CHAPTER 2 Concepts and values in health promotion
Chapter 1 identified important principles in Primary Health Care and the New Public Health movement. The centrality of social justice and equity in the promotion of health and directly addressing the determinants of health problems were identified as fundamental principles for contemplation and action in public health. Definitions of health and health promotion were examined in the context of their historical development.
Given the importance of these issues, and some of the dilemmas that have been presented, this chapter will explore these issues in greater depth, and present some other key concepts and values, raising a number of important challenges that health workers will face as they grapple with the complexities of health promotion. Many of these serve to reiterate the particular value base of the Primary Health Care approach to health promotion.
No examination of health promotion is possible without first considering what health is. The health of individuals is strongly influenced by their social and physical environments and it can never be fully considered outside the context of people’s everyday lives.
In 1948 the World Health Organization (WHO) defined health as ‘a complete state of physical, mental and social wellbeing, and not merely the absence of disease or infirmity’. This is probably the most often cited definition of health. It has been important for the role it has played in highlighting that health is about much more than the absence of disease, and that it is much more than a physical state.
Individual health is defined in different ways depending on who you are. Probably the main distinction between definitions of individual health is between those that define health as the absence of disease and those that define it more broadly as a sense of wellness.
In defining health, it is not sufficient to consider only the health of the individual. If health is defined only in individual terms, then issues of power and control, and the unequal access to life chances because of socioeconomic status, ethnicity and gender or environment, for example, are easily ignored.
Two notable efforts to define health of individuals within a broader socio-environmental context have come from the Aboriginal health movement and the environmental movement, where concern for spiritual and cultural connectedness and ecological sustainability, respectively, have moved health definitions beyond the individual, and so, for example, Aboriginal health has been defined as:
Not just the physical wellbeing of the individual but the social, emotional, and cultural wellbeing of the whole community. This is a whole-of-life view and it also includes the cyclical concept of life-death-life.
Similarly, Honari (1993: 23), attempting a similar approach, provides an environmental definition of health by defining health as ‘a sustainable state of wellbeing, within sustainable ecosystems, within a sustainable biosphere’.
How health is defined is very important because definitions determine what are regarded as health problems and therefore what will be regarded as appropriate health promotion. If we define health as merely the absence of disease, we see health promotion as disease prevention, and ignore the significance of positive wellbeing or the social determinants of health that may make people’s lives uncomfortable, but which are not medically classified as diseases. Ignoring those problems, such as chronic back pain, discrimination, social isolation or fear for safety, for example, may leave people suffering from conditions that limit their abilities or reduce their quality of life. It is quite possible that, if we address only medically defined problems, we could be ignoring issues that play an important role in disease causation, including mental illnesses. Furthermore, many environmental health issues are ignored on the grounds that there is no ‘evidence’ of a problem, when evidence may take 20 years to surface and people’s health may have already suffered greatly during this time.
Attitudes and values are ‘constructs’ — terms that are used to explain things that cannot be observed directly. People act in response to their personal and professional values, attitudes and beliefs and we observe these outcomes. There may not always be congruence between a person’s stated values and attitudes and their overt behaviours.
Values refer to the concept of what a person considers desirable. They are a set of standards or principles. Values are defined in sociological terms as ‘the things of social life (ideals, customs, institutions etc.) towards which the people of the group have an affective (emotional) regard’ (Macquarie Dictionary 2001: 1556). Within each culture, these values are seen as positive or negative. In Australia for example, values such as cleanliness, freedom, education, sincerity and compassion are considered as positive values, and cruelty, crime, or blasphemy are negative (Macquarie Dictionary 2001: 1556). Thus, a person’s individual values have a large emotional component. People sometimes make judgments about others on the basis of differing cultural values.
Attitudes are positive or negative feelings about certain things. Attitudes are something internal to a person but attitudes influence the way the person thinks about, feels about, or behaves in response to an issue or stimulus. Attitudes consist of cognitive, affective and motor aspects. The cognitive aspect means that we have personal understandings about that thing, such as smoking, violence or service to the community. A person’s attitude may be based on accurate or inaccurate information. The affective aspect means we are influenced in forming attitudes by our emotions or feelings, such as if we have had a personal experience of someone close to us suffering lung disease, or if we have been regularly verbally and socially abused, or have had a family tradition of volunteering for community organisations. The motor component relates to our tendency or likelihood to take action; or example, not smoking, taking assertiveness classes, or volunteering to work for a cause or something we believe in (Quinn 1988: 359). It is clear that our attitudes affect what we see and how we see it. Studies have shown there is a low correlation between attitudes and behaviour. Attitudes can also be powerfully influenced by external forces, such as media cues and images. Yet, attitudes are personal, and sometimes irrational. They may be based on unbalanced or inaccurate information. They are derived from the diverse cultural, family and social range of experiences that make up our individual lives. Attitudes can change and be changed over time, as a result of new learning or new experiences.
Beliefs can be defined as ‘a conviction of the truth or reality of a thing, based on grounds insufficient to afford positive knowledge’ (Macquarie Dictionary 2001: 170). Depending on their culture and life experience, people may hold various beliefs about the things that contribute to health and cause illness. Beliefs may vary over time as a result of situational changes. In this context, beliefs about the influence of lifestyle conditions or health risk behaviours or about personal risk of certain diseases are likely to affect personal actions.
The likelihood that values, attitudes and beliefs can be changed as a result of a person receiving new or accurate information, developing an emotional commitment to making a change, or having a significant health experience or outcome, has been the basis of formulation of a number of behaviour-change models of health education, such as the Health Belief Model (Becker 1974) and the Transtheoretical Model (Stages of Change) (Petrushka & Di Clementi 1984). These models will be presented in more detail in Chapter 7.
By its nature, health promotion practice involves working with a range of different individuals and communities in a diverse range of possible settings, from acute hospital wards to isolated rural schools. Wherever practice occurs there is potential for the personal values and attitudes of the health workers to be in conflict with those of the community they are working with. Health promotion practice implies a set of values underpinning the service, such as equity, empowerment and social justice.
As indicated in the introduction to this section, there can be a low correlation between a person’s attitudes and their behaviour, meaning what they express in their views on a topic and their actions around the same issue are antithetical. A common example occurs with people’s attitudes and actions with regard to racism. A similar pattern emerges with incongruence between attitudes and actions towards a number of other ‘-isms’; for example, sexism, ageism and so forth. Similarly, workers sometimes find themselves in an ‘ethical dilemma’ in a situation where values conflict in a practice setting. They may be forced to make a moral decision about what is the correct way to deal with a situation (Ife & Tesoriero 2006).
Values of health promotion practice may be implicit, implied in the common values and standards expected in society, such as respect for others, or they may be made explicit in the guiding principles of the health agency, perhaps set out in a professional code of practice, mission statement or other strategic planning documents. Expected professional values may also be made explicit in a formal contract that a worker enters into when they are employed, or in the ‘oath’ that professionals take when they are formally accepted into a professional role, such as the nurses’ codes of professional practice. Professional practice in health promotion implies that a health worker’s actions will be guided by the values set out in the philosophical frameworks that underpin their practice; primarily, the Declaration of Alma-Ata (see Appendix 1), but also, other complementary documents such as the Declaration of Human Rights (see Appendix 3) and the Earth Charter (see Appendix 4). Equity and social justice are key values that are common across these and other philosophical frameworks.
While it is unusual for health workers to act deliberately dishonestly or unethically, they frequently find themselves in positions of considerable power, particularly when they are working with a disempowered group or community. In these situations it is relatively easy for health workers to impose their personal values on the community, because they believe it is ‘right’ or ‘best’ for the community. They may have the ‘wisdom’ of experience of having worked with other, similar communities, or ‘wisdom’ derived from formal education. In acute care and community settings this power can be exercised in simple ways such as the use of the particular jargon of the discipline, which can exclude other practitioners and clients from discussion. Health workers need to constantly remind themselves that their work cannot be value-free; values and attitudes are socially constructed. McKenzie, Neiger and Smeltzer (2005) remind practitioners that even though their actions may be legal, this does not necessarily mean they are moral or ethical. Communities of interest need to be provided with opportunities to express their values through community consultation and partnerships of practice, and health workers need to take the time to examine their own values.
Encouraging people to take responsibility for their own health, both individually and at the levels of the community and the country, is part of the Primary Health Care approach. The re-emergence of these ideas began with the Declaration of Alma-Ata’s call for action ‘in the spirit of self-reliance’ (see Appendix 1), and with the introduction of social marketing messages, designed to ‘sell’ the ideas of personal behaviour change for health maintenance. As the relationships between individual behaviours and illness were identified, calls for change in individual behaviours became more and more popular as an increasing number of diseases were labelled as ‘lifestyle’ diseases; the inference being that people ‘chose’ these behaviours as a part of their lifestyle, and thus it was a matter of individual choice for them to change to healthier behaviours.
Individuals live their lives in a social context and there are many factors that influence an individual’s lifestyle. As the previous discussion points out, a great many of the determinants of health are the result of the social, economic and political structures in which people live their lives. There are some real dangers, therefore, in focusing only on the role of individual behaviours in disease causation and management. People may be blamed for ill health, and for some of the determinants of ill health, when they do not have control over the factors affecting their health or the freedom to make healthy choices. They may be unable to make changes in their personal health behaviours because of the social, environmental or cultural circumstances of their lives. Making judgments about those who are unable to change has become known as ‘blaming the victim’.
Blaming the victim occurs when the structural causes of ill health are ignored and attention is focused on the individual or individuals affected by the problem, with the aim of changing their behaviour (Crawford 1977; Baum 2008). Victim blaming is a subtle process. Ryan (1976: 8; Baum 2008) described it as ‘cloaked in kindness and concern’. It occurs when people fail to see the structural causes of deprivation and ill health, and still seek to solve the problem by working to change the individual (Ryan 1976; Baum 2008).
One of the real strengths of the Ottawa Charter for Health Promotion’s five-pronged approach to health promotion action is that it minimises the chance of victim blaming occurring: if health promotion action occurs at the level of working for healthier public policy and creating supportive community environments as well as at the level of further developing the skills of the individual, the structural barriers to ill health are likely to be addressed. It is vital, therefore, that the broad approach to health promotion action described in the Ottawa Charter for Health Promotion is not watered down to the point where structural action disappears and is replaced by more action at the level of the individual.
Victim blaming does not happen only at the level of the individual. With a focus on community development and community-based action, when many problems stem from national or international issues, there is a danger that disadvantaged communities may be blamed if they are unable to ‘pick themselves up by their bootstraps’ (Labonté 1989a: 88; Gould in Fleming & Parker 2009).
The issues surrounding individual responsibility for health versus social responsibility for health are complex and interrelated. It is not a case of choosing one over the other, but of what balance there is between the two. Unfortunately, because they have come to represent opposing philosophical viewpoints, many discussions present them as opposite to each other, which does not help individual workers clarify how they will address health issues and assist individuals in making changes in their lives. Health workers may need to clarify for themselves how to work with the tension between these two aspects of health promotion, to be aware of their own biases, and to keep clear in their minds how both aspects of a problem need to be addressed in whatever balance is appropriate for the issue in question.
The concept of labelling is very much related to the notion of victim blaming. The stereotyping or labelling of people, often because of their ethnicity, gender, age or socioeconomic status, can have a powerful impact on the way in which they are treated. Health workers’ response to issues and problems that arise may be influenced by beliefs and expectations about particular groups, stages of life, or illness experiences. Ife and Tesoriero (2006) identify that the discourse of disadvantage, the way language is used to portray and maintain a negative image of a vulnerable group, can have a very strong and lasting effect and perpetuate their disadvantage. Disempowerment itself can become a major health issue in communities or with individuals if strengths are not acknowledged along with disadvantage.
The use of ‘strengths perspectives’ (Wieck et al 1989, cited in Jimerson et al 2004: 9) is increasing in many disciplines including mental health (e.g. constructivist therapies), nursing (e.g. wellness vs illness), asset-based community assessments (which will be referred to in Chapter 6), and education research (e.g. resilience) (Jimerson et al 2004). Terminology such as ‘asset’ and ‘protective factors’ are used instead of ‘needs’ and ‘risk factors’. The identification of and building of strengths within individuals, families and communities describes positive relationships, competencies and opportunities, rather than a ‘deficits’ focus (Jimerson et al 2004: 9).
Some of the issues raised by health promotion practice create conflict between people with opposing philosophical views. This is particularly so where health promotion action challenges profit or power, and the role of a health worker is to advocate for more equitable power relations. People’s view of health and health promotion reflects their broader views on the way the world works. As a result, many of the issues underpinning discussions of health promotion reflect the world views that people hold. It is therefore not surprising that some of the issues raised by health promotion create conflict between people with opposing philosophical views. This is particularly so where health promotion action challenges profit or power, and the role of a health worker may be to advocate for more equitable power relations.
Conflicts can occur with industries whose work has a negative impact on health, and for which profit has a higher priority than health and so challenging conflicting values can be an inherent part of health promotion work. Health promotion requires effective communication and joint action with individuals, health workers from a variety of backgrounds, workers from a range of other sectors (e.g. local council workers, teachers, police, environmental workers and road safety workers) and community groups. Key health promotion frameworks and international covenants can be powerful tools for leverage in advocacy work.
Values conflicts in health promotion can also occur within the individual health worker as they make choices and adopt priorities as part of their normal working lives. Different aspects of health promotion may compete for priority, and choices made to support one aspect of health promotion may result in a worker feeling uncomfortable about the implications of this choice for other aspects of health promotion. These values conflicts can occur regularly in health promotion work, and these need to be recognised and reconciled by health workers.
Similarly, as practice changes through evidence-informed development and experience, it is quite possible that values that seemed acceptable in the past no longer seem appropriate. However, the past cannot be changed, and health workers have to come to terms with their previous decisions.
The extent to which people value their health depends on a wide range of factors in addition to the state of their bodies. However, the WHO definition of health has been criticised on a number of grounds (see, for example, Sax 1990; Naidoo & Wills 2000). On one hand, firstly, it has been argued that it is unrealistic and unachievable, because it describes a state of such total wellbeing that it is unlikely that anyone could achieve it for more than a very brief period in their lives. With its focus on perfection, too, it excludes those with disabilities or long-term medical conditions. Secondly, it has been criticised for being unmeasurable, describing, as it does, a general state of wellbeing. It has been pointed out that, despite health having been defined this way since 1948, health statistics still only enable us to measure death and disease and we remain without effective measures of health broadly defined (Mathers & Douglas 1998: 125). On the other hand, some have criticised the WHO definition for not being broad enough. For example, a number of authors have noted its lack of inclusion of spiritual wellbeing, which is increasingly being recognised as important (Teshuva et al 1997; Raeburn & Rootman 1998). And, as noted above, those in the Aboriginal health and environmental movements have criticised its definition of individual health out of a cultural and ecological context. Despite the criticisms that have been made of the WHO definition of health; that it is too broad and unmeasurable, or too narrow and lacking spiritual and ecological dimensions, it remains an important concept, and is an important starting point because it has pointed the way to consideration of the determinants of health (Naidoo & Wills 2000).
With its inclusion of social wellbeing, the WHO definition does touch on the interrelationship between humans and their physical and social environments. Many people identify themselves as healthy more by a sense of wellbeing within the context of their whole lives than by the presence or absence of disease. Wellbeing is ‘the state of being or doing well in life; happy, healthy, or prosperous condition; moral or physical welfare (of a person or community)’ (Australian Concise Oxford Dictionary 1988).
This definition emphasises the multiple layers of influence on our overall health status; personal factors, interpersonal factors, and factors from the social, cultural, spiritual and environmental contexts of our lives. The definition also draws attention to the diverse opportunities for influencing wellbeing through government, social programs, health promotion and policy approaches.
In the previous chapter we outlined the ten WHO determinants of health. Various nations and states are developing their own priorities for action, derived from local population health data, as a first stage towards addressing the social determinants of health. Some population health epidemiologists feel a sense of urgency for action; they argue that there is now sufficient evidence of the social determinants of health, and rather than seeking to know more about unusual or novel minor risk factors, attention should now be directed to understanding the mechanisms for reversing causes of the social determinants of health that are most amenable to change, depending on health care system factors, history and culture (Lynch 2008b) and the prevailing political ideology of the time. The South Australian Government has prioritised a number of determinants of wellbeing, based on local population health indicators. These are the ‘flip-side’ of the social determinants of health — what must be acted upon to make improvements.
1. Income and socioeconomic position. Important factors in explaining differences in wellbeing are not only access to material conditions, but also the social advantages attached to a particular social position.
2. Culture and kinship. For many people, the expression of shared identity, values, beliefs and language is an enabling and protective factor for their wellbeing. Cultural safely is an important health protective factor.
4. Employment and working conditions. Employment provides opportunities for people to exercise control over their lives. Like income there are gradients of control and workplace safety which may enhance or inhibit wellbeing.
8. Individual behaviours and lifestyle factors. Our personal behaviours and practices can promote or compromise health and wellbeing. However, many of these lifestyle behaviours reflect decisions that are socially patterned by people’s economic and social opportunities.
(Source: Adapted from South Australian Key Determinants of Health and Well-being Report 2004 Inequality in South Australia — Key Determinants of Wellbeing, Volume 1: The Evidence. www.publichealth.gov.au/publications/inequality-in-south-australia—key-determinants-of-wellbeing_-volume-1:-the-evidence.html)
Identifying the determinants of wellbeing for a defined population would appear to be important steps towards health enhancement. They move the focus away from physical health, and away from the health sector, and they provide distinct guidance for the mechanisms for change, and the basis for the measurement of progress. This potential for measurement and tracking the effectiveness of specific strategies is very useful given the complexity of addressing the social determinants of health across entire population groups.
De Vries reminds us that a sense of wellbeing equates with a sense of wholeness, which is what the term health originally meant. As de Vries points out ‘wholeness is not the same as being happy or living without pain, frustration or handicaps; wholeness may be achieved in the presence of disease or infirmity’ (de Vries 1993: 129). This sense of wholeness, or integrity, seems to be an important dimension in health. It is interesting to note that this approach takes the WHO definition of health further, as it suggests that this sense of wholeness may be present even if disease or disability are also present (Naidoo & Wills 2000).
It is out of recognition of these issues that the notion of quality of life has gained increased attention in health research. In the context of quality of life, cross-cultural studies indicate that people’s experience of health can be usefully organised as follows:
There is growing recognition of the importance of quality of life in people’s experience of health, but judgments about factors such as these can only be made by the individual. This is significant firstly because it loses impact in the language of epidemiology, but secondly because it alerts us to the importance of enabling people to make the decisions about their own health and quality of life, rather than imposing judgments on them (Johnstone 1994: 391–7). There is also growing evidence that wellbeing and quality of life have a direct bearing on physical health (Marmot & Wilkinson 2006). Knowledge about the inextricable relationship between physical and mental health is growing all the time, but we still have a great deal to learn in this area.
Equity is not the same as equality although the terms are often used interchangeably. Equality is about ‘sameness’ whereas equity is about ‘fairness’. Achieving equality in service provision does not necessarily translate into equity of access or equitable opportunities for health gain. Social justice is the collective expression of the principle of equity.
Equity is about the degree of sharing of available resources in order to provide fair access. Reflect back to the determinants of health presented in the previous chapter and the determinants of wellbeing presented in the previous section. Access to the resources needed to maintain health and wellbeing is not the same for all people; the resources reflect the underlying social characteristics and the hierarchies of wealth, power and influence. Equity relates to the processes needed to ensure fair distribution of resources. This implies that some people, because of their life situation, will require additional support just to be able to access a service that other people take for granted. It relates to the values about providing access to services based on people’s social situation. For instance, some isolated community members need transport assistance or child care in order for them to access health services, or separate, culturally sensitive programs may be established for pregnant women from minority groups. Various ‘affirmative action’ and ‘equal opportunity programs’ have been established to ensure better access or representation of groups who have not been fairly represented. Gender issues have been a key basis on which equity of access can be argued.
Ethical values are closely related to human rights principles and they refer to the rights of humans everywhere to attain the highest possible standard of health. Inequities in access to health services put people who are already disadvantaged, perhaps because they are poor, female, or from a minority racial group, at further disadvantage. Equity principles are needed to address these systematic disadvantages.
Thus, social health policies designed to ensure equity of access become a means of achieving equality. Many strategies to enhance equitable access to health services are outside the domain of the health sector. These can include strategies to redistribute wealth through the taxation system or a universal health insurance system. They relate to activities in transport, housing, sanitation, water supply and education. Equity also means consideration of the needs of future inhabitants of our communities.
Equity of access to public health services is a significant factor that influences the health status of the whole population of a nation. Social and public health policy directions create the context for the quality of access that is, to a large extent, not dependent on the total funds expended.
Equality implies a similarity of status or sameness in service provision. Equality policies in health provide a framework that allows people to have the same means of achieving health. A universal access health insurance system is an example of an equality based health care system.
There is a clear distinction here between policies that provide for equality of service, where people are offered the same support or services irrespective of the circumstances in their lives, and policies that ensure equality of capability or access, where some people are selectively advantaged in order to enable them to access services.
Equality in health care is an outcome measure; it is about the sameness of a service for all. The aim of equality in health service provision is to create a democratic system in which all people can have the same services. When equality is achieved all citizens are entitled to the goods they need to function as free and equal citizens and to avoid oppression by others. When some people are granted easier access or better service, perhaps because they have private health insurance, access is not equitable. Democratic equality also obliges citizens, and people working in the health sector, in particular, to promote equality, to be advocates for change when inequities exist. It is evident that the outcomes are equality of opportunities; equality of access is achieved when equity principles underpin service access and service provision. Building equality into political practice and institutions such as the health care system can yield tremendous social and health consequences. Policy approaches can provide a context for people to achieve equality of capabilities, a social system where people have the capability and freedom to choose one type of life rather than another (Sen 1992; Callinicos 2000).
This does not mean that an absolute principle of equality or sameness across a population is an ideal. It is impossible and undesirable to ‘even-out’ the natural differences in people’s colour, shape, strengths, talents, desires, and physical and mental attributes. Likewise, not all disparities in health status are unfair. For instance, men and women are affected by different diseases, such as prostate and breast cancer, and female newborns tend to be a naturally lighter weight at birth. Inequality exists when there is unfairness in access to education or in the way food is distributed, when distinctions in opportunities are made in gender or other grounds.
One of the major objections to the ideals of equality is that the social pursuit of equality, such as through policy approaches, inevitably violates the personal liberty of some — equality ideals as a basis for resource allocation may impinge on a person’s abilities to make individual decisions. It is true that sometimes equality policies, such as the taxation system, will be contrary to personal choice, but a society needs to have policy which reflects equal concern for its citizens and to create an environment where all citizens have the opportunity to achieve their health goals (Sen 1992; Duckett 2007).
Equity, equality and social justice are fundamental values that underpin health promotion practice. Putting these values into practice means working to reduce the systematic disparities in society by providing opportunities for disadvantaged groups to take control over aspects of their lives that would improve their health. Jeanne Daly’s story of the structural and social factors influencing the lives of passengers aboard the Titanic, presented in Insight 2.1, provides a classic example of how such factors can be largely outside the control of people who are affected most.
The White Star Royal Mail Triple-Screw Steamer Titanic was the biggest ship of its time, the acme of industrial progress, designed to capture the trans-Atlantic trade from the Cunard shipping company. The ‘Queen of the Ocean’ was advertised as the ultimate in luxury and its maiden voyage was expected to draw on board some of the richest people of the time. In the boardroom of the White Star line the decision was taken to increase the space for the first class promenade by reducing the number of lifeboats installed on the top deck.
On its maiden voyage the ship sailed from Southampton, stopped at Cherbourg, and made its last port of call in Ireland at Queenstown. As the ship sailed away, Eugene Daly (no relation) took his Irish bagpipes to the third class promenade and played ‘Erin’s Lament’. Despite the advertised glamour, this was an emigrant ship. In steerage (third class) were 706 people, many from the Balkans, Scandinavia, The Netherlands, England and Ireland, going to seek a new life in the New World. It was the fares of these third class passengers that helped justify the building of the luxury liners. There were an estimated 325 people travelling in first class and 285 in second class.
Life on the ship was strictly segregated, reflecting the class divisions of the time. First class passengers had the upper decks. Here the Astors, the Guggenheims and other wealthy American industrialists promenaded and socialised. Corseted women sat on deck chairs while children played. The men struck business deals in the all-male smoking room, sending messages to their companies on the revolutionary new wireless system. First class meals were served in grand dining rooms. Their day started with the enormous breakfasts that characterised the excesses of the Edwardian era. The dinner menu boasted 11 rich courses. A different wine was served with each course. This was not a healthy lifestyle.
A descent into the bowels of the liner was also a descent on the social ladder. Let us skip over second class and go to third class, the passengers travelling on the lowest decks. Here the dining room was a lot less plush, but comfortable. Dinner, served at midday, was a sensible meal of meat, vegetables and pudding or fruit. There was no alcohol served at meal times, but there was a public bar. In the general room there was a piano, and on the deck outside was a small promenade. Except for the limited space for exercise, we would find little fault with this much healthier lifestyle.
The internal structure of the liner set in place the rigid segregation of the three classes. They ate and exercised on separate decks, even had their hair cut by different barbers. Passageways connected first and third class, but these were hidden, used mainly by staff to traverse the ship without being seen by passengers. There was no lifeboat drill, so third class passengers were never shown how to negotiate their way to first class and the lifeboats. If there was conflict between the classes, it was structurally contained by geographic separation. Passengers saw only their own section of the ship.
Despite the unhealthy lifestyle of the first class passengers, on the Titanic, as in life, third class passengers had higher mortality rates (Table 1) [not reproduced]. The mortality rate for cooks was 94%. On the Titanic, as in life, it was healthier to eat first class meals than to cook them.
But, of course, the problem was not the meals eaten or the smoking and drinking, but a structural lack of opportunity. When the ship hit the iceberg and sank, there were only lifeboats for half the people on board. Women and children were to be saved first. Third class passengers were trapped below decks, although some managed to negotiate the labyrinthine passages to the top deck. There are accounts of crew making way for women and children by hauling from the lifeboats ‘swarthy’ men from third class who were hiding under the blankets. So intent were they on this task that some lifeboats were not filled.
On the deck, as the ship went down, a priest heard confession from those remaining on board. The band played on — according to some survivors they were playing the hymn, ‘Nearer, My God, to Thee’ — until they were swept away as the ship went down. Perhaps the third class passengers also sang ‘Nearer, My God, to Thee’ around the piano in the general room as the freezing water rose around their feet.
The Titanic’s mortality statistics tell a stark story of inequality. While 62% of first class passengers were saved, 62% of third class passengers drowned. While all children in first and second class were saved, 65% of those in third class drowned. While 54% of third class women went down with the ship, 33% of first class men were saved. Included in the first class men who survived was Sir Cosmo Duff Gordon. He was later accused of bribing the crew in his half-empty lifeboat to row away from the ship, ignoring the desperate cries of survivors trying to cling to anything that would save them from the freezing water. Also saved was J. Bruce Ismay, chief executive of the White Star line. When he went on board the Carpathia, the ship that rescued the survivors, he sent a wireless message to New York to stop the wages of all crew rescued from the time the ship sank.
The disaster threw into stark detail social inequalities that usually remain hidden. The interpretation of these statistics gives rise to a rich variety of understandings. Early reports glorified the heroic behaviour of the ‘kings of finance, captains of industry’ who stood aside to save ‘some sabot-shod, shawl-enshrouded, illiterate and penniless peasant woman from Europe’. Why struggle for greater social equality, the rhetoric went: all that it would achieve would be to replace these glorious Anglo-Saxon heroes with the ‘frenzied mob of armed brutes’ (the ‘foreigners’ from third class) who had to be kept out of the lifeboats at gunpoint.
This version of events found its echo in the inquiry into the sinking. The inquiry found that third class passengers were partly responsible for their own deaths. They were reluctant to leave the ship, unwilling to part with their baggage, or unable to speak English. There was a lesson, too, for women supporting the growing Suffragette Movement: equality would mean an end to preferential access to lifeboats. Images of rich and poor men dying together to save their women thus provided reassuring images of an harmonious social consensus that denied class and gender inequality but that emphasised the threat to it from the undisciplined brutes in third class.
These conservative images faded under the combined criticism of other interpretations of the event. Ben Tillett, of the Dock, Wharf, Riverside and General Workers’ Union, railed against ‘the vicious class antagonism shown in the practical forbidding of the saving of the lives of the third class passengers’. The New York Evening Journal of 16 April 1912 published an editorial on:
The Titanic Crime . . . What a satire in modern civilization! What irony of mechanical progress! … The steamship companies, in their hurry for the last increment of dividends, lie under the illusion that the inevitable disaster will always strike elsewhere than upon their own greed and folly.
The crew on the Olympic, sister ship to the Titanic, went on strike for safer working conditions pointing out that they would be in an unenviable situation in the event of a sinking, ‘even if accompanied by the band playing “Nearer, My God, to Thee”. Women’s unions pointed out that, far from benefiting from the system, ‘the lives and health of thousands of women and children are sacrificed continually through their exploitation in mills, workshops and factories’.
The result was that shipping regulations were changed to make it compulsory to have a seat in a lifeboat for every passenger. Although the inquiry into the sinking failed to identify any villains on the Titanic, history, and Hollywood, have pilloried the owners of the White Star shipping line. Even at the time, J. Bruce Ismay became popularly known as J. Brute Ismay. He retired from public life.
(Source: Health Promotion Journal of Australia 2000, 10(1), April, footnotes deleted)
Social justice implies a commitment to fairness or equity of access to health opportunities for all members of society. Social justice is the collective expression of equity. In Primary Health Care, social justice or ‘equity for all’ must supersede individual goals and must inform international health enhancement goals (United Nations 2006).
When we reflect on the social determinants of health, and the determinants of wellbeing, it becomes clear that a socially just society is much more likely to be a healthy society. If policy approaches, planning decisions and the strategies that are undertaken constantly seek to enhance access to those factors and situations that support health, then the society is acting in a socially just manner. As indicated earlier, the social gradient, even within minority nations is a key determinant of health and wellbeing. The link between health and socioeconomic status follows the social gradient (Wilkinson & Marmot 2003). Countries with more even income distribution have higher life expectancy (Marmot & Wilkinson 2006), even in relatively poor nations. Kaplan et al (1996) identified that states within the United States of America (USA) with greater inequality in income distribution had higher mortality rates, lower birth weight rates, higher crime rates, higher levels of expenditure on medical care, and higher smoking and lower exercise rates than states with more equal income distribution. They identified that this association between poor health and income inequality was also associated with poor employment, imprisonment, social services and education levels.
The effect of the social gradient on health is not explained by effects on health caused by individual lifestyle factors, such as smoking. Rather, the death rate pattern across groups with differing income levels seems far stronger than the effect of any individual risk factors for most diseases (Marmot & Wilkinson 2006). Even for diseases regarded as strongly amenable to behavioural change, such as coronary heart disease, the impact of income inequality is strong (Marmot & Elliott 1992). This work highlights the significant impact that inequality and the conditions that encourage it have on health, even in conditions of relative affluence or poverty (Beaglehole & Bonita 2004).
The evidence of the impact of inequality on both individual health and the health and wellbeing of societies serves to highlight the importance of social justice on both the experience of individuals living in a society and the health and success of society as a whole. Glyn and Miliband (1994) identified that inequality affects more than the health of the population — it also affects the economic health of a society. Drawing together a wide range of research, they argued that social justice is actually good for a country’s economy, and that inequalities in a society have detrimental effects on a country’s economic growth. This evidence serves to highlight and reconfirm the importance of the Primary Health Care approach.
Taxation system — the level of taxation and the redistributive nature of taxation — wealthy people are taxed at higher levels than those on modest incomes, and the funds are used to pay for universal access to public health measures.
Social welfare philosophy is enshrined in legislation, or the national/state constitution. A nation or government may see it as a public duty to provide services to all people to protect their health.
Proportion of the Gross Domestic Product (GDP) spent on health services — the proportion of money drawn from national income that is allocated to health, compared to competing demands, such as spending on warfare. When this is low, fewer services are available, and/or costs to the individual are greater.