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5.0 out of 5 stars
The best book ever written on health promotion, August 4, 2001
This review is from: Rethinking Health Promotion: A Global Approach (Paperback)
In this excellent book, Theo MacDonald, Professor and Director of Postgraduate Studies in Health at Brunel University, traces the history and philosophy of health promotion. He shows that health promotion is not a modern innovation and that it has existed as a distinct enterprise for as long as biomedicine. He examines its relationships with clinical science and health education. Medicine has always applied reductionist thinking to problems of disease and illness, ascertaining details of how things work in order to combat illness. But health is more than the absence of illness, so to understand health we need a holistic approach.
At the heart of the book is a brilliant discussion of the ethics of health promotion. He describes the Hippocratic medical model as paternalistic: to do good and do no harm is a start but it is not enough. Respect for patients' autonomy should instead be primary; practitioners must listen to the patient. We should consider patients not as consumers of health care, rather as co-producers of healthy lives. We should seek people's collaboration not their compliance (doesn't compliance just mean obedience?) Mozart complied with his doctor's instructions to take an antimony/mercury mixture for his colic and it killed him! Complaints of noncompliance lead to bad faith and victim-blaming, with accusations of `difficult patients' ( shouldn't it be the difficult doctor? Ask the patient!)
It is not a good idea to run health promotion through primary care commissioning arrangements with cash-limited budgets. The result will be to impose the medical model, in which health promotion is directed towards the individual. It is like healthism - the kind of individualist approach derived from American models (in both senses of the word!) with which we are all too familiar. The individualist approach detracts from the need for longer-term social, economic and political change to address the wider socioeconomic and environmental determinants of health. The Government's 1992 White Paper `The Health of the Nation' was just about disease prevention, not health provision, and did not provide a viable strategy for improving the nation's health. It avoided a social agenda, chose arbitrarily five areas of concern, and its targets were variously unrealistic, unchallenging and irrelevant.
He shows how health promotion can assist in preventing HIV/AIDS, tobacco use and alcohol abuse. He reviews the evidence proving the indisputable links between unemployment and poor health, poverty and poor health, and bad housing and poor health, and concludes that health is a social and political issue. Britain is a world leader in the science of nutrition, yet we are hardly the best fed nation in the world. Nutritional deficiencies increase the likelihood of developing diseases such as diabetes, coronary artery diseases and certain cancers.
Health promotion is essentially collective. It combines educational, organisational, economic and environmental support for actions conducive to health. It is about empowering people to take responsibility for their health, not telling them how to behave. It must be sustained by neighbourhood advocacy, with people participating at all levels. For example, dietary health can be promoted successfully through mutual aid groups, eg the `Look After Your Heart' cooperative schemes in Bolton. Health promotion can then be a force for progress towards health for all, a key part of the new public health, whose goal is to effect national and local political change, to create those social and economic conditions that promote rather than damage health.
When we plan what we need for the NHS, in terms of rebuilding cooperation and promoting long-term planning, health promotion should have a vital role to play. This book should assist us to think clearly about what we need to do to improve public health.
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