Somalian athlete at the Beijing Games was one of those who perished on a boat earlier this year trying to cross the Mediterranean to escape to a better life in Europe. The links with the colonial past are clearly seen in the multicultural, multiracial Team GB, and the BBC commentary team at one point, made up of the white commentator John Inverdale and three black athletes, all previous medal winners, had a sensitive and thoughtful discussion about why so many brilliant athletes are black, and why a white man hasn’t won the 100 metres since 1980. It’s easy to be flippant and say that black athletes are just better and we could offer all sorts of cultural and physiological explanations, but the fact that the discussion took place shows something of the confidence that Britain has in its multiculturalism. A poll in the last week showed that 68% of respondents agreed that Britain is stronger as a country of many cultures, rising to 79% in London and 81% among the 18-24 age group.

It’s noticeable that African athletes and those from the global South excelled in those sports that didn’t require expensive equipment. The sports involving horses, boats, bicycles, (and much of the winter Olympics) are the preserve of the global North, apart from a few exceptions such as a cyclist from Trinidad and I think I spotted a black rower from South Africa. This isn’t surprising, of course. To get up and run doesn’t need resources – though obviously it does to get up to international level, and that's where people like David Rudisha have been lucky to have been spotted and enabled to develop their talent. What is perhaps more surprising is how the athletes and medalists from the UK are still so over-represented by the privileged, and attended private schools. At the Beijing Games, 50% of GB’s gold medal winners were from fee-paying schools. One school, Millfield in Somerset taught seven of the competitors at London 2012, two of them gold medal winners.  An estimated quarter of the Team GB was educated at fee-paying schools (attended by 7% of the population).  (Incidentally, two thirds of England’s rugby team was educated in such schools too.) The facilities at these schools bear no relation to those at the schools most children attend; Tonbridge School in Kent for example, has a 25 metre indoor pool, 12 rugby pitches, 18 tennis courts and an Olympic standard athletics track. Well, I guess this is what the annual boarding fee of £32, 823 buys. Meanwhile, although there has been a scandal about the number of school playing fields that have been sold even since the Olympics, the number of children taking part in competitive sport is up from 58% in 2006/07 to 78% in 2009/10.  Yet the Tory Education Secretary, Michael Gove, on getting into government axed the £160 million budget for school sports partnerships. The debate about a lasting sporting legacy from London 2012 rumbles on, with contradictory policy moves.

The athletes exemplify a key idea in health promotion, that of deferred gratification – putting in hard work and making sacrifices now for the sake of a pay-off sometime in a distant future. Also it’s not just individual effort – all the athletes, winners or losers, thanked their teams – coaches, families, teammates – in interviews, showing how much of a group effort it all was.  They clearly felt a sense of belonging to something, which spurred them on.

An ICM poll showed that 55% of Britons felt the Games were worth the investment, as they are helping to cheer the country in hard economic times.

In terms of legacy, membership of clubs such as cycling clubs has already gone up and some of the top cyclists have spoken out for cyclists’ rights to a safer road environment. The fact that Team GB won so many medals wasn’t just due to home advantage – it showed what a sustained strategy of substantial investment in sport can achieve. The Games did attract a lot of corporate funding but also it really shows what public investment can do, including revitalizing one of the poorest parts of London, and hopefully, leaving behind an area with factories providing employment, houses and social amenities. The Games also enabled ordinary people to get involved, and volunteering is another of those ideas that is being talked about a lot in public health circles – it appears to help people develop a sense of wellbeing. 70,000 people were taken on as volunteers for these Games. This kind of community activity, and joining clubs, generates a sense of belonging and what we increasingly talk about as social capital; ‘Bowling Alone’ isn’t possible for many sports and for me it’s the sociability, team work, problem solving and having fun together that’s the real point of sport. It does concern me that young people get hooked up in the excessive competitiveness that leads to cheating, or can get obsessed with those hundredths of a second that make a difference. Making a difference is surely more about using sport to tackle social issues – racism, homophobia, HIV – or using some of the technology to solve practical problems. (We have bicycles that can shave seconds off a time by being more aerodynamic but a bike that can withstand the brutal paths in parts of the poorer world seems to elude us, for example). It’s a good move that under the new lottery deal with UK Sport, top athletes have to spend 5 days a year in schools motivating pupils to be more active.

Finally, what about all those amazing bodies? One man, watching a swimmer, exclaimed, “Look at this…what a beautiful boy”. That man was the father of the athlete in question, Chad Le Clos, and he had just beaten Michael Phelps, the so-called greatest Olympian of all time, in the 200 metres butterfly.  He, and all the other parents, were of course bursting with pride and overwhelmed at what extraordinary children they had produced. But it was ok for any of us to exclaim at the beauty of the bodies, as they were amazing: sport gives us permission to admire such beautiful bodies and what they can do, without being voyeuristic. The kit worn does seem to have become more body-revealing over the years, with the men’s diving kit and the women’s for the beach volley ball especially notable…… but the origin of the Greek games was centered on the beauty of the human form as much as it was about sporting prowess, with athletes expected to parade naked.  This of course is why some cultures disapprove of sport, with the link between nakedness, sexuality and the sporting body.  The Paralympics are about to start and it gives us a chance to appreciate different bodies, differently beautiful. I’m proud that the Paralympics originated in England, the inspiration of a German doctor given asylum here from Nazi Germany, Ludwig Guttmann. The Stoke Mandeville Games evolved into a challenge to prejudicial views about those who are differently abled, and fuelled the disability movement.

Lastly, just a note on Michael Phelps, who I mentioned as the “so-called” greatest Olympian. His achievement is fantastic of course, and he seems a very nice young man. No doubt he has had all the privileges though and my vote for greatest Olympian would go to his compatriot Jesse Owens, who defied the racism of the USA and of Nazi Germany to win four gold at the 1936 German Olympics in front of Hitler. He inspired so many generations of black American athletes and was a great role model – though maybe not in that he smoked a pack of cigarettes a day and died in 1980 from lung cancer.  He was perhaps in the minds of Tommie Smith and John Carlos from the USA on the day that they gave the black salute on the medal podium at the 1968 Games to highlight black poverty, together with the white Australian Peter Norman. All were supporting the Olympic Project for Human Rights. The opening and closing ceremonies too, at the London 2012 Games seemed to reflect some of the social context and politics within which sport takes place which helps me at least overcome some of those ambiguous feelings that elite sport creates.

Our health and The Arctic

I have just returned from the high Arctic, having done a circumnavigation of Spitsbergen, the largest of the islands making up Svalbard. We called at a number of the other islands, and saw stunning ice scenes, mountains, glaciers, and polar bears, walrus, reindeer…. Svalbard is about as far north as you can go, and is on a level with the top of Greenland. It was a huge privilege to have the money, time and ability to get there and to see it for myself. For me, wild places are essential to my ability to function in the modern world and the world of work; it’s what I want to do in my free time. I’m aware of course of what a luxury that is, and the danger of these areas being playgrounds for the rich. The paradox often, is that tourism destroys the wildness that we seek; I went with an environmentally-conscious and allegedly ‘responsible’ tour operator. The Association of Artic Expedition Cruise Operators (AECO) is an international association aiming to manage responsible and environmentally-friendly cruise operations in the Arctic and to educate those who visit about the issues facing this amazing part of the world. It undertakes studies to assess the impact on wildlife, the cultures and people and environment, in the hope of minimizing unwanted impacts.

Tourism however, is a complex area, and I’m not going into it here. (I do supervise a PhD student looking at pro-poor tourism in The Gambia, and that could be the subject of another blog…) Apart from being important to me, the Arctic is essential to the health of everyone in the world. Everyone on the planet depends on the health of the Arctic. It is what keeps the planet cool – the ice reflects the sun’s rays off its ice, thus acting like a giant air-conditioner. However, we know that the Arctic is heating up twice as fast as anywhere else.

Glaciologists have noted the seventh successive summer of a pattern of warm air circulating on the ice sheet of Greenland, and earlier this month, over only four days, a rapid melting took place over 97% of the surface of Greenland. NASA was so surprised at the findings that it first questioned the instrumentation, but the results have since been confirmed. Although conditions returned to normal by a couple of weeks later, it was highly unusual, as was the breaking off of a huge iceberg (about the size of Manhattan island) from the Petermann Glacier.  There are periods of natural rapid thawing occurring about every 150 years, but there is no doubt that some of the well-documented trends are due to human-made global warming. About a fifth of the annual sea level rise (at the moment about 3mm) is due to the Greenland ice sheet melting.  The National Centre for Atmospheric Science at Reading University in England has recently published studies carried out by Dr. Jonny Day, which concludes that more than 70% of the decline in sea ice is due to human activity, and could be up to 95%. They have compared the variability in the extent of ice over its natural cycle (a cycle of cooling and warming which occurs every 60 to 80 years), using computer simulations to see what would have happened without the input of greenhouse gases. The frightening thing is that as the ice melts, the effect accelerates (the ice-albedo feedback effect), with the sea absorbing even more radiation and therefore warming faster.  Prof. Peter Wadhams from the University of Cambridge predicts that all ice might be lost during the summer months from the Arctic Ocean by 2016. His views are mentioned in the newspaper article highlighted below.

The burning of fossil fuels, is of course one of key contributors to global warming, and the Arctic is now under threat itself from the scramble to find more fuel resources. The reduction in ice means the area is more opened up to exploration. This article of July 21^st explores the issues:

http://www.guardian.co.uk/world/2012/jul/22/arctic-ice-melting-oil-drilling

The rush to extract resources from the Arctic is being spearheaded by companies that already have poor records for environmental pollution. According to Greenpeace Russia, at least 300,000 to 500,000 tonnes of oil leaks into the Arctic Ocean every year from on-land drilling. The oil industry has polluted major water bodies such as Lake Baikal and its surrounding waterways, meaning that locals cannot catch fish or use water for drinking. The key Russian-owned company, Gazprom, is now expanding north into even more risky waters. It has established a second rig in the Pechora Sea off Siberia this year, in an area surrounded by wildlife sanctuaries and national parks. Greenpeace has been holding up icebreakers en route to the Arctic in advance of the drilling ships and have also started a campaign to establish a global sanctuary in the uninhabited area around the North Pole. The goal is to get the UN to designate it as a protected area for the sake of the health of the planet. Greenpeace also calls for a ban on offshore drilling and unsustainable fishing in the Arctic. The campaign is at:

www.SaveTheArctic.org

It seems clear that the Arctic is a huge part of the problem of global warming and therefore a major part of finding solutions. Greenpeace’s actions are therefore welcome in an age where governments and the UN seem to be taking action too slowly, and where they have conflicting agendas.

How the health promotion community responds to these issues is vital. Of course, people can take action in their personal lives, and as with any community, opinions will vary as to how seriously to take the threats of global warming. However, as health practitioners, our responsibilities to get involved are to me, very clear. Jenny Griffiths in the UK is perhaps the best-known advocate on the role of health practitioners on climate change. With three other editors, she has produced “The Health Practitioner’s Guide to Climate Change, Diagnosis and Cure”, a packed book of 350 pages on understanding climate change, but more importantly, on how to take steps to tackle it. It’s a practical book explaining how we can take action within the compass of our own work lives and practice. Health promotion is the professional area of practice that can persuade people to take action on something as important as climate change. Chapter 7 uses Mahatma Gandhi’s saying “Be the change you want to see in the world” to encourage us as health workers to make changes in our own lives, and then other chapters tackle organizational change, community change and so on.  It’s an essential book to help to start organizing your own response to these dire environmental challenges.

Meanwhile, who or what within the epistemic health promotion community is taking the lead on the threat to the health of the planet? Please use the 'comments' option in this blog to add your views. 

Reference:

Griffiths, J., Rao, M., Adshead, F., and Thorpe, A. (2009) The Health Practitioner’s Guide to Climate Change, Diagnosis and Cure. Earthscan.

Human Rights and Gay Rights

The European football championship was played in Poland and Ukraine a couple of weeks ago, inevitably focusing attention on those two countries.  Ukraine was in the news during the tournament, for failing to curb racist incidents directed at footballers, and it has remained in the news for further unfortunate reasons. Firstly there have been clashes between police and protesters angry at the “russification” of the language after the Parliament’s elevation of Russian to the status of a regional language, with the use of the Ukrainian language a statement of autonomy after years of Soviet rule. Secondly, the Ukrainian Parliament was, last week, debating draft law number 8711, that would make it an offence to talk about lesbian, gay, bisexual and transgender (LGBT) issues in the media. This threatens education and advice about sexuality, or sexually transmitted infections such as HIV; it threatens public gatherings where LGBT issues are discussed. There has been anti-gay violence in Ukraine, and the country is following the trend set by parts of Russia, which passed laws banning literature about homosexuality, making it illegal to hold film festivals, pride marches or exhibitions where LBGT people were expressing their identity and issues. 

Not so long ago, Britain had its own legislation, passed under Margaret Thatcher’s government and known as “Clause 28”, which made it an offence to ‘promote’ being gay as a ‘normal lifestyle’. Teachers and schools interpreted it as meaning that they could not talk about homosexuality. This law was finally repealed. The comparison is not an especially good one, as the laws currently being debated in Eastern Europe go further than this in terms of being much more punitive. The UN has come out to say that the laws proposed in the Ukraine would violate rights protected under treaties that the Ukraine has itself signed.

The Ukraine is not the only country currently to be debating gay rights. The Global Journal (theglobaljournal.net) featured the Ugandan gay rights activist Kasha Nabagesera in its May 2012 edition, with the headline, “Being gay in Uganda could soon attract the death penalty. Knowing and not reporting that your sister is a lesbian could soon be punishable with a prison sentence”. (p31) Kasha comments, “Uganda… (is)committed to uphold all human rights with no distinction, no exception…My government is proposing too kill me. What is the UN doing about it?” (p33). The ex-prime minister of the UK, Tony Blair, recently ran into a sticky moment in a meeting with the president of Liberia, Ellen Johnson Sirleaf, where gay rights were alluded to.  She stated, “We like ourselves just the way we are”, defending a law that criminalises homosexual acts (Ford and Allen 2011:19). Other African countries appear to be strengthening anti-gay legislation and homosexuality remains illegal in 37 African countries.

Despite this, there is a lot of LGBT rights activity in Africa, which often only comes into public view when a crisis occurs, such as the murder of the Ugandan gay rights activist, David Kato. The extent of this grassroots activity in Africa is shown by Epprecht’s (2011) useful paper (see reference below). He also suggests that possibly, men who have sex with men (msm) is one of the overlooked factors which might help to explain why sub-Saharan Africa has such high rates of HIV. He reports that in one study in Uganda, for example, 90% of the respondents (msm) had (female) wives as did over 60% in a Kenyan study. Homosexuality is clearly present, and the fact that it is not acknowledged means that health education and promotion are compromised. In Lusaka central prison in Zambia, for example, a well-conducted study found HIV rates of 42% among male inmates. (In the general popualtion it is 14%). Condoms are not distributed in prison as msm is not felt to exist by those who would have the authority to provide condoms. The whole issue is too political, and meanwhile men’s health, and that of the women they go on to have sex with on release, is fundamentally compromised.

Under international law, criminalising homosexuality is illegal, but in many countries, homosexuality is indeed illegal. Wilkipedia provides a useful overview of LGBT rights by country:

http://en.wikipedia.org/wiki/LGBT_rights_by_country_or_territory

The Human Dignity Trust has recently launched a campaign to combat homophobic legislation globally, and it includes activists from all over the world, including Africa:

http://www.humandignitytrust.org/

Homosexuality is illegal in 78 countries around the world. The maximum penalty in five of those countries is death. There is no clear reason for this extreme response; in Japan, homosexuality has been legal since 1880. What causes some countries to have no problems with respecting the rights of gay people and others to have major difficulties with it?  The Human Dignity Trust is campaigning on the single issue of decriminalising same-sex between consenting adults.

Even in a country such as the UK, where homosexuality is legal, and civil partnerships are available, there are effects on health due to the stigma still existing in some circles.  Stonewall, the gay rights campaigning organization posted this recently on its website:

“5 July 2012

Homophobic bullying ‘a daily nightmare’ for over half of Britain’s school pupils

Pioneering research reveals serious concerns about homophobic language
Nearly a quarter of gay young people attempt suicide

New research carried out by the University of Cambridge for Stonewall’s School Report 2012 has found that 55 per cent of lesbian, gay and bisexual pupils in Britain’s secondary schools experience homophobic bullying. The research, based on a national survey of 1,614 young people, also found that nearly a quarter (23 per cent) of gay young people have attempted to take their own life, and more than half (56 per cent) deliberately harm themselves.”

The report can be found at:

http://www.stonewall.org.uk/at_school/education_for_all/quick_links/education_resources/7956.asp

Gay people are humans like everyone else and thus should come under the same protection under international law, just like everyone else; gay rights are human rights and human rights are gay rights. An attack on gay people is an attack on human rights. And of course, human rights are fundamental to achieving health for all.

References:

Epprecht, M. (2011) Sexual Minorities, Human Rights and Public Health Strategies in Africa. African Affairs, 111/443, 223-243

Ford, T. & Allen, B. (2011) An awkward silence: Liberia’s President defends anti-gay laws – as Blair squirms. The Guardian, 20 March 2012.