Health Promotion and the World Cup?

When my colleague and graduate of Leeds Met,  Ebenezer Owusu-Addo,

read my last blog post, he emailed me and said “what will your next blog be on – health promotion and the world cup?!” Eben is Assistant Research Fellow at the Bureau of Integrated Rural Development, Kwame Nkrumah University of Science & Technology in Kumasi, Ghana, and like many of us, is a football fan.  So this one’s for you, Eben!

Initially I thought that the world cup doesn’t have much to do with health promotion, but I like a challenge, so I've been thinking about it. And of course, the world cup is important and I’m writing this on the same glorious day in 1966 that England beat Germany 4-2. I watched it alone as a child, in a cavernous room in a castle whilst on holiday with my family and it remains one of the best sporting events of my life, and that of many other people. This was only 21 years after the end of the Second World War and victory over Germany is always sweeter than that over any other nation. Here start the problems – what’s the line between national pride in achievement, and nationalism?

Now, in my view there are lots more important and pertinent issues than football and the world cup. I’d like to mention a few before returning to the main theme. To start with, over 1000 Palestinians have been killed in the last three weeks by the action against Hamas by Israel. Children and women have been the largest part of these deaths; about 50 Israelis have lost their lives, mainly military personnel. There seems to be no end to the violence there and no solutions; I wept again at seeing the images of children in hospital in Gaza, aware that they would become the next generation of angry young people. And there’s the downing of Malaysia Airlines flight MH17, again bringing heart-rending scenes of parents who have lost their children. Right now we are commemorating a random act of violence a hundred years ago that led to the First World War; even if flight MH17 was accidently shot down, it’s the kind of thing that has the potential to shatter peace on a global scale. How many times have we heard “Never Again”?

From a professional point of view, (and knowing that all lives are of equal worth), one death that struck me, of those killed on flight MH17, was Professor Joep Lange. He was the Dutch doctor and specialist in infectious disease whose work developed antiretroviral therapy. ARTs are now saving millions of lives throughout the world, making HIV a manageable disease as long as these drugs remain available. He worked tirelessly to make sure the drugs were available throughout poorer countries from the 1990s. He was a founder of the Amsterdam Institute for Global Health and Development, and had started to take on a series of other major issues, such as health care financing. He has been described as having a heart of gold and a strong sense of humour, a highly intelligent and cultured man. He was 59 and surely had many more years of life to enjoy and many more ways to contribute to improving health. One senseless death among so many.

Back to football. Yes I enjoyed the world cup. Yes of course I wanted Ghana to win. Being an academic, where our job is to be critical, it’s often the case that you feel split – you can simply enjoy an amazing spectacle, young men showing extraordinary skill, the excitement of a competition, plus the feeling that you are joining in with everyone else. On the other hand, you are aware of the deeper level of analysis that’s required, aware that along with everyone else, you are watching a spectacle that has something to do with ‘bread and circuses’. There are of course, many who ignore it all completely, and there are those who live and breathe football. We know that heart attacks rise during important televised matches (and there were a few points in the world cup where one might have been concerned about the state of Angela Merkel’s arteries) – there are fans and there are ‘fanatics’.  Seeing the anguish and tears on Brazilian faces as they were thrashed 7-1 by Germany; the frenzied fist pumping from managers, the breakdowns (such as Neymar’s) at having to retire injured all would lead anyone to ponder on how healthy this was. To be so overwrought – is it healthy that it matters this much?  China has reported a number of deaths related to nervous exhaustion due to so many people rearranging their sleep and work around the awkward time differences of Brazil. The fouls, let alone Luis Suarez’s use of his teeth show how important it is to win at any cost, and it’s one of the reasons why one of the matches I enjoyed most was that between the USA and Belgium – played impeccably, with good grace and hardly any nasty physical contact. There were of course lots of great moments too. Columbia’s team dance was a joy. At the end, the crown went to a country with not only the best team – which they were – but also to a country that can afford the resources and have a well organized machine to produce such a team.  Could a resource-poor country such as Costa Rica or Ghana ever get to the final? Does football demonstrate the global inequalities that are so evident in every other aspect of life?

All this leads to the question of whether football is real life or whether it mimics real life. Is football a mirror on the world or a parallel universe? In my view it’s the former, which is why the campaigns to stamp out racism, homophobia and sexism in sport are so important. Health promotion is first and foremost about all people being able to live freely as themselves and to achieve their potential.  There are still no openly gay male players at the top levels. Football is all about looking at young men – the women’s game gets little TV coverage.  The football world seems to be deeply sexist and homophobic and whilst black people and other minorities are becoming well represented on the pitch, they are not at more senior management levels. There’s been controversy recently in scientific and media discussions trying to understand why so many black people make great athletes, particular Jamaicans, with a theory regarding the genetic selection caused by the Atlantic slave trade. I don’t know enough about the details to discuss it, but it’s plausible. My colleague at Leeds Met, Professor Kevin Hylton, has used critical race theory to explore racism and sport, the subject of his inaugural lecture. See:

https://www.leedsmet.ac.uk/news/lecture-to-examine-racism-in-sport-leisure-and-society28102013.htm

In Iran, women are banned from watching football alongside men, so they have been watching it in defiance of the authorities, in mixed cafes.

So the football pitch demonstrates ‘personal politics’ as well as politics at the highest level.  Football is a means of demonstrating ‘soft power’; Germany certainly is the dominant European power, and you have to hand it to them – they are such an accomplished nation. There’s a reason why I drive a German-made car! And of course it’s great to see those countries that are not party to the seats of power doing well in such a tournament, and in so doing, challenging the global order, even if in a not very significant way.

Globalization has led to increasing diasporas, meaning that the followers of particular nations may be found all over the globe – Mexico’s victory against Croatia was celebrated wildly in Californian streets and that of Algeria moving into the second round was cheered on city streets all over France. The fact that so many players from all around the world play in the English premier league has been linked to the poor performance of the England team, as it means that not enough English players get exposure at these highest levels, undermining the formation of a solid national team, and also the dominance of the premier league has led some clubs to want to limit players’ involvement (and potential for injury) outside club games. These seem to be excuses to me, but certainly if we want examples of globalization, we need look no further than football.

I use the example of the obscene level of footballers’ salaries to demonstrate the huge inequity in income in the UK; I’m saddened by the takeover of what started as a working class game by big business. This has happened to such an extent that many now feel that the beautiful game has been poisoned – by corruption, political interference, bribery and fixing – whether that is of the location for future world cups or of individual matches. I’ve written in this blog before about the appalling conditions facing the migrant labourers working on the stadia in Qatar, and since then there have of course been widespread allegations of corruption in how Qatar was awarded the world cup.  The international body, FIFA increasingly looks like a corrupt oligarchy operating in a secret world.

As in football, as in life – the world cup illustrates key health promotion values in that we can use it to point out inequalities, power, oppression and discrimination. Sport of course is often used to promote health, in encouraging individuals to become more active. We can see the Tour de France effect on cycling in Britain, and even before that, the number of people cycling once a week in the last six months in the UK had grown to 2.1 million. Whilst the figures for people getting involved in sport are generally on the increase, the numbers playing football once a week have fallen in the last 12 months, and falls are particularly prominent in working class areas. See:

http://www.theguardian.com/sport/2014/jun/12/sport-england-figures-15m-adults-play-sport

Sport is also implicated in social capital; locally organized football and other sports clubs are often used as one measure of this important concept.  See the book Nicholson, M. and Hoye, R (2008) Sport and Social Capital, Taylor and Francis for a thorough overview of the role of sport in participation, social engagement and social capital.

The World Cup in Brazil cost $11 billion. It led to all sorts of protests from ‘ordinary’ Brazilians when so many in Brazil live in poverty.  Peaceful protest and social action are part of our repertoire of activities to create meaningful social change for a healthier world – but sometimes I’m not optimistic.

Health Promotion and 'British values'

Health promotion is based on a clear set of values. There’s been a lot of debate about its ability to provide evidence of effectiveness and to be ‘evidence-based’ and evidence-driven. BUT – having said that, health promotion as an activity and as a discipline is really values-driven, and we have discussed these in depth in our book and in our teaching. Health promotion is concerned with social justice, with tackling health inequities, with fairness, redistributing power, creating strong cohesive communities, and helping all people everywhere to reach their full potential without having to worry about their wellbeing, pain, disability and disadvantage. An ethical thread thus runs deeply through our whole endeavour. We know a lot about values! It was therefore interesting to see our government over the last few weeks talk so much about British values, and to assert how important they are.

These values, according to street interviews with the British public, are about ‘fairness’, ‘fair play’, cheeriness, stoicism, everyone pulling together in a crisis. I do agree that these are to be found in communities around me. It’s when I look at those who run the country, the decision makers and powerful, that I despair. Here are some examples over the same few weeks that show to me that Britain does not demonstrate those values.

Firstly, the number of British households falling below minimum living standards has more than doubled in the last 30 years. This has just been revealed at the third annual Peter Townsend conference. (http://www.poverty.ac.uk/take-part/events/final-conference)

For those of you unaware of the contribution of the great Peter Townsend, he was the chief architect behind the Black Report of 1979 that showed so clearly how health inequalities are linked to poverty and deprivation. He was one of the key thinkers who developed clear measures of disadvantage and his work had a huge impact on people like me, grappling with how to understand just why so much relative deprivation could exist in an affluent country.  As his Wikipedia entry says, Townsend was dedicated to studying "very carefully the life of the poorest and most handicapped members of society". See: http://en.wikipedia.org/wiki/Peter_Townsend_(sociologist)

He co-founded Child Poverty Action and also the Disability Alliance. (If you Google him of course, you’re likely first to find Pete Townsend from The Who, so try Peter Townsend, sociologist).

The new research, described as the most detailed study ever of poverty in the UK shows that 18 million Britons live in inadequate housing, 2.5 million children live in damp homes, and that 12 million are too poor to take part in basic social activities. The report shows that one in three people cannot afford to heat their homes properly and 4 million adults and children are not able to eat healthily. One in five adults have to borrow money to fund basic day-to-day needs. The Townsend Centre for International Poverty Research led the research, funded by the ESRC. Professor David Gordon from the Townsend Centre has said, “The coalition government aimed to eradicate poverty by tackling the causes of poverty. Their strategy has clearly failed. The available high quality scientific evidence shows that poverty and deprivation have increased. The poor are suffering from deeper poverty and the gap between the rich and poor is widening.”

All in all, the message is that over the last thirty years, the proportion of households having to cope in ‘below-par’ living conditions has risen from 14% in the early 1980s to 33% now. What’s fair about that?

A key message from this new research is that poverty is not especially caused by lack of paid employment, as the majority of children suffering poverty are in households where at least one parent is employed. These findings echo those reported a week earlier by the Social Mobility and Child Poverty Commission, whose recent report has concluded that this will be the first decade since 1960 not to see a fall in absolute child poverty. The Child Poverty Act, one of the last acts passed by the previous Labour Government, set targets to get relative child poverty below 10% by 2020. (Relative child poverty is the proportion of children living in households on below 60% median income). The Commission has said there’s not a chance of meeting these targets, as 3.5 million children are expected to be in absolute poverty in 2020 – five times the target.

The government keeps talking about the way out of poverty being employment, and that child poverty can be addressed by getting more parents into work. The Commission though has said that addressing poverty through the labour market “does not look remotely realistic”, and now the latest Townsend Centre research confirms that employment is not a sufficient protection against poverty.

We know that poverty is the key cause of ill health. It came as no surprise therefore that another report, from the Office of National Statistics last month, showed that about a quarter of people are dying prematurely from preventable causes. The report showed that 23% of deaths registered in 2012 were “caused by certain conditions which should not occur in the presence of timely and effective healthcare or through wider public health interventions”.

This statement seems to imply that public health and health promotion has somehow failed and in my view, it’s being blamed for not ‘saving lives’. But given the well known links between social status and health inequalities, dating back to the Black Report and Townsend’s seminal work, and the recent dramatic increase in poverty, it’s not at all surprising that people are dying from preventable causes. Moreover, the rise in poverty is happening alongside the cutting of funding on public health, the dismantling of health promotion and community health projects and wider cuts such as in Sure Start or Children’s Centres. It’s also happening at a time of huge change in the NHS. So even if we did accept that more “timely and effective health care or wider public health interventions” could effectively tackle health inequalities, these services are under threat.

Official figures also show how people’s chances of not dying from preventable causes such as certain cancers, are being threatened by what’s happening in the NHS. NHS performance data show increasing delays in carrying out vital tests – the number of people waiting more than six weeks for a scan is now at its highest level since 2008. In April 2014, 17,000 people with suspected cancer had to wait more than six weeks for tests, which is twice the total in the same month last year. In the same week, the Royal College of Nurses said that by 2025, district nurses, the backbone of community nurses may ‘face extinction’. The decline in their numbers comes despite the increase in the need for them, given the increase in lifestyle-related diseases such as type-2 diabetes. (Another recent piece of research from the University of Leicester, analyzing data from the Health Survey for England, and published in the BMJ Open, shows that the number of people with pre-diabetes has risen from 11.6% in 2003 to 35.3% in 2011.)

On the 5^th of June, Harry Leslie wrote a moving piece in the Guardian, from his new book, “Harry’s Last Stand”.  In his lifetime, (he was born in 1923) he saw the birth of the NHS and knew what it meant for working class people like him and his family. See: http://www.theguardian.com/society/2014/jun/04/coalition-attacks-nhs-return-britain-age-workhouse

His sister Marion, paralyzed by TB that spread to her spine, died aged 10 in the 1920s, in a workhouse infirmary, her life dominated by having to live in a ‘disease-ridden mining slum’. He concludes the piece with this:

“It ends where I began my life – in a Britain that believed health care depended on your social status. So if you were rich and insured you received timely medical treatment, while the rest of the country got the drippings. One-fifth of the lords who voted in the controversial act – which provides a gateway to privatize our health care system – were found to have connections to private health care companies. If that doesn’t make you angry, nothing will.

Sometimes I try to think how I might explain to Marion how we built these beautiful structures in our society – which protected the poor, which kept them safe at work, healthy in their lives, supported them when they were down on their luck – only to watch them be destroyed within a few short generations. But I cannot find the words”.

Indeed.

British values?

I cannot find the words.

Girls' education at Risk

The kidnap of more than 270 girls by Boko Haram in northeastern Nigeria has now slipped down the news agenda. Previously it was headline news, with the dramatic event on April 14^th being the top story; a few weeks later the rather late public statements by the Nigerian President Goodluck Jonathan caused a further flurry of attention, especially as it came with a wave of international condemnation of both the act of kidnap and of Nigeria’s seemingly slow reaction. Michelle Obama used her husband’s weekly video address to express her outrage at the kidnap; World Bank employees held a short demonstration of solidarity, gathering outside their headquarters on May 7th in a silent moment of reflection and giving out the following statement:

"This morning, hundreds of World Bank Group staff and management gathered together for a moment of solidarity with the more than 200 Nigerian school girls stolen from their families in recent weeks.

Like many others, we are horrified by the abduction of these girls. Every girl - every child - in the world should have the right to go to school to learn and pursue her dreams without fear.

Our hearts go out to these girls and their families, and we urge their swift release and safe return home."

The kidnapping does bring out the horror of seeing terrible things happen to your children, evoking the Pied Piper of Hamlyn robbing a community not only of the joy and laughter of young children now, but also robbing it of its hopes for the future, of its next generation. As Malala Yousafzai, the schoolgirl who was shot in the head for standing up for the right to go to school, has said, their “only ‘crime’ was going to school and learning”.

Denying girls and women access to education has occurred throughout history and continues today, though not usually in such dramatic fashion as happened to Malala or to the girls of Chibok in Nigeria. The campaign group Women without Borders, which stands up for women and girls’ human rights, notes that:

“Two-thirds of the world’s 774 million illiterates are women. Of the 72 million children who are growing up without an education, 34 million are girls. Less than a third of all girls are enrolled in secondary school.”

http://women-without-borders.net/inequalities-in-education/

This is one of the best sites to gain a quick overview of the situation facing girls’ education today.

The failure to see the necessity of educating girls relates of course, to the patriarchy that dominates all cultures and to the essentialism that sees girls as less educable, and in need only of such education that will suit them to a life where they fulfill their roles as homemakers, mothers and wives. The situation  has clearly changed in many parts of the world, where girls outnumber boys in many University courses and in areas traditionally the preserve of men, such as on medical courses. These changes have only come about after struggle though – what’s happening in many countries now echoes what was happening in Victorian England for example, where education wasn’t seen as necessary. It was often the actions of women educationalists that brought about reform.  These Victorian-era struggles are described in detail in the literature but for a quick summary, see http://www.logicmgmt.com/1876/overview/victorian_woman/victorian_woman_education.htm

Here it was slowly realized that it might be a good idea to educate women so that their husbands could have intelligent conversations with their wives, for example!

So denying women decent schools and good quality education are hardly new and not confined to poorer parts of the world. Some of the current debates also tend not to see female education as a human right in and for itself, but as contributing to some greater good. Thus the World Bank has a slogan of ‘Gender equality as smart economics’, suggesting that in the current economic climate, women should be treated equally as this brings economic advantage. One of its reports measures the effects of investing in girls, and suggests that:

 “Returns to girls’ education in developing countries are substantial, and in most cases they exceed those observed in developed countries and those of boys. A cross country study on the effect of education on average wages (a proxy for productivity) estimates that primary education increases girls’ earnings by 5 to 15 percent over their lifetimes, while boys experience a rate of return between 4 and 8 percent (Psacharopoulos and Patrinos 2002).4        And, for example, returns to female secondary education are 15 to 25 percent higher for women than men in Thailand, Ghana and Cote d’Ivoire (Schultz 2002).”  (Chaaban and Cunningham 2011, p2)

Accusing the World Bank of the charge that it’s only interested in girls as investments is not entirely fair, as whatever its motives, the World Bank has been one of the champions of equality in girls’ education. Some of its reports have tried also to consider how other factors such as class and ethnicity interact with gender to create deeper inequalities. The purpose of looking at intersectionality is to show up interlocking oppressions, and the report notes that,

“Lewis and Lockheed (2007) show that inter-group disparities are common phenomena in countries with diverse ethno-linguistic populations. Testing the link between girls’ school participation and ethno-linguistic fractionalization across 120 countries, they show that countries with multiple ethnic and language groups have lower primary school completion for girls, a larger gap between male and female primary school completion rates, and lower overall achievement.”

It’s not surprising that women in certain ethnic groups face worse access to schools, but it’s good to have this documented factually. Thus in India, “Das et al. (2010) find that educational attainment among tribal women in India is lower compared to tribal men and other groups, including women in the disadvantaged castes. Further, rural tribal women face additional disadvantages due to their remoteness from rural and urban centers, which translates into triple disadvantages based on their tribal affiliation, gender and place of residence. Similarly, King and van de Walle (2007) report that indigenous women in Lao PDR are five times more likely to never attend school compared to nonindigenous women. Whereas 34 percent if non-Lao-Tai women never attended school in 2003, the share among Lao- Tai girls was only 6 percent.” (Tas, Reimao and Orlando 2013, p8)

Gains have certainly been made over this century; in 2001 for example, in Afghanistan, only 5000 girls were enrolled in school. In 2011 it was 2.7 million – a huge increase since the fall of the Taliban. There is concern now however, that this gains might be reversed, and Oxfam has started a campaign to alert the international community that girls’ education is once again at risk. See

http://www.oxfam.org/en/campaigns/health-education/afghanistan-girls-education-risk

The full report is available from:

http://www.oxfam.org/en/policy/high-stakes-girls-education-afghanistan

It calls upon the international community to

Focus on improving secondary and higher levels of education;

Support the Afghan government to increase the number of female-friendly, well-equipped schools for girls, especially in rural or remote areas;

Increase the number and quality of female teachers, especially in rural or remote areas;

Ensure that girls’ access to education is not sacrificed in any political settlement (with insurgent groups) and girls’ access to education continues to improve.

It also says the Afghanistan Ministry of Education should improve the monitoring and accountability of schools.

These points could be part of a global manifesto to ensure that girls and women have continued access to education. Of course, in many parts of the world, the education available for boys is also of not the best quality and so we should not be calling for girls to have equal access to boys. Rather, we need to call for excellent education for all.

There’s a video exploring some of these issues in Pakistan. See:

http://portal.sliderocket.com/BBVXH/Hoshyar-Foundation

Boko Haram’s actions have certainly intimidated parents in northeast Nigeria not to send their girls to school. Their inhuman and criminal acts seem to be mobilizing Nigerians into political activity and something surely has to give soon in that troubled country – a country with many intelligent, articulate and capable women in positions of high office and authority. Let’s hope that the Daughters of Chibok are returned soon.

References:

Chaaban, J and Cunningham, W.  (2011) Measuring the Economic Gain of Investing in Girls: The Girl Effect Dividend, World Bank Report, available from http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2011/08/08/000158349_20110808092702/Rendered/PDF/WPS5753.pdf

Tas, E.O., Reimao, M.E., and Orlando, M.B. (2103) Gender, Ethnicity and Cumulative Disadvantage in Education: Evidence from Latin American and African Censuses, World bank Report, available from http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2013/12/30/000158349_20131230111115/Rendered/PDF/WPS6734.pdf