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Health Promotion Forum of New Zealand Runanga Whakapiki Ake i te Hauora o Aotearoa
Experts, Global, News

HPF caught up with leading global advocate for action on the social determinants of health and health inequalities, Sir Michael Marmot recently to get his views on issues including lessons learned from Covid-19, how it has amplified underlying health inequalities and the need for governments to follow NZ’s lead and put a wellbeing approach at the heart of policy.

The Professor of Epidemiology and Public Health at University College London and the Director of The UCL Institute of Health Equity (pictured speaking at the world health promotion conference in Rotorua last year) also touches on the climate crisis and the role of health promoters in helping to tackle these global challenges.


HAUORA: What are some of the lessons we have learned from Covid-19?

SIR MICHAEL: Two keys lessons from the UK, that I think are more widely applicable, came with the onset of the pandemic. First, was respect for science and evidence. In the UK there had been overt disregard for the opinions of experts. For example, the assessments from economists that Brexit would harm the economy – probably making inequality worse – were dismissed as fear-mongering. In the US, the dismissal of science was worse, imperilling the planet, when the US President labelled climate change “a hoax”. Come the pandemic, suddenly our politicians were openly expressing their appreciation for the science in countries across Europe but, catastrophically, not in the US or Brazil.

A second lesson relates to public expenditure. After the financial crisis of 2007/8 many governments adopted austerity as their creed. With the economic shock that followed lockdown, suddenly austerity and concern about government debt was put on hold. “Whatever it takes”, said the British Prime Minister. Countries at high levels of human development spent a great deal, and increased national debt, to reduce the economic burden of the pandemic and societal response to it.

I would like to think there is third lesson: the importance of government in delivering the public good. That lesson has only partly been learned.


HAUORA: When the pandemic first hit, many commented that it had been the “great leveller” or “equaliser” but you have pointed out that it has actually exposed “underlying health inequalities” and amplified them. Can you please elaborate on this?

SIR MICHAEL: There are two aspects to these inequalities, at least: the toll that Covid-19 is taking on the population health; and the effect of the societal response, lockdown, on inequalities. In the UK, our Office of National Statistics (ONS) has been impressive in the regular and timely output of publications on the pandemic. Related to my theme, there are three observations that both reveal and amplify the underlying inequalities in society. First, is the high mortality from Covid-19 in those in front-line occupations: workers in social care, drivers, shop assistants, and chefs. These occupations were already at the lower end of the social hierarchy, and lowly paid.

Second, mortality rates from Covid-19 follow the social gradient: the more deprived the area the greater the mortality rate. This Covid-19 gradient looks very similar to the gradient from all causes. This suggests that the causes of inequalities in health more generally are likely to be the causes of inequalities in Covid-19 mortality.

Third, there is high mortality among Black, Asian and Minority Ethnic Groups. Much of this excess can be accounted for statistically by deprivation. We can no longer ignore structural racism that gives rise to the systematic disadvantage of some ethnic groups, not just in Britain, but more generally.

Lockdown itself has exaggerated inequalities. People in higher status occupations were far more likely than those in lower status to be able to work from home. Higher income people could spend less on entertainments and dining out, thus increasing their income and savings. It was precisely these occupations where workers lost their jobs or were exposed to the virus. We have seen exaggerations of food poverty during the pandemic.


HAUORA: You have said you would like to see a ‘wellbeing economy’ emerge from this crisis and in fact it was just last year at the global health promotion conference in Rotorua, NZ that you commended the ‘wellbeing approach’ taken by NZ. Recently you were quoted as saying: “The New Zealand Treasury shows what is possible. Before the COVID-19 pandemic, it put a wellbeing approach… at the heart of its policies.” Would you like to see governments following a similar direction post-Covid?

SIR MICHAEL: In Britain, my colleagues and I published a report, Health Equity in England: the Marmot Review 10 Years On, on the eve of lockdown, February 2020. I had published the Marmot Review in 2010 on what we could do to address health inequalities, in the light of the Commission on Social Determinants of Health. My 10 Years On Review, Marmot 2020, presented a grim picture: marked slowing of the improvement of life expectancy; increased health inequalities; and falling life expectancy for women in the most deprived areas outside London. Therefore, as we emerge from the pandemic, the status quo ante is hardly something we want to reproduce. Ideally, we need to use this dramatic shock to create a better society, to deliver sustainable health equity. And, to do that, we need to put wellbeing at the heart of what we are seeking to achieve.


HAUORA: The NZ Government, and our PM, have been lauded world-wide for their handling of the Covid crisis. What is your view?

SIR MICHAEL: From the outside, it appeared that Prime Minister Ardern displayed several characteristics that were key to controlling the pandemic: she was decisive in initiating control measures in quick and timely fashion; she was clear in her communication about the threat faced and what was needed from the population to combat the threat; her actions were evidenced-based; she was empathetic. Honesty, clarity, decisiveness, consistency and human warmth were not characteristics that were in abundant display elsewhere.


HAUORA: While Covid-19 has been the overriding issue for the world over the past few months, the call to fight climate change is ramping up again – particularly as experts have linked Covid-19 to planetary health. What is your advice to countries/governments on how to tackle this? Do you feel that indigenous knowledge needs to play a more major role?

SIR MICHAEL: Sustainable health equity has to be the watchword as the global community recovers from the biological, social and economic shocks attendant on the pandemic. The twin challenges of dramatic inequalities and the climate crisis have to be tackled together.


HAUORA: How can health promotion contribute more effectively towards addressing these global challenges?

SIR MICHAEL: I see health promotion as tackling the social determinants of health. Health, and health inequalities are good measures of how we are doing as societies. Therefore, those of us committed to improving health and reducing health inequalities need to be active participants in what constitutes the good society.




Experts, News, Pacific

Without a doubt, a stand out figure from the global health, health promotion and public health sectors is Colin Tukuitonga.  Speaking from Noumea, Colin shared some thoughts with us on his current work as Director-General of The Pacific Community (SPC).

Thank you for your time this afternoon Colin. Firstly, what proportion of SPC work would you identify as health promotion?

Given the broad scope of my organisation’s mandate in food security, fisheries management & education, agriculture, public health, human rights and geoscience, this is difficult to answer however all of these things at one level or another are health promoting in their outcomes. We have a separate public health programme that has a large health promotion component and we work in 26 countries.


What are the biggest public health issues in the Pacific nations?

Most definitely non-communicable diseases (NCDs). Obesity affects three out of every four adults. We also have the increasing issue of childhood obesity. All islands were part of developing the Pacific NCD roadmap with specific recommended actions. One of these was to introduce a tax on sugary drinks. Another was an increase in tax on tobacco.  The Pacific NCD roadmap is essentially a blueprint for the islands to follow. Some are active on this. Others less so. However, we expect all islands to implement a sugary drink tax.

Communicable diseases can affect some islands for example tuberculosis in Papua New Guinea.


What do you see  as the role of health promotion in addressing these issues?

Without a doubt this (taking a health promotion approach) is where we need to be overall but resourcing places constraints on this. Many islands are doing their best to help but again, more often than not, hospital and treatment services take up the lion’s share of funding. We do what we can at SPC to encourage island nations to invest in core public health functions but it is challenging.


You have signalled SPC’s strong support for the 2019 World IUHPE conference to be held in NZ. What do you see as SPC’s role at the conference?

We have three roles. Firstly, general support for the hui. It is just fantastic that we get to have this event in this part of the world. Secondly, we are planning to provide some financial support. Thirdly, and most importantly, our role is to facilitate an opportunity at this global event for small islands to  share concerns and then work together, to take strength and to think about a way forward as an organisation of small islands. That is what we would hope to achieve.


Climate change is a major issue facing the peoples of the Pacific. What actions do you think are necessary to address this global environmental issue?

We made significant gains with the Paris Agreement, the United Nations Framework Convention on Climate Change.  Now with United States of America withdrawing from that, it may take us back to before the agreement so trying to maintain momentum is really difficult. We need political support from many to honour the Paris Agreement. Without this we will be going backwards. Pacific nations have put a lot of energy into the agreement particularly the recommendations to limit emissions and enable funds for good work. Right now we are at risk of inertia with the US not agreeing to continue.


How do you see public health and health promotion developing over the years?

Well when I started people talked about more traditional quarantine measures, or the role of legislation to regulate behaviours or control diseases. We’ve come a long way since then. The watershed moment for me was the emergence of the Ottawa Charter. This changed things from a conventional public health approach to one of empowerment of communities and of developing healthy public policy.

For me it is about continuing this Ottawa Charter type approach and supporting nations to invest more in health promotion practices. To undertake things like health impact assessment and environmental impact assessment when large development projects are on the table. We have a range of tools to choose from but in general these are not always applied consistently.


Having worked in both New Zealand and the Pacific, how would you characterise the relationship between the two?

In some areas it is going well however I would say there seems to be a general lack of awareness in New Zealand about what is happening in the Pacific regions. I do note though that there is more and more interaction taking place.

We could learn a lot from the health promotion models and ideas in New Zealand. Smoking continues to be a significant problem in the islands.  We have been impressed with New Zealand’s smoke free work over many years.


Are there any other pointers from your recent work we could learn from?

Recently I was part of the World Health Organisation Global Commission on Ending Childhood Obesity as a commissioner. From that we produced a final report with a set of recommendations and cost-effective measures for ending childhood obesity. New Zealand and Pacific nations have been slow to pick these up. One would hope governments provide leadership and look seriously at the recommendations of this report.


If you look at recent news on sugary drinks and obesity in New Zealand, chances are you will come across the name Dr Gerhard Sundborn, or the advocacy Dr Sundborn undertakes at FIZZ (Fighting Sugar In Soft Drinks). Health Promotion Forum caught up with Dr Sundborn to find out more about his role and recent work. 
Gerhard, thank you for your time. Could you tell our readers a little about your role and background please?
I have a few varied roles. I am a public health researcher/epidemiologist based at the University of Auckland. In 2013, I with a number of colleagues established FIZZ (which stands for Fighting Sugar in Soft-drinks) a Public Health Advocacy Group to address sugary drink consumption. More recently (since February) I have also started a part-time role for ARPHS as a Project and Public Health Analyst.
I have spent most of my time in Auckland and as a child and teenager lived in Wellington for 2 years and Rotorua for 3 years. My father is originally from Huntly and my Mother is from Vava’u, Tonga. Together with my wife Meliame we have three young children Sola 8y, Wayne 6y and Chloe 5y.     
We are aware that you have a symposium coming up. What is it about and why is it important?
The symposium ‘Taxing Sugary Drinks’ on the 26th June in Auckland is the fourth that FIZZ has run. It will provide information and explain the science as to why sugar and sugary drinks are harmful, profile a large number of initiatives that have been created to address this issue both here in NZ and the USA, and finally we will also focus on the issue of taxing sugary drinks- looking at the most recent examples in Berkley (USA) and determine whether this is or should be an election issue leading up to our vote on 23rd September. To conclude the symposium we will have a political panel debate with representatives from all the major political parties with the only exception being National (Greens, Labour, The Māori Party, NZ First and The Opportunities Party will all be represented).   
What are you hoping to achieve from the symposium?
We hope that the symposium will further raise awareness about the need to look seriously at reducing sugar and sugary drink intake to improve health.
We also hope that by providing a forum to profile the great work that many people and organisations are already doing in this area, it will encourage others to do the same and/or similar things.
We hope that this symposium will also promote wider public debate on a sugary drink tax being a key election issue.    
How has society/ NZ/ communities responded to this issue and how has this changed over the years?
Since we started (back in 2013) the issue of sugar and sugary drinks is now becoming part of normal commentary when we think of the health debate. Our health sector and researchers in academic organisations I think have embraced this issue and driven a lot of great work. The general public too I think now see the need to address sugar and sugary drinks as a high priority. This increase in public awareness/support can be seen in the huge increase in support of a sugary drink tax that went from 44% in early 2014 to 86% in late 2016.    
How does health promotion work alongside other approaches to improve wellbeing in this area?
Health promotion is an essential part of the work needed to address the problem of high sugar intake in NZ. It is important to work with schools, churches, sports clubs and all parts of our community to provide them with accurate and easily understood information about sugar in our diets and the massive amount of sugar in many drinks, the harm it causes but most importantly – possible solutions. There is some amazing health promotion work that is going on in this area where many large Māori and Pasifika festivals have gone sugary-drink free or water only such as Creekfest in Cannons Creek Porirua, Te Wānanga o Raukawa Events in Ōtaki and the Matatini event that was held in Hawkes Bay this year.
What are some of the challenges and opportunities to achieving your goals on this issue? 
Industry present challenges to this work for obvious reasons in that they make money from the sale of sugar, however, we hope that industry will move to creating more low/no sugar products, and there are examples of this happening already.
Other challenges come from an argument that we shouldn’t limit people’s choice! However, we don’t want to limit choice but move the landscape so that healthier choices in the form of very low and no sugar products are the easier choice to make.

Case Studies, Experts, Smoking

As the Smokefree Coalition prepared to wind down its operations – a victim of its own success – Hauora’s Jo Lawrence-King talked to its outgoing Executive Director, Dr Prudence Stone, about the Smokefree movement as a health promotion initiative.

Smoking cessation as a health promotion intervention

Dr Stone believes both tobacco control and smoking cessation exemplify health promotion.  Together they empower communities with knowledge, evidence and resources to take control back from the ‘Big Tobacco’ industry; allowing those who smoke to free themselves from an industry that seeks to keep them addicted.

As a sociologist Dr Stone says she is fascinated with what motivates people.  She believes this fascination has helped her in her approach to health promotion. “My sociological imagination really helps me to stay aware of the cultural dymanics and structures underlying people’s motivations. So it was really great when Professor Marmott came to town and spelled out to our public health community the ‘social determinants’ of health and health inequalities. I was already applying this framework when I was rallying submissions from the membership to the Maori Affairs Select committee Inquiry.

“I believe there are too many people in health promotion with qualifications in only health promotion. This area of expertise, from what I have seen, can be counter-intuitive to their role in engaging communities and influencing peoples’ choices and behavior.”

She cites many examples of health promotion messages that presume people simply need to know the right choice to stay healthy, and they will make that right choice. But, she says, health is not what motivates people. “People are unconscious of their health!” She claims. “Asking someone to engage consciously with the healthy choice for the healthy choice’s sake makes the one who asks it seem wacky at best, annoying at worst.” Instead Dr Stone asserts people become conscious of their health only when it is gone, and they become sick.

For this reason, she believes raising the price on tobacco is the single most effective measure that can be taken to reduce demand for tobacco.  “The prospect of losing money is what motivates people – the prospect of saving money is what motivates people: effective health promotion ditches the language we learn in the classroom about why it’s necessary for society, and starts talking directly to the values embedded in that society.”

Looking back on the success of the Smokefree Coalition

The bad news for the Smokefree Coalition is that its funding has come to an end.  The good news is that this is due to its enormous success: achieving record lows in smoking in Aotearoa New Zealand.  “I feel very proud of the unity of voice we’ve demonstrated and the impact it has had on helping New Zealand reach this point,” says Dr Stone.

A longstanding child advocate, Prudence cites as a measure of the Coalition’s success the record low in year 10 children who have never smoked.  “I believe we’ve reached a tipping point of public support for further measures [to support the Smokefree movement],” she says.  “There is an acceleration of expansive Smokefree environmental policy at local government level, a burgeoning groundswell of retailers removing tobacco from their stores, and a commitment to an endgame from our government leaders.”

But there is a cautionary note from her as well: “so long as there are New Zealanders addicted to tobacco and a marketplace saturated with tobacco products, there is a need for health professionals to lead and coalesce, and develop a cohesive strategy for effective support and advocacy,” she warns.

The Smokefree movement is personal and poignant

Always acutely aware of injustice and the imbalance of power, at university Dr Stone focused on an area of sociology called the political economy of information. This is the field of study that exposes the way multinational corporations manipulate the information the public receives, to keep it unaware of injustices in their business practices and the truth behind their products.  “You could say I was in training at university for a job fighting Big Tobacco.”

When Prudence was 11 years old, she was the first to wake up one morning and find her grandmother – ‘my best friend’ – dead.  “Her pack of smokes was right there beside her and I still remember seeing the longest line of ash on the butt of a cigarette in the ashtray. She had lit it up and then died before it had gone out.”  Prudence later named her daughter after her beloved grandmother.

Smoking cessation measures favour non-Maori populations

Dr Stone is anxious to answer claims that the tax measures and price rises are racist.  The claim is based on the fact that Maori are more highly represented than non-Maori in smoking statistics; giving rise to the (misguided) belief that tangata whenua are being targeted with punitive measures.

Looking at the data alone it’s easy to see that proportionally more Māori than non-Maori tend to smoke. “Claims that tax measures are racist go against robust evidence to the contrary.” Says Dr Stone.  “People making these claims fail to notice to the government’s ‘population-based approach’ to cessation advice and triage, which by its nature fails to reach a significant proportion of Maori.

The government programme is provided only to those who visit primary and secondary care facilities.  According to Prudence up to a quarter of the New Zealand population does not visit a primary or secondary care facility in a given year.  She believes much of this sub-section of the population consists of Maori; many of whom have no money to afford healthcare, or whose past experiences with the health system have caused them to lose any faith in it to serve them with cultural competence.  Dr Stone postulates that these are the very people the government’ describes as ‘hard to reach smokers’.

What’s impossible to observe from the data, she says, is the story of colonisation, and the introduction of tobacco via trade.  “Wahine Maori became addicted to tobacco long before it was considered acceptable for European women to smoke. That background is very important to understand. These are the two hundred year-old social determinants that underlie today’s data.”

The price of tobacco is set in place to motivate those people who are not reached by other cessation programmes, she says.

During her time at the Smokefree coalition Dr Stone has worked hard to frame the inequities of government policy and statistical inequalities in a more constructive way for tangata whenua, but she fears the risk of misinterpretation remains.

Seven years to make significant improvements

Prudence Stone began her solo role at the Smokefree Coalition nearly seven years ago in 2009; the same week Maori Affairs called for submissions to its public inquiry on the tobacco industry and the consequences of tobacco use for Maori.

Over the next few years she built the Coalition to over 50 members; in the process justifying a second staff member to assist her.  Her work unified the efforts of the Coalition’s members to support a range of measures that have led to a massive reduction in smoking rates in this country.  “The Smokefree Coalition is small and cost-efficient when it comes to its operations, but vast and nationwide when it comes to its broad membership and scope of influence.”

Dr Stone is quick to acknowledge that she and her colleague were strongly supported by a board, active key members and “incredible” DHB and PHU stakeholders.   “The readiness and responsiveness of our sector makes it feel as if we’re one awesome whanau.”

Where to next for Dr Stone?

As Prudence prepares to finish her work at the Smokefree Coalition she is eyeing her future with energy and determination.  Advocacy will remain central to her, but she is also not ruling out the idea of entering politics one day.  “There is just so much I want to get done before I die,” she enthuses. “Luckily I’m a great planner and strategist, so I have the fortune of seeing at least a tenth of it achieved by now. I love to help, I love great ideas, and I’m not jealous at all about whose great idea it is. If it’s someone else’s great idea, I just want to play a part in helping seed it on some fertile ground.”

She cites her children as her motivation. “There’s a world to leave behind, and for now it’s a mess and needs cleaning up!”

About the Smokefree Coalition

The Smokefree Coalition was established back in the ‘90s to be a united voice for action and advocacy for evidence-based tobacco control measures. The premise is that while so many organisations have a vested interest in tobacco control, their core business is focused on representing a particular health-related workforce or a specific non-communicable disease: for efficiency’s sake you need one organisation focused on uniting them all and coordinating their activities for maximum influence and clarity of message.

The Smokefree Coalition is itself a member of the Framework Convention Alliance, a global coalition of organisations supporting and informing the implementation of the World Health Organisation’s Framework Convention on Tobacco Control (FCTC). This Framework provides the raft of evidence-based measures to take, and guidelines for signatory nations in order to implement them.  Prudence believes New Zealand is only ‘pretty good’, in staying faithful to the FCTC.  “Perhaps only because members of the Smokefree Coalition are vigilantly holding our government representatives accountable to it.”

Members of the Smokefree Coalition have supported and informed all the legislative measures that have been put in place in New Zealand: the Smokefree Environments Bill Amendments which have

  • made bars and restaurants Smokefree,
  • banned tobacco’s promotional retail display,
  • reduce allowances of duty-free tobacco
  • raised tobacco’s excise tax,
  • currently; introducing standardised packaging of tobacco and banning smoking in cars carrying children.

In 2009 the Smokefree Coalition published a landmark document, Achieving the Vision: Tupeka Kore Aotearoa 2020 which members used to advocate a radical idea: regulating tobacco’s supply and eliminating demand for tobacco altogether, to return Aotearoa to its original state, free of tobacco. This vision was well-received during the Maori Affairs Select Committee’s Inquiry on the tobacco industry and the consequences of tobacco use for Maori. It was this select committee’s Inquiry report which inspired government’s commitment to making Aotearoa a Smokefree nation by 2025.




October 2016

Jo Lawrence-King


Experts, Global, News, What is HP

Leaders pledge support for World Conference

The leaders of two highly regarded international bodies have signalled their support of the next World Health Promotion Conference. United Nations Development Programme (UNDP) Administrator the Rt Hon Helen Clark and Dr Colin Tukuitonga, Director-General of the Secretariat of the Pacific Community (SPC) have both indicated their organisations’ support of the Conference, to be held in Rotorua in April 2019.

Representatives of host organisation Health Promotion Forum met with both Ms Clark and Dr Tukuitonga during a conference in Tonga this month.

Ms Clark who, as New Zealand’s Prime Minister has spoken at Health Promotion Forum’s annual symposium, acknowledged the importance of planetary health and sustainable development and expressed her organisation’s interest in being involved.

Ms Clark was the keynote speaker on Monday at the Pacific NCD Summit in Nuku’alofa, June 20-22, for health ministers of the Pacific, which was organised by the Secretariat to the Pacific Community (SPC).

Dr Tukuitonga has expressed his wish for a strong Pacific presence at the conference and has pledged the involvement of his Pacific-wide organisation to support this aim.

The theme of the triennial conference of the International Union for Health Promotion and Education (IUHPE) is “Promoting Planetary Health and Sustainable Development for All.”


Pictured from left

  1. Ms Osnat Lubrani, UN Resident Coordinator and UNDP Resident Representative, UNDP Pacific Office,
  2. Dr Viliami Puloka, HPF Pacific Leader and Otago University Research Fellow,
  3. Rt Hon Helen Clark, UNDP Administrator and former Prime Minister of New Zealand,
  4. Ms Leanne Eruera, HPF Business Manager and 2019 Conference Project Manager,
  5. Mr Sione Tu’itahi, HPF Executive Director and IUHPE Vice-President.



Experts, Global, Policy, What is HP

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.


March 2016

Jo Lawrence-King

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We asked three health promotion professionals three questions for the spring/summer 2015 issue of Hauora, focusing on health promotion in Aotearoa New Zealand and the Health Promotion Forum.

Here are their responses:

What do you see as some of the major issues regarding health promotion in Aotearoa New Zealand and the world today?

Zoe Aroha Martin-Hawke identifies two interconnected issues facing health promotion in Aotearoa; the wide-ranging use and understanding of the term ‘health promotion’ and a decrease in the use of the term in workplace titles.

“The use and understanding of the term ‘health promotion’ is wide-ranging, with some perceptions overlapping and others quite separate.  The challenge is to find a balance between autonomy of each perspective and enabling collaborative working in the areas that intersect.  The emergence of competitive funding contracts, with a set health promotion agenda, makes this particularly difficult.

“Secondly a decrease in the use of the term ‘health promotion’ in job titles, work departments and job descriptions sees fewer people identifying as health promoters.  This may be related to the lack of consensus on the definition of health promotion and/or on  funding directives.  Such a lack of clarity may restrict the ability of people to practice the health promotion model they believe in.  As a result, Zoe is concerned that the discipline is losing its value, respect and presence in Aotearoa.”

“Health promotion consists of so many dimensions that are strongly connected with Māori thinking it would be sad to see it disappear in the formal sense,” says Zoe.  “Furthermore people have invested time and money into the study of health promotion and are passionately connected to the discipline.  To not be able to practice what they have been students of for many years seems unethical. “


Much of Wiki Shepherd Sinclair’s 11 year career in health has focused on Health Promotion.  She believes that the challenges facing the Health Promotion space in Aotearoa New Zealand – and the world – today include lack of collaboration and communication, poor cultural awareness, lack of community engagement and an experienced, but unqualified workforce.

According to Dr Mihi Ratima – and as outlined in the recent book she edited with Associate Professor Louise Signal (Promoting Health in Aotearoa New Zealand) – major issues facing health promotion include the challenge of neoliberalism, the positioning of health promotion on the periphery, and the difficulty in maintaining the health equity focus.

As noted in the book, the health of the planet – and all of us who live on it – is under dire threat from factors such as climate change, obesity and new infectious disease. Progressive health promotion is an approach that can counterbalance threats to health with practice, policy and advocacy for health, well-being and equity. “There is an urgent need for further government investment in this approach”, she says.

Perhaps our greatest challenge, according to Mihi, is in achieving health equity. “We are good at the rhetoric around reducing inequities, but are things really changing? If not, why don’t we have a sense of urgency about it? What does the evidence say about some of the issues we know are important from a public health perspective, like income inequality? What is going on with those wider determinants? We know we can be effective, as evidenced by narrowing of gaps in life expectancy between ethnic groups over time.  But we also know that many of our interventions continue to have a majority population focus, leaving out some groups, and inadvertently increasing inequities. We must normalise a commitment to health equity in everything we do in health promotion, use the excellent health equity tools we have at our disposal, and ensure that no one is left out. The lived realities and voices of those who are different from us need to be part of the solutions.”


What do you see as the role of the Health Promotion Forum in population health today? 

Zoe Aroha Martin-Hawke:“To lead workforce development to ensure that there is a shared understanding, respect and pathway for health promotion champions throughout the country.”

To keep the sector up to date on health promotion internationally and nationally.

To keep information flowing into the NZ context to secure a strong health promotion lens and voice to keep us connected and focused on the areas we need to collaborate on. Progressing indigenous perspectives on health, health equity and everyone’s right to health are key messages and activities that the health promotion forum are leading and can continue to lead in the quest for equitable population health. Health promotion leadership is needed and the health promotion forum can build that leadership through its membership.

Wiki Shepherd-Sinclair suggested the following;

  • Supporting organisations to gain a better understanding of what health promotion in Aotearoa is and what this looks like in practice
  • Supporting organisations to have a shared understanding and common language of health promotion
  • To have a lead advocacy role in health promotion and public health
  • To promote Healthy public policy
  • Encouraging organisations to grow their networks and/or partnerships
  • To help organisations build awareness and skills to implement the Health Promotion Competencies
  •  Providing a set of practical tools and training around the HP competencies

According to Mihi Ratima “Health promotion is an established approach to addressing public health problems in New Zealand. A key role of the Health Promotion Forum is in supporting the workforce and organisations to develop shared understandings of effective health promotion approaches.  This leads to greater health equity and improved outcomes for individuals, whanau and communities: what works and how to apply health promotion through policy, practice and advocacy”.

Mihi also believes the Health Promotion Forum has a role to play in supporting the development and growth of the body of theory and evidence for effective health promotion.


What would you say to an organisation considering membership of the health promotion forum?

Zoe Aroha Martin-Hawke : “For clarity, consistency, ongoing workforce development and the ability to connect with like-minded health promotion workers from across the country, to keep up to date with international health promotion movements the Health Promotion Forum is exemplary.”

“HPF is one of those rare examples of how to truly work from a reducing inequalities framework.”

“As a member of the Health Promotion Forum you can trust that their statements around “prioritising activities that will benefit people communities who are least disadvantage” are not just words.  They take a systems approach to tackling these issues by starting with their own organisation – where it should start.

“Their team consists of a strong Pacific and Māori team at all levels from the Board, to the Executive Director, to Deputy Executive Director to accountant.  All members of the team understand and are dedicated to viewing the reduction on inequalities in a broad socio-economic context, where promotion, prevention and protection are at the forefront.”


Wiki Shepherd-Sinclair encourages organisations to consider membership of HPF as the health promotion leader in Aotearoa New Zealand.  “The connections with regional and international leaders are a real plus for organisations that also want to grow their networks and strengthen relationships. The sharing of health promotion expertise and best practice, to increase better outcomes for our communities and populations, is of huge importance,” she says.


“It is critical that we have shared understandings of effective approaches to health promotion and work collaboratively,” saysMihi Ratima. “The HPF provides a mechanism through which organisations are able to work together and leverage off one another for the benefit of the entire membership. Member organisations are able to form relationships with one another and access training and expertise that is not otherwise available to them. This network of provision provides an expanded sphere of influence whereby innovation in health promotion is able to be easily shared and its value maximised through uptake within the network.”





Jo Lawrence-King

7 October 2015


First New Zealand Health Promotion book

Promoting Health in Aotearoa New Zealand

Promoting Health in Aotearoa New Zealand was conceptualised as a text that equally integrates Māori and Pākehā analysis; consistent with an approach that emphasises the Treaty of Waitangi partnership and indigenous rights. The editors have endeavoured to achieve this through collaboration between Māori and Pākehā editors, advisors and contributors. Contributors to the book include: Professor Sir Mason Durie, Professor John Raeburn, Associate Professor Papaarangi Reid, HPF’s Executive Director Sione Tu’itahi, Associate Professor Cindy Kiro, and HPF’s previous Executive Director Dr Alison Blaiklock.

Health promotion in Aotearoa New Zealand has elements that, in combination, make for a unique approach.  Ratima explains: “Key features are the unique contribution of Māori understandings and approaches; the application of a rights-based approach for example in relation to Treaty of Waitangi-based rights and indigenous rights; the strong equity focus; commitment to addressing determinants of health; an emphasis on strengthening community development and self-determination; and the use of local models, frameworks and tools.”

There is very little text available that looks at health promotion in New Zealand – particularly as it relates to Māori. In fact Promoting Health in Aotearoa New Zealand is rare internationally for its strong focus on indigenous health. Frequently we refer to overseas texts when teaching and supporting public health practice.  Often these are not relevant to Māori, other New Zealanders or the New Zealand context. This has been of concern to health promotion academics and practitioners for some years.

“This book has been written to address that gap,” says Mihi.  It explores ways in which Māori, and other, perspectives have been melded with Western ideas to produce distinctly New Zealand approaches. In doing so it addresses the need for locally written material for use in teaching and practice, and provides direction for all those wanting to solve complex public health problems.

The book highlights the “dire threat” to the health of the planet – and all of us who live on it – from factors such as climate change, obesity and new infectious diseases. It concludes that progressive health promotion is an approach that can counterbalance threats to health with practice, policy and advocacy for health, well-being and equity.


HPF’s Executive Director Sione Tu’itahi was invited to speak a the book launch.  He was also a contributor to the book.

“…The process by which the book was produced, both in contents and presentation, reflects a successful partnership that resonates with the letter and spirit of our nation’s founding document, Te Tiriti o Waitangi; an example worth emulating. It also places Matauranga Maori (Maori knowledge)  prominently, while it weaves together the knowledge of the West, the knowledge of the East, and Indigenous knowledge systems as a set of effective solutions for addressing  our health challenges.

Although the primary focus is on Aotearoa, the book brings in the experience and knowledge of Moana Nui a Kiwa and other regions, thus making the book a very valuable contribution to our collective effort at the global level to address planetary health.

The recent launching of Promoting Health in Aoteroa New Zealand is very timely because:

– there is an increasing awareness in all sectors, government, community, and the corporate sectors, that  to be effective in addressing our socio-economic, cultural, physical, ecological and spiritual wellbeing, we have to be health promotional and preventative in our integrated approaches

– there is also a marked increase in the number of courses and qualifications on health promotion and public health in universities, polytechs and wananga. This book is a ‘must have’ reading and resources for all learners and practioners

– additionally, there is an increasing awareness in other sectors, such as social development and education, of the connectedness of the set of challenges that we all try to address, and therefore, the increasing need to learn from other sectors such as health and some of their comprehensive and effective tools and approaches such as health promotion

I would like to congratulate the hard-working editors, Associate Professor Louise Signal, and Dr Mihi Ratima.  Your perseverance, dedication, endless patience, and professionalism, have paid off. Well done!”







Jo Lawrence-King

7 October 2015