Promoting health by altering institutions and environments

Dr Ilona Kickbusch: We need change and health in tomorrow«s world

r Ilona Kickbusch, responsible for health promotion at the WHO, believes we are in the midst of a new era in global health developments. Though the concept of global health has never been easy to grasp, Dr Kickbusch believes that now we face an even more of a complex set of competing forces involving ever larger audiences and new players.

"In the '80s health promotion was seen very much as a state responsibility, and was wholly funded by it. Now, we are much more knowledgeable and creative in approaching financing mechanisms. We need new types of institutions and infrastructures..."

"Ten years ago we still believed in simple strategies. We could never have dreamed of what has happened, say, in the area of sports goods, with its high profile and vastly profitable fashion appeal that attracts a whole generation of kids. People are spending millions of dollars on shoes. On the other hand we have seen governments reduce their health care spending, in many cases as a cost control agenda without new health policy orientations.

"In the '80s health promotion was seen very much as a state responsibility, and was wholly funded by it. Now, we are much more knowledgeable and creative in approaching financing mechanisms. We need new types of institutions and infrastructures, and we should fully appreciate the possibilities of what non-governmental organizations can do."

I want poetry

Dr Kickbusch recalls the valuable sense of perspective for approaching health promotion she gained from an unexpected literary source.

"When I started working in health promotion, I always kept a quote from Aldous Huxley«s 'Brave New World' on my wall. It told of how the savage from the old world protests that he does not want comfort: '... I want poetry, I want real danger, I want freedom, I want goodness, I want sin.' The protagonist from the new world responds by describing what this means in terms of pain, suffering, illness and insecurity: 'In fact, you are claiming the right to be unhappy.' The savage thinks for a long time after having heard the description--which, given the time it was written, includes typhoid rather than AIDS--and then responds: 'I claim them all'. I think everyone involved in health promotion should read this dialogue regularly, have it on their bathroom mirror. It describes the dream of every teenage cohort offset by the 'boring' adult response, it covers the whole ambiguity of our professional task, but most importantly it reminds us that health is only one dimension of the human condition.

Industries

Three industries are particularly active in the health promotion market the communications industry, the lifestyle and leisure industry and, of course, the health industry itself. But does the WHO see itself as a big business component?

"We are inter-governmental agency," says Dr Kickbusch."The WHO logo is not for sale. That's the simple answer. On the other hand, there is a tremendous interest in health in our society, and there are tremendous opportunities for health in terms what governments and the private sector can do. An ideal would be that we could find more constructive ways of working together: societies would be more health conscious, but in the positive way--I don't mean in terms of health-control societies where everything unhealthy is forbidden.

It has been calculated that if you take the wider notion of health and health care, it becomes the third largest industry in the world.

"If you take a wider notion of the health industry, there are many actors that produce health products: health videos, health magazines, sports goods, travel, and so on. It has been calculated that if you take the wider notion of health and health care, it becomes the third largest industry in the world.

"WHO must be in dialogue with this industry. We already take a clear stand concerning those industries that are hazardous to health, such as the tobacco industry. We have a critical discourse with the food industries, the chemical industry and of course the phamaceutical industry. But now we are looking at another side of the issue, in particular by exploring alliances for health between the public and private sectors that aim to sustain health.

Message

"No one stands to gain if the population is unhealthy.In certain cases the private sector can reach parts of population that are otherwise hard to get through to. How, for instance, do you reach poor teenage boys who are not bothered about health messages? The American Cancer Society conducted an interesting programme with a major food company in the United States. Together they set up an alliance designed to get the message of the Cancer Society to people through the sales of food products by the company. The intermediate role of the food company allowed the Cancer Society to get its message across to low income populations, as the programme evaluation clearly showed."

Ilona Kickbusch emphasises that WHO has always had a wide range of contacts with the private sector, for instance the pharmaceutical industry.

"Industries, particularly multinational ones, have an interest in standard setting. But the competitive edge of the future lies in company credibility. Consumers are increasingly asking questions about how goods are produced, for example child labour used in making sports goods."

Media

If health concerns generate the world's third largest industry, they also stimulate enormous publicity. Dr Kickbusch reckons that the media have become an ever present environment in which vast numbers of messages concerning health are exchanged.

"We do not know what the long-term effects of this environment will be. People are learning to communicate in virtual communities. Nowadays there are talk shows where participants discuss how to live with your partner following a stroke, whereas before such things were discussed in closed rooms.

"In the US, in particular, people are learning to communicate through e-mail and the internet. There have been fascinating programmes where people who take care of relatives afflicted by dementia or Alzheimer«s disease can communicate with each other by e-mail. The only free time they have is in the early hours, when they can read their e-mail and send messages to other people in similar situations and give each other support."

Money

Nowadays, an average of US$250 per capita is spent annually world-wide on product packaging and marketing. By comparison the money allotted to health promotion within health care budgets is small and rarely exceeds $5 per capita. Dr Kickbusch believes that we should explore alternative ways to generate money for promoting health.

"Voluntary funds could be established. It is models such as this that we have to think about."

Risk strategies

Given a social environment that is vibrant with pro-health messages, Dr Kickbusch draws attention to the tactics of the tobacco industry in trying to open up new markets among young people.

"Tobacco marketing has changed so much in just the last five years. Before, they showed happy mainstream people smoking together. If you now look at the messages being put out, the approach is quite different and clearly aims to appeal to young people. All the advertisements point out that you are different, and that this difference is linked to adventure, risk, travel and other things associated with youth culture. The tobacco industry is also conspicuous in many youth-oriented projects, such as rock-concerts and the World Wide Web. The shift is unambiguous and the aim is clear: the recruitment of the next generation. n

Interview by Satu Lipponen

Smoke Free Europe - A Forum for Networks - 14 AUG 1997

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