Health Promotion Forum was fortunate to get some time with Emeritus Professor John Raeburn recently, to ask him about his more than 40 years as a health promotion advocate.
As one of two NZ delegates at the WHO’s first International Conference on Health Promotion, from which the Ottawa Charter emerged, Professor Raeburn made a small but significant contribution to the content of the document; the inclusion of a sentence emphasising the importance of empowerment. This was the only time the word appeared in the Charter. He has upheld the principles of community and health promotion ever since.
Invited to attend the 1986 Conference in Ottawa by the Ministry of Health, Prof Raeburn had recently returned from a sabbatical in Canada from his teaching role at the University of Auckland Medical School. There he had been working alongside Ron Draper; head of the Health Promotion Directorate at Health Canada. He considered this the ‘Mecca’ of health promotion and Ron Draper one of his heroes. “Canada actually invented health promotion in the 1970s,” says Prof Raeburn. Little did he know that his year’s sabbatical would see him caught up in the preparations for the seminal Conference at which he was to later play such a significant role.
The other New Zealand delegate to the Conference was a Canadian man called Larry Peters, who was asked to go in his capacity as the first director of the Health Promotion Forum (Larry later went back to Canada and worked in the Health Promotion Directorate).
What was the experience of participating in the conference like?
It was a mixed experience, and I wrote an article about it for a public health magazine in New Zealand when I got back, which was essentially a critique. I’ll start with the negative aspects. It was mainly organised by WHO, who did things in a very grand style with multiple flags and so on, much formality, and participants invited from all around the world. (It wasn’t open to everyone – governments were asked to send representatives). The conference process was awful.
First of all, it was organised out of Europe, and the organisers succeeded in somehow alienating most of the developing world, with the result that most of the attendees were European, white and from industrialised countries.(Only 46 countries were represented).
Second, it was conducted in a very disempowering and top-down way – the opposite of “real” health promotion! They went through the motions of having a participatory workshop format, but the European bureaucrats had already decided the outcomes beforehand.
Third, they didn’t tell us until almost the end of the several-day conference that they had a charter in mind, and it was clear that it had already been pre-written by them. So we were basically there to rubberstamp it. Well, the anger that surged around the huge room when the hundreds of delegates realized what had happened was spectacular.
WHO then had to back down somewhat, and then said they’d accept some of the workshop material. They also said that, although the Charter was ready to be printed, if people wanted to scribble something down and hand them into the printing room, they would be considered for inclusion as well.
I hurriedly wrote a sentence down on the back of an envelope (literally) and handed it in. You can imagine how delighted I was to find that whole sentence in the final Charter. My passion has always been the community dimension of health promotion, and the empowerment of ordinary people, and I’m happy to say that the only time that the term “empowerment” appears in the Charter is in that sentence. It’s in the community action stream (of course!) and says: “At the heart of this process [of community action] is the empowerment of communities, their ownership and control of their own endeavours and destinies”. The sentiments expressed in the sentence are as important to me now, 30 years later, as they were then, and sums up for me the very essence of the health promotion enterprise.
And also on the positive side, on a wider level, thanks to the various changes done at the last moment, the world got a health promotion charter that still remains a brilliant document. And I have to say, that when the conference participants heard what WHO had finally came up with after they had incorporating the workshop materials, there was thunderous applause. What a transformation! By some miracle, WHO had got it right. Once again, it’s proof of how important it is to have full-scale participation.
Did you realise at the time how seminal the conference and charter would be?
Yes I think we were all aware that we were at a history-making event. When Larry and I got back to New Zealand, we spent the next year going around the country promoting the Charter, with the result that New Zealand had arguably the biggest uptake of the Charter of any country in the world, including Canada.
You talk about health promotion moving away from the focus of changing lifestyles and behaviours to one of policy ‘changing society so that people and communities can more easily live healthy lives’. How far do you think NZ (and global) society has come?
This question is a slightly tricky one for me. I have over the last few years presented in various settings a critique of the Ottawa Charter, including one memorable occasion in Canada when I was invited to do a keynote on this topic at a conference to mark the 25th anniversary on the Charter. I was nervous, because the Ottawa Charter is like a sacred document in Canada. Happily it went down well.
Part of my critique is that the movement of health promotion away from the older style of health promotion which emphasised changing lifestyle, behaviour and community, threw the baby out with the bathwater. It’s not by chance that the first action stream in the Charter is to do with policy – that was definitely the main interest of WHO. However, my main interest, and clearly that of most of the participants at the conference, was in people. In the late 90s, I published a book co-authored with Canadian grandfather of health promotion, Irving Rootman, called “People-Centred Health Promotion”, which makes just this point.
My argument is that the focal point of health promotion should be community, a stance that enables one both to look “up” to the larger picture of policy and environment, and “down” to the more intimate and personal level of personal skills and family life. Community is where people do their lives, and is the great meeting point of those two perspectives.
My fear has always been that health promotion would increasingly become preoccupied with policy – with statistics and abstract documents – and as far as most academic health promotion is concerned, that’s definitely the case. The result has been, I believe, a major gap between grassroots practitioners of health promotion and communities, and academics and policymakers. And largely, the public likes a lifestyle/community approach, and is turned off by policy approach. I’m not saying we shouldn’t have policy in health promotion – of course we should. But we equally need the community and people level.
My favourite image, which I’ve shown in multiple PowerPoint presentations, is a picture of a gannet in the sky with its wings spread, with one wing labelled “policy”, and the other “people”. This balanced approach is the one I strongly advocate.
So as to the question about how far NZ and global society has come in regard to these issues, I see that health promotion is probably going backwards, and has lost its broad public constituency, mainly because it has got lost in the arid desert of too much policy.
Community development is your passion. In an increasingly populous and multi-cultural society how do you think we are progressing with this area of health promotion?
I don’t think we are progressing at all well. In short, I feel health promotion has gone too far in the policy direction, and needs to go back to its heartland, which is community.
There was a time in the ‘70s and ‘80s when there was fantastic progress, with all sorts of great community initiatives around. One of the best contributions of government here was something called CHIFS; the Community Health Initiatives Funding Scheme, which supported communities coming up with their own empowering projects.
What changed all that was the arrival around 1985 of “Rogernomics”, followed by “Ruthanasia” in the ‘90s, which is to say that both Labour and National governments swung far to the right by adopting wholeheartedly the fashionable new economic policies of neoliberalism. These were first introduced by Maggie Thatcher in the UK, who was famous for a statement that “there’s is no such thing as society”. Rather, she said, there are ony individuals, and unequal ones at that.
Such a philosophy is harmful to community and empowerment of ordinary people, and we still largely live under this system globally and In New Zealand today. So community remains an unpopular concept. But at least now many are more aware of how damaging to society this approach is, and how it favours corporates and the wealthy, and makes the already miserable life of the poor and disempowered even more miserable.
On the other hand, this is offset in Aotearoa by the bicultural and multicultural nature of our society, where Māori and Pacific people in particular see society very much in “true” community terms. This is a perspective where people are indeed the most important thing in life, and where life is about cooperation, whanau, aroha and connectedness with others. So definitely, the saving grace in Aotearoa is the health promotion approach of these populations, and also in other cultural populations. So it’s a mixed bag here. Because government policy is not generally supportive of community and the less well off, it’s an uphill battle. At the same time, we in this country have a deeply embedded belief in the value of community, which for health promoters applies to health and wellbeing in particular. A well-connected and well-liked local community means healthy and happy people. (There’s lots of research to back that statement up). However, for the present time, in spite of positive aspects, at a general level, the community approach to health promotion is currently on the back foot, and has been so for at least two decades.
Talking about your Public Health Champion award 2015, you are quoted as saying that health promotion is the area of public health with which that you identify most. What are your thoughts behind seeing health promotion as a subset of public health?
This is a fascinating question, and when I was working at the University of Auckland’s School of Population Health, I was continually aware of it; surrounded as I was by public health people such as epidemiologists.
Because it has its roots in disease prevention and medical approaches to health, mainstream public health has always had an uneasy relationship with the ‘upstart’ called health promotion, which is largely a non-medical enterprise, and operates out of an entirely different model.
I’ve worked hard over the years to make the point that public health is a combination of three components – protection, prevention and promotion – and it’s important to distinguish the three of them.
One of the other things that has put health promotion on the back foot for decades is the fact that it frequently gets confused with prevention, and therefore is based on concepts of disease rather than concepts of health and well-being. And, while I definitely think that health promotion is part of public health, it has yet to carve out its full identity within that context. I constantly see health promotion being seduced off in the direction of disease-oriented prevention, largely because it doesn’t have a strong kaupapa to the contrary
At the same time, I also think that health promotion goes well beyond what is conventionally regarded as public health. All sorts of things affect our wellbeing outside what’s conventionally regarded as public health. For example, at the simplest level, going to Weight Watchers, playing rugby, being on a marae, or having a good time with friends, all contribute to health and wellbeing in their various ways (again supported by research evidence). In a way, the whole of life can be either health promoting or health destroying.
So yes, while public health has an arm called “health promotion”, I really think that it’s only one expression of health promotion, which is much wider than that. But I can’t say that seems to be a popular view either. Of recent years, I have become enamoured of the concept of wellbeing promotion rather than health promotion, and I think this represents a more inclusive type of health promotion than the public health version currently provides.
You were recently involved in the publication of the Manifesto of Planetary Health. Can you tell us more about this paper and the project?
Well, this question relates directly to what I was just talking about – I see planetary health as also a great new inclusive concept that will benefit both health promotion and public health, and could well be the future.
I was lucky to be involved in this project through my friendship with Robert Beaglehole and Ruth Bonita, who were asked by the Lancet to participate in the authorship of the trailblazing one page article that is the Planetary Health Manifesto. When I saw the first drafts, I thought it was very light on community, and too heavy on policy and government action. So me being me, I pulled out all the stops and kept inserting references to community in the document. And if you now read that document, it almost looks as though community is the number one consideration, so naturally I’m very pleased with all that.
And what is planetary health? It’s a concept designed to revolutionise public health, which is seen as having lost ground both professionally and in terms of public engagement. It’s quite clear that the greatest threats to health and well-being in the future are quite different from what they were 30 years ago, or even 10 years ago. Global warming, terrorism, globalisation, ferocious inequity , ever-growing populations, food and water shortages, new and damaging addictions like gambling and designer drugs, robotization and fewer jobs, are just some of the factors that are going to deeply affect everyone’s health in the future. This manifesto is designed to bring public health kicking and struggling into the 21st century. But its goals won’t be achieved, in my view, simply by government policy being developed in a top-down way, and dumped onto populations. Without community participation, and indeed community leadership rather than just “consultation”, we won’t get anywhere. The only way to change the world, in my view, is by local people working with the things that concern them most, in their own settings and culture, in partnership with government.
How do you see the manifesto impacting on New Zealand health and Health Promotion?
Well so far it’s not very advanced. The manifesto was only published in 2014, and it’s not very well known here yet. I and others have given a few workshops and presentations on it, and I must say there’s been a very positive response to it at those. So definitely, there’s a huge potential for public-health people and other people of good will to become passionately involved in this enterprise. But we’ve got a long way to go yet.
I understand you are writing a book about spirituality. Can you tell us more about this?
Have you got all day? Briefly, ten years ago when I was leaving the University of Auckland, I wanted to spend more time meditating and doing “spiritual” things, given that I had a strong interest in Zen and Taoism. I have a property in the wilds of Great Barrier, and had the romantic vision of spending lots of time there in the bush in the pursuit of – whatever it is one pursues in such a setting. But when the time came, I got cold feet, and wondered whether spirituality was simply a psychological entity dreamed up by humans to provide us with hope and happiness in a stressful world. (My background is as a psychologist). I then got to thinking that there were large numbers of people in the 21st century labelling themselves spiritual, and many declare themselve “spiritual but not religious.” I decided I wanted to know what they meant. What is this thing called spirituality? It’s definitely not religion, although religion has elements of it of course. So what is it? It’s taken me all those years to figure it out , and I’ll give just a clue as to what that might be. I believe it’s in our genes, the result of millions of years of evolutionary development at both the prehuman and human level, and it serves very important survival and well-being purposes. Unsurprisingly, I believe it also has a very strong community dimension in it’s background. But at this point I’ll say no more, partly because I’m still working on it, but also partly because once I start on this topic, it could take all day!
And does it relate to health promotion? Yes indeed it does, and also to planetary health. For several years at the University of Auckland, I used to teach a postgraduate course called Spirituality and Health, and it had a strong health promotion bias. It used to attract students from every kind of background, from atheist to fundamenalist, and all cultures, and this enabled me to develop a concept of spirituality as it related to health promotion. But don’t get me started on that either!
We thank Professor Raeburn for his valuable time, warmth and considered replies.
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