Health promotion finally takes center stage

The 25th anniversary of the Ottawa Charter for Health Promotion provided a glimpse into Israel's struggle for a healthier population.

Healthy food 311 (photo credit: Judy Siegel-Itzkovich)
Healthy food 311
(photo credit: Judy Siegel-Itzkovich)
There are signs all around us of a new era. People in running shoes walk briskly or jog soon after dawn and in the dark of night. Supermarket shoppers carefully examine the small print of ingredients, on the alert for high calories and artificial colors and flavors. Many customers are willing to pay substantially more for foods claimed to be organic and patronize huge stores that sell only healthful products. Mineral water, although not proven to be better than what comes from the tap, has become a popular beverage.
The Education Ministry has declared it the “Year of Healthy Lifestyles” in schools.
Before moving homes, people check for air pollution, traffic, noise, radon and cellular phone antennas. Individuals who do not contaminate their bodies with the toxins of tobacco are no longer on the defensive when smokers attempt to light up in public spaces.
The Social-Economic Cabinet has unanimously approved a comprehensive program to educate the public on adopting healthy lifestyles for which the government is allocating NIS 175 million over the next four years. Health promotion programs have been adopted even in the prison system.
Yes, as life expectancy gets longer and people want to enjoy their later years, disease prevention and health promotion are in fashion, and even cigar-smoking, obese politicians are sitting up and taking notice.
But at the same time, Israeli girls and women are more likely than most of their counterparts in the Western world to have a bad body image and to go on diets, risking anorexia or bulimia, even if they are not overweight. Cola, french fries, burekas and gooey cakes are almost omnipresent at social events. And type 2 diabetes and obesity have been diagnosed in a growing number of school-age children.
So what is happening here? Are some Israelis getting healthier and more aware of their bodies and others getting sicker and less vigilant? Studies almost unanimously point to the fact that those in better-educated, higher-income sectors belong to the first, while those on the other end of the spectrum belong to the second group, who need help.
The 25th anniversary of the Ottawa Charter for Health Promotion – marked last week at the Jerusalem International Convention Center by the Health Ministry’s 17th Annual National Conference for Education and Health Promotion – was a good time to ponder these changes and where Israel stands in the struggle for a healthier population.
Not only was it the largest ever, with some 600 participants, but among them were two physicians who had been in Toronto in November 1986 and helped write the document.
Prof. Alex Leventhal, then the ministry’s Jerusalem district health officer, later the ministry’s head of public health services and now head of its international relations department, and Dr. Bosse Pettersson, a senior Swedish government health official and now an independent public health consultant, reminisced for hours about that watershed event.
“Before Ottawa, there really wasn’t a concept of public health as we know it today,” said Leventhal, who also teaches at the Hebrew University-Hadassah Braun School of Public Health and Community Medicine.
That school existed then, but it was involved in epidemiological studies, studies of the efficacy of vaccination and breast-feeding and other individual subjects, not the all-encompassing field of preventing illness and allowing the entire population to make the most of their lives by maximizing health.
It was a snowy few days in the Canadian capital, where Leventhal was sent by his ministry boss, totally unprepared and unaware of the issues or, for that matter, how to write an international charter. Pettersson, the Israeli physician recalls, knew much more, and together with others they hammered out the document, which had stood up well ever since.
There were 228 health officials from 38 countries around the world there for the event. To give a perspective, Leventhal recalled that the Iron Curtain had fallen, perestroika had been introduced in Russia, Anatoly Shcharansky had been freed from prison and allowed to move to Israel and globalization, PCs and cellphones were unknown entities. Leventhal confided that for the occasion, he bought his first business suit.
After working with the team that composed the document, the Jerusalem doctor brought it home to translate it into Hebrew and found that equivalents of words like “advocacy” hadn’t even been set by the Hebrew Language Academy Pettersson said in Jerusalem that one “should celebrate the Ottawa Charter” once every five years or so because it is “good for explaining and educating.” But he was sorry that a series of half a dozen international conferences that followed up the charter did “not change the priorities” of the UN’s World Health Organization (WHO) or increase the amount of funding for broad public health purposes. “I believe that the achievements of these committees were not adequately implemented” since then, he said.
The 1986 conference was mostly a response to growing expectations for a new public health movement around the world, according to the WHO. Discussions focused on the needs in industrialized countries, but took into account similar concerns in all other regions. It built on the progress made through the Declaration on Primary Health Care at Alma-Ata (formerly in the Soviet Union, now in Kazakhstan); the World Health Organization’s Targets for Health for All document; and the World Health Assembly on intersectoral action for health.
As a result of the charter, health promotion was defined as the process of enabling people to increase control over – and to improve – their health.
“To reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs and to change or cope with the environment.
Health is, therefore, seen as a resource for everyday life, not the objective of living.
Health is a positive concept emphasizing social and personal resources, as well as physical capacities. Therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy lifestyles to well-being.”
According to the document, the fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity.
“Improvement in health requires a secure foundation in these basic prerequisites,” it says.
It would sound contemporary to the Israelis who demonstrated in tent cities for social justice for months this summer.
“Good health is a major resource for social, economic and personal development and an important dimension of quality of life. Political, economic, social, cultural, environmental, behavioral and biological factors can all favour health or be harmful to it. Health promotion action aims at making these conditions favourable through advocacy for health,” the final document went on.
“Health promotion focuses on achieving equity in health... this includes a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices. People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health. This must apply equally to women and men....
The prerequisites and prospects for health cannot be ensured by the health sector alone. More importantly, health promotion demands coordinated action by all concerned – by governments, by health and other social and economic sectors, by nongovernmental and voluntary organization, by local authorities, by industry and by the media.
“People in all walks of life are involved as individuals, families and communities. Professional and social groups and health personnel have a major responsibility to mediate between differing interests in society for the pursuit of health... Health promotion goes beyond health care. It puts health on the agenda of policy makers in all sectors and at all levels, directing them to be aware of the health consequences of their decisions and to accept their responsibilities for health.”
The authors from around the world continued: “Our societies are complex and interrelated. Health cannot be separated from other goals. The inextricable links between people and their environment constitutes the basis for a socioecological approach to health. The overall guiding principle for the world, nations, regions and communities alike, is the need to encourage reciprocal maintenance – to take care of each other, our communities and our natural environment. The conservation of natural resources throughout the world should be emphasized as a global responsibility.
Changing patterns of life, work and leisure have a significant impact on health. Work and leisure should be a source of health for people. The way society organizes work should help create a healthy society. Health promotion generates living and working conditions that are safe, stimulating, satisfying and enjoyable.”
At the end, the participants pledged to move into the arena of healthy public policy and to advocate a clear political commitment to health and equity in all sectors; counteract the pressures towards harmful products, resource depletion, unhealthy living conditions and environments, and bad nutrition; and to focus attention on public health issues such as pollution, occupational hazards, housing and settlements; respond to the health gap within and between societies and to tackle the inequities in health produced by the rules and practices of these societies; and, among other things, to acknowledge people as the main health resource; to support and enable them to keep themselves, their families and friends healthy through financial and other means, and to accept the community as the essential voice in matters of its health, living conditions and well-being.
Leventhal, still a novice in the field upon his return to Israel, went to Jerusalem’s legendary former mayor Teddy Kollek and explained what he had learned in Ottawa.
Teddy, he said, understood the significance in a few minutes and agreed to launch a Healthy City project in the capital. It was in 1990 turned into a network of Israeli municipalities that committed itself to their residents’ pro-health projects and headed by the Braun school’s Dr. Milka Donchin, who remains at its head.
Prof. Ronni Gamzu, the Health Ministry’s director-general, who has become a vocal public-health activist (even though in his first public appearance at a Dead Sea conference in office 18 months ago, he gave a twohour speech and press conference without once mentioning the subject), addressed the Jerusalem meeting.
“We worked for a year-and-a-half to develop our strategic plan for health promotion, not only in our ministry but with many other government offices and other public institutions as well. Our Health 2020 Project is ahead even of those in other advanced countries. We have created momentum. We have prepared a bill for further restriction of smoking. We argue with the Justice Ministry and against vested interests. It is not easy. We have to fight against cigarette vending machines. We must restrict advertising of alcohol. The food industry wants to sell more salt and calories. The show of an iron fist is needed.”
At the Jerusalem event, if the reception tables and lunch were any indication, health promotion is indeed “in” and the wave of the future. There weren’t margarine- laden burekas in sight. The opening snack included smoked salmon, baguette sandwiches of tuna and avocado spread and fresh vegetables. Lunch included sweet potatoes, quinoa, baked salmon, skinless chicken and piles of salad greens and miniature tomatoes. Vive la difference.