Most of my life’s work has been in the field of population-health promotion — working to improve the health of the population. Thirty years ago, the World Health Organization launched the modern version of health promotion at a landmark conference in Ottawa. I was there as a participant and the author of one of the theme papers (on creating healthy environments).
The Ottawa Charter for Health Promotion defined health promotion as “the process of enabling people to increase control over, and improve, their health.” Three key points stand out here.
First, this is a process; as such, there really is no end point, no point at which we say: ‘OK, we’ve done that, let’s move on.’ No matter how healthy the population is, it can always be healthier.
Moreover, since the mechanisms involved were defined in terms of developing public policies that are good for health, creating physical and social environments that are supportive of health, strengthening community action for health, developing personal skills for health, and re-orienting health-care systems to focus more on health, the process is clearly socio-political.
Second, the word “people” here is ambiguous. It can mean people as individuals, but it can also mean people as a collective: “We, the people.” In practice, it is both.
This becomes important when we consider the third key point, and the focus of this column: Health promotion is a process of empowering people, both as individuals and as the collective, to take more control over all the factors that affect their health. Fundamentally, it is a democratic process.
So what does empowerment for health involve? First, we need to understand a bit about empowerment. There are two different but related meanings — a formal process of legally giving power or authority to someone, or some group, and a less formal process of enabling someone or some group to become more powerful. It is the latter I am largely concerned with here.
But what does personal and community empowerment mean, how do we do it and what are the benefits for health? In order to understand better what it means, and what it does to our health, consider the opposite. Have you ever felt powerless, that things are out of your control, that you can’t shape or influence the events of your life?
How does that feel? Awful, stressful, unhealthy? How would it be if you felt that way most of your life? Would that affect your health, even your life expectancy? You bet it would.
Since we are really a body-mind duality, our bodies sense this chronic stress. There is a large body of scientific literature that has explored this issue. In a nutshell, our bodies respond to stress through pathways that link the mind through our neurological system to our immune and endocrine systems. We feel this in acute stress as a clenching of our guts, our heart speeds up, we sweat — we are ready to fight or flee.
But chronic stress has more long-lasting, even permanent effects, resulting in higher rates of a whole range of chronic and acute illnesses, even injuries, and it can start from an early age. Indeed, it begins even before birth, as the mother’s stress response is passed on to her developing infant.
Moreover, chronic stress and its consequences are socio-economically related and linked to empowerment, or the lack of it. The most stressful jobs are not those of the executives and senior managers, but of the frontline workers in service industries, the assembly-line workers in factories or the food servers in part-time, temporary jobs.
Their lack of power is often compounded by their living conditions, which can include poor-quality rental housing, less safe neighbourhoods with fewer amenities and services, and a disconnect from the political processes that can make their lives better.
The lack of influence and control over their lives that low-income, less-skilled and less-educated people experience translates into higher rates of death, disease and injury. Seen in these terms, lack of empowerment is one of the major causes of death and disease, and needs to be addressed as such. How we do that will be the topic of my next column.
Dr. Trevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy.