By Laura Tomm-Bonde & Megan Kirk
PhD Students at the University of Victoria
As students, when we read the title of the planned session, The Ottawa Charter for Health Promotion: 25 Years and Beyond, at this year’s Canadian Public Health Association (CPHA) annual conference (2011), our hearts jumped! Not only was the title alluring in and of itself, the speakers on the panel, Trevor Hancock, Michel O’Neill and Louise Potvin, are legends in the field of public health. These three panelists shared their perspectives on the impact the Ottawa Charter has had on public health over the last 25 years. The Ottawa Charter for Health Promotion is an action document that was the outcome of the First International Conference on Health Promotion meeting held in Ottawa in 1986. This internationally recognized and signed document was a response to the growing expectations for a new public health movement around the world (WHO, 2011). In this article we will reflect on the perspectives explored during this session, through a summary of each panelist’s presented perspectives.
Trevor Hancock, a revolutionary thinker and contributor to the health promotion field, suggested that the charter was influential because it shifted the way in which people approached public health policy: it got people to consider a more upstream approach focusing on prevention and promotion from one that was traditionally downstream and focused solely on health care. He believes that the Ottawa Charter is still relevant today; however, it faces many challenges. For instance, within the health field there has always been a dominant discourse of individualism, and this discourse is now stronger than it was 10-15 years ago. Hancock finds the individualism framework problematic, as it leads us to focus on personal behavioural change and prevents health promotion from addressing inequities from a social justice perspective. As Hancock and many others note, the majority of the determinants of health lay beyond the health care system. We must remember that health is not just about individual behavior change, but is in fact a much broader consideration of environmental influences that require some attention. A behaviour change approach is inadequate in addressing the health of a population.
We believe, along with Hancock, that a more complex approach to health, as articulated in the Ottawa Charter, is even more important now than ever. One obstacle we are faced with in Canada is a right-winged political context that does not align well with the values embedded within the Charter. Hancock points out that what we have is a tension between values. Such tensions are reflected in the commitment of our current government to grow an economy in place of a concern to grow people.
Hancock reflectively offered reasons why the Ottawa Charter was not as successful in Canada as hoped and where it might go from here. He claimed that, similar to feminist and environmental movements, health promotion has failed to become a popular movement whereby principles are taken up outside of the professional discourse. He suggested that a social movement may have assisted in making health promotion more visible as other movements made for their causes. He felt that the approach health promotion takes in the future depends on how we, as public health professionals, continue to frame health. He claimed we must continue to follow the World Health Organization’s (WHO) example of framing health as a human right and promote this discourse as they did in the preamble of their latest publication “Closing the gap in a generation: Health equity through action on the social determinants of health” (2008). Using WHO’s work and drawing on theories, such as salutogenesis, to view health will assist public health professionals in changing the discourse at a policy level from “band-aid” solutions toward more upstream actions.
Lastly, Hancock suggested that the current Canadian electoral process needs to be considered a public health issue as it influences the health of a population. He spoke of the recent election and explained that a majority government only reflects the values of 40% of voters. The current electoral process, in this light, is an inequitable representation of the population. Thus, electoral reform from a public health perspective could aim to improve representation of the public with the goal to represent the values of the population rather than the current government values of economic growth and prosperity. Another way to move away from a preoccupation with economic growth and prosperity, according to Hancock, would be to create a Ministry of Human Development. This initiative would aim to re-instate people at the center for policy development as a beginning step to address the battle over values.
Michel O’Neill, a well-established teacher, researcher and health promotion and community health expert, had a particularly strong opinion about the Ottawa Charter. He agreed with Potvin that the charter has had a wide distribution and suggested it has become a near religious approach. O’Neill thought it was important to acknowledge that the Ottawa Charter is not only a health promotion document, but also a public document. This document introduced values and ideas into the discourse on health. O’Neill asserted that the rhetoric around the Ottawa Charter was successful in introducing a call for a ‘new public health’ which emphasized the importance of an upstream approach to health. He argued that the public health community still has a tight grip on the ownership of the Ottawa Charter and suggested loosening our grip in order to create shared ownership with the hope of making progress.
O’Neill claimed that to make progress for health promotion we need to develop a framework and be critical of our tools. While Potvin cites a lack of tools as a barrier to being able to take up the Ottawa Charter, O’Neill suggests we need to develop tools for health promotion that originate from the fields of political science and social policy. Although attitudes are slowly changing towards social science perspectives, public health remains dominated by experimental science. There may be openness to broader perspectives, but O’Neill notes that the process of integrating multiple perspectives will be a challenge. Despite his advice to incorporate various perspectives, ultimately O’Neill spoke to the need to give up the Ottawa Charter while simultaneously ripping up the document in front of the audience. He explained that the values within the charter are no longer relevant because they are incongruent with the current climate and suggested drawing on young people’s perspectives to incorporate their values into a future vision.
Louise Potvin, a well-known professor of public health and expert on community approaches and health inequalities, supported the idea that the Ottawa Charter was a champion in expressing, in written form, the values that have become a part of everyday discourse in public health. Potvin explained how the Ottawa Charter has had widespread distribution throughout the world. For instance, countries such as Sweden and Finland embraced many of the strategic action areas of the Ottawa Charter. In Canada, Potvin asserted that equity and intersectoral action have been successfully applied. In her presentation Potvin provided two examples of how equity and intersectoral action have become part of the public health discourse.
On the other hand, Potvin disagreed with Hancock’s suggestion that health promotion needs to become a social movement. She explained that public health is a state responsibility and a social movement is a citizen’s responsibility. Potvin argued that health promotion was not started in the right way if the intent of health promotion was to be a popular movement. From this framework, Potvin disagreed with Hancock and supported the position that health promotion ought to be a state responsibility and not a popular social movement. Potvin asserts that the inadequate integration of the Ottawa Charter is not due to a lack of a social movement, but is more directly related to the failure to provide public health professionals with the right tools to meet the objectives of the Charter.
Potvin highlighted that the Ottawa Charter originally made no reference to the role of research. She sees this as a limitation and stressed the importance of research in advancing the field of health promotion. Another factor that Potvin considered integral to the development of health promotion as a growing field is to seek out philosophers with varying perspectives. She recognized the tensions of inter-disciplinary and trans-disciplinary work, but encouraged us to embrace the complexities of such work.
Hancock, Potvin and O’Neill provided the audience with varying perspectives on the influence of the Ottawa Charter over the last 25 years and thoughts on future directions. Whether health promotion is considered a citizen’s responsibility or a state’s responsibility, the issue is: how do we move health promotion discourse into everyday discourse and simultaneously embrace multiple perspectives? We are the young people with the perspectives that O’Neill called to be included. With that being said, we disagreed that the Ottawa Charter should be thrown out, but agreed with many of the suggestions put forward by the panelists. For instance, we agree that it is imperative to be selective in the way we frame health, as this will have many future ramifications. We also embrace including diverse viewpoints to broaden our understanding within the health field.
Although we share optimism around the Ottawa Charter, this does not take away from the fact that there are still many concerns about its future. This panel raised questions for us around how the Ottawa Charter and the principles and values embedded within this document are or are not being taken up within the current context of public health renewal in Canada. We question how the Ottawa Charter can be integrated into a context that is increasingly being dominated by an individualistic political, social and economic global environment. The collectivist and social justice values that underpin the Ottawa Charter appear incongruent with an individualistic context. Therefore, although some people claim the Ottawa Charter has become irrelevant (Labonte, 1994), others still maintain it has barely reached its potential, as certain strategies haven’t even been embraced (Kickbusch, 2007). The question still remains, has public health’s relationship with the Ottawa Charter come to an end, as does all fleeting love affairs, or are we committed to it for the long haul?
(1.) Kickbusch, I. (2007). The move towards a new public health. In International Union for Health Promotion and Education, The Ottawa Charter for Health Promotion: A Critical Reflection. Promotion and Education. France: IUHPE.
(2.) Labonté, R. (1994). Death of a program, birth of metaphor: The development of health promotion in Canada. In Pederson, A., O’Neill, M. & Rootman, I. (eds), Health promotion in Canada provincial, national & international perspectives: Canada, Saunders.
(3.) WHO & Commission on SDOH (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva, Switzerland: WHO. Retrieved May, 2010: http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf
(4.) WHO (2011). Health promotion: Ottawa charter for health promotion. http://www.who.int/healthpromotion/conferences/previous/ottawa/en/
Published: July 2011