The Commission on the Social Determinants
of Health quite rightly turned the focus on the ‘causes of the causes’ and gave
a boost to those of us in health promotion who had always called for a
sociological analysis of poor health. I have been wondering recently whether
the radical intent of the CSDH has been diluted - a tendency affecting any
radical initiative. The Commission was
headed by Sir Michael Marmot, a medical doctor, and some have argued that the
reason the report was taken so seriously was because it had the legitimacy
afforded by its provenance within those medically trained. (Fran Baum, as one
of the Commissioners, was the most notable health promoter. ) Following this
line of thought, it could be argued – and it has been suggested by some - that the CSDH shows continuity with the
biomedical approach to disease and ill-health, showing the continued battle
between the social and medical models of diseases, and the dominance of the latter
in the discourse. Certainly reading various national government reports and
those from the UN there is a real emphasis on the proximate causes of ill
health, those related to individual lifestyles, ‘choices’ and ‘risk factors’. Mainstream
epidemiology can often, perhaps unwittingly, reinforce the dominant discourse,
and also, of course, the further upstream, to more distal factors, the harder
it is to show the precise relationship between causes. Thus the ‘causes of the
causes’ discourse has perhaps become rhetoric.
The dominance of the neo-liberal agenda and
the collapse of some of promising challenges to it do not lead to great
optimism for a real change to the power structures that create health
inequalities. There seems to be a great disjuncture between the ideas embedded
within emancipatory health promotion, with its emphasis on empowerment and
people taking control of the factors determining their health, and the reality
on the ground facing those experiencing health inequalities. Emancipatory
health promotion has citizenship and personal agency at its heart, as it is all
about individuals and communities being able to change the material
circumstances in which they live. Emancipatory health promotion thinks about
the social determination of health,
not simply the social determinants of
health. How can health be socially determined by ‘ordinary’ people, those that
professionals tend to call ‘lay’ people? The social determination of health
requires citizens to have a voice, power, skills and to be able to operate
within the kind of state that welcomes such involvement. This is clearly not
the case in so many countries today and certainly not in some of the worse
cases, such as Syria, and (having just returned from Eastern Europe) not in the
case of minorities such as gypsies and Roma people. Despite the focus on ‘assets’
within the health promotion discourse, many groups have neither a voice or the
ability to take collective action.
Our Centre for Health Promotion Research
has always followed its principles by focusing on inequalities in health,
enabling ‘lay’ voices, and involving lay people as fellow researchers. My
colleague
Professor Jane South has recently edited a special edition the Perspectives in
Public Health journal, on health trainers. The Centre for Health Promotion
Research has been involved in the evaluation of health trainers since the
inception of this new public health service in 2005.
The special
edition carries a paper by Jane and Leeds Met colleagues Judy White and
Jenny Woodward, on how health trainers can tackle health inequalities. Jane
South and Dr. Shelina Vishram provide an editorial on the whole concept and
evidence base for health trainers. This
journal edition is unique in also including opinion pieces from a health
trainer and a service user, bringing a truly bottom-up perspective to academic
publications. Although the idea can appear to mimic the use of
individualistic, ‘lifestyle’ trainers, the reality is that the Health trainers programme
is a fascinating example of community empowerment and is a refreshing approach
to tackling health in communities facing damaging social conditions.
See:
Health inequalities mean that people bear
the scars of social conditions in their bodies and minds. ‘Embodiment’ is an outward
show of power differentials, though those scars are often carried internally,
in the form of depression, despair and low expectations. To be active citizens
means that people have the chance to develop their own meanings of health, and also
not only to respond to public health policies, but also help to create them. The
health trainers programme provides one framework by which such active
citizenship can be fostered. There are other examples from around the world, and
they need to be heard about. Moving towards the social determination of health has to be high up in our debate within
the health promotion community. Perhaps it could be the focus of the next
symposium, conference, web discussion, journal edition, so that the ‘causes of
the causes’ discourse does not become tamed, that the momentum of the CSDH is
not lost, and that the principles, methods, and practice of socially determined
health can be shared.
