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 21st 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
