Health Promotion International, Vol. 14, No. 2, 189-191,
June 1999
© Oxford University Press 1999
Resource Reviews |
Rethinking Health Promotion: A Global Approach
T. MacDonald, Routledge, London, 1998, ISBN 0 415 16475 3 (pbk)
Department of Health Studies, Faculty of Health, University of Central Lancashire, UK In the preface to Rethinking Health Promotion: A Global Approach, Théodore MacDonald whets the reader's appetite by touching on a number of important issues facing health promotion at the close of the millennium. Is health promotion in danger of becoming a ‘theory of everything’? How can it be defined coherently? Should it avoid being seen as a discipline in itself? And—as highlighted in the book's title—how can health promotion develop a global imperative?
Designed for use in postgraduate and undergraduate education and professional training, the book is broadly structured into three sections. The first section, Chapters 1–4, considers the history and philosophy of health promotion; the second section, Chapters 5–6, focuses on the British experience; and the third section, Chapters 7–14 comprises a number of relatively self-contained lecture papers dealing with an eclectic —and somewhat confusing—mix of health promotion topics (e.g. sexual health, diet, tobacco), methods (e.g. mass media, assessment) and issues (e.g. ethics).
Chapter 1 provides an interesting and thought-provoking discussion of the origins of health promotion and biomedicine, and seeks to demonstrate the epistemological differences between them. MacDonald argues that health promotion has two ‘histories’—the first developing in conjunction with biomedicine's ‘Hippocratic’ tradition (600BC–AD200), the second emerging in 1974 with the work of Lalonde (1974) as a response to the progressive determinism and specificity of modern rational medicine. He illustrates the distinction between health promotion as ‘holistic’ and biomedicine as ‘reductionist’ by expounding the Greek ideas of ‘Hygeia’ and ‘Panacaea’, and concludes by defining what he sees to be a ‘distinct intellectual territory’ for health promotion. In doing this, he contrasts health promotion with health education and sets out a radical agenda, arguing that the latter is characterized by a concern with empowerment, neighbourhood advocacy and the eschewal of medicalization.
Chapter 2 develops these themes, asserting that health promotion involves a three-step approach with empowerment leading to neighbourhood advocacy leading to intersectorality. Outlining the spread of health promotion, MacDonald suggests that it is underpinned by the three ideological/political thrusts of feminism, environmentalism and anti-authoritarianism, and goes on to discuss concepts, e.g. ‘healthism', ‘empowerment' and ‘holism'. The potentially exciting and innovative subject matter is, however, weakened by an unclear structure and a failure to provide either a convincing rationale or adequate referencing for his bold analysis. For instance, health education is summarily dismissed as ‘having a brief to acquaint people with the facts of what health is in explicit and identifiable terms' without reference to either educational theory or the rich debate that has taken place over the years concerning the relationship of health education to health promotion. Furthermore, whilst MacDonald's distinction between ‘impowerment' (referring to power giving by those in authority) and ‘empowerment' (referring to the cultivation of a person's self-esteem) may be valuable, it would have been strengthened by making reference to the work of other authors who have written extensively on the subject, and in particular by acknowledging that empowerment as a concept has roots in a diversity of disciplines.
The next chapter focuses on the history of the ‘old’ and ‘new’ public health in Britain, outlines the milestones represented by the Lalonde Report, the Alma Ata Conference, Health for All and the Ottawa Charter, and once more grapples with the question ‘what is health promotion’? Whilst the chapter is interesting and informative, it does not obviously say anything that has not been said in a number of other health promotion textbooks.
Chapter 4, entitled ‘Health Promotion: A Eurocentric Phenomenon’, promises to get to grips with the book's central question—how can health promotion develop a global approach? MacDonald's starting point is that there is a paradox between the imperative to understand health promotion as global and the culture-specific nature of what health promotion itself is. His argument that Western health promotion is a product of European psychology and is therefore intrinsically ‘Eurocentric’ and unable to be applied to non-Western societies rests on his claim that it is solidly based on concepts of ‘individual autonomy’ and ‘empowerment’. This itself builds on his earlier (unsubstantiated) assertion that health promotion as we know it involves a sequential approach comprising empowerment, neighbourhood advocacy and intersectorality. Whilst the overview of Freudian and other psychology is interesting and informative, the chapter as a whole is disappointing. MacDonald's argument seemingly disregards the influence of disciplines other than psychology, and fails to acknowledge the diversity of health promotion models which inform Western theory and practice.
The reader is thus left with a sense of dissonance between the author's radical vision as outlined in his earlier discussion of health promotion's socio-economic and political focus (p. 28) and the current chapter's extreme individual focus, particularly evident in his analysis of empowerment (there is, e.g. no mention of the work of Freire, who has significantly influenced British health promotion and empowerment practice). Furthermore, having highlighted the need for a global approach, MacDonald focuses only on the problems of applying Western models to ‘third world’ practice and fails to engage with many of the key global challenges facing health promotion at the turn of the century. It would have been useful, e.g. to consider some of the following questions: How can Healthy Cities/Communities programmes retain the global focus of Health for All? How can Western health promotion advocate for disinvestment and investment decisions which will promote global health and reduce inequalities between the North and the South? How does health promotion relate to the global imperatives set out in Agenda 21? How can an awareness of global issues (e.g. fair trade, structural readjustment) become an integral part of Western health promotion concerned with issues, e.g. food, smoking and HIV/AIDS?
Having narrowed the focus in Chapters 5 and 6 to consider the experience, consequences of health being viewed as a ‘commodity’, shifting nature of the relationship between medicine and the state, and the value of the 1992 Health Strategy for England, The Health of the Nation (Department of Health, 1992
), Chapters 7–14 are devoted to an eclectic mix of topics, methods and issues. Whilst MacDonald acknowledges in his preface that it is impossible to deal with every important health promotion issue, it would have been helpful to understand his choice of subject matter, which ranges in no particular order from sexual health promotion (focusing almost exclusively on HIV/AIDS), through diet, ethics, mass media, employment and unemployment to tobacco, alcohol and assessment of health promotion initiatives. These chapters are all interesting and offer the reader stimulating and unconventional perspectives on the topics. However, their self-contained nature and their failure to meaningfully address or at times even demonstrate links to the book's central concern with ‘a global approach’ leave the reader with a sense of disconnectedness. For instance, in Chapter 7, there is no discussion of HIV/AIDS as a global problem let alone an analysis of the political and economic factors contributing to its prevalence in countries of the South.
In summary, then, Rethinking Health Promotion: A Global Approach offers a thought-provoking and visionary historical and philosophical analysis of health promotion, provides a number of interesting essays on a diversity of issues, methods and topics, and raises important and stimulating questions which should prompt further reflection and debate in the field. However, the book is disappointing in a number of ways. Firstly, it fails to cogently or comprehensively address its central concern with developing a truly global approach. Secondly, it lacks coherence and at times reads like a series of self-contained essays, with individual chapters lacking connectedness and engagement with the book's central focus. Thirdly, for a new textbook on health promotion, it fails to refer to a number of recent developments and influences (e.g. sustainable development, settings-based health promotion). And lastly, even though it contains a myriad of useful references, many of MacDonald's boldest and most significant assertions (e.g. the distinction between ‘impowerment’ and ‘empowerment’: health promotion being underpinned by feminism, environmentalism and anti-authoritarianism) are unsubstantiated and developed with minimal reference to the work of other authors.
REFERENCES
Department of Health (1992) The Health of the Nation: A Strategy for Health on England. HMSO, London, UK.
Lalonde, M. (1974) A New Perspective on the Health of Canadians. Information Canada, Ottawa, Canada.
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