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Reflections on the Bangkok Charter for Health Promotion

 I Introduction

The Bangkok Charter for Health Promotion has been agreed to by 700
participants representing over 100 countries at the 6th Global
Conference on Health Promotion held in Bangkok, Thailand in August
2005  (http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/index.html). 
It identifies major challenges, actions and commitments needed to
address the determinants of health in a globalized world by reaching
out to people, groups and organizations that are critical to the
achievement of health.
                                           

This article presents

  • a broad outline of the new Charter,
  • opinions from a few health promotion practitioners, and
  • reflections on the relevance of the Charter for the practitioners on the field.

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II The Bangkok Charter for Health Promotion

A Background

The new Charter is based on the fact that the world context of health
promotion has drastically changed since the 1986 charter. The factors
affecting this change are the increase in inequalities within and
between the countries; new models of consumer society, communication,
and marketing; and world environmental changes and urbanization.
                                           

The Bangkok Charter for Health Promotion affirms that policies and
partnerships to empower communities, and to improve health and health
equality, should be at the centre of global and national development
(read the charter online at http://www.who.int/healthpromotion/conferences/6gchp/bangkok_charter/en/;
text from the charter quoted below is from the webpage).  It gives
new directions to health promotion by emphasizing the coherence of
policies, investments and partnerships and, most particularly, joins
governments, international organizations, civil society and the private
sector to work on four key commitments (listed below). 
Essentially, it is based on the principle of social justice and seeks
to find solutions to changes caused by globalization and involving a
growing economic gap between countries, rapid urbanization and
pollution. Its also seeks to influence the evolution of certain chronic
diseases.

The definition of the word globalization helps us better define the
charter's context: according to Wikipedia, globalization is the term
used to describe the changes in societies and the world economy that
result from dramatically increased international trade and cultural
exchange. It describes the increase of trade and investment due to the
falling of barriers and the interdependence of countries. In economic
contexts specifically, the term refers almost exclusively to the
effects of trade, particularly trade liberalization or "free trade."
More broadly, the term refers to the overall integration and the
resulting increase in interdependance among global actors (be they
political, economic or otherwise) (http://en.wikipedia.org/wiki/Mondialisation).
   
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B Four commitments to "health for all"

These commitments are based on an integrated approach to government and
international-organization policies. They also focus on work with both
individuals and the private sector.  The Charter's four key
commitments "are to make the promotion of health
    * central to the global development agenda,
    * a core responsibility for all of government,
    * a key focus of communities and civil society, and
    * a requirement for good corporate practice."

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C Three areas of intervention and five proposed actions

The charter further identifies five actions required to implement the
strategies it outlines, which themselves can be sorted into three areas
of intervention:

Strong political action

  • "regulate and legislate to ensure a high level of protection from
    harm and enable equal opportunity for health and well-being for all
    people"

Broad participation

  • "build capacity for policy development, leadership, health
    promotion practice, knowledge transfer and research, and health
    literacy"
  • "partner and build alliances with public, private, non
    governmental and international organizations and civil society to
    create sustainable actions"

Sustainable advocacy

  • "advocate for health based on human rights and solidarity"
  • "invest in sustainable policies, actions and infrastructure to address the determinants of health"

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III What Does the Community Think?

A Reactions at the international level

The reaction of  People' S Health Movement (PHM) was radical: "The
new Charter is an inadequate and timid document that falls far short of
what is required to tackle global health problems today" (https://listserv.yorku.ca/cgi-bin/wa?A2=ind0508&L=CLICK4HP&P=R2430&I=-3).

The PHM states that the Charter does not take into account the causes
of world poverty and the gaps of health systems. This organization
advocates for more concrete strategies such as cancellation of the
unjustified and non-viable debts, the introduction of an equitable
system of taxes to eliminate the unjustified international tax
exemption, and the equitable redistribution of resources and public
financing for the essential services for all individuals. This
international organization gathers social activists, health
professionals, academics and researchers and non profit organizations;
and have their own Charter People's Charter For Health that states that
"inequality, poverty, exploitation, violence and injustice are at the
root of ill-health and the deaths of poor and marginalised people" (http://phmovement.org/charter/pch-english.html).

Using colourful language, a professor at the University of Paris XIII,
Moncef Marzouki,  communicates his "firm opposition" due to "a
weakness in the analysis, at worst like a deliberated will to drown the
fish. The text places all the actors on a equal level: individuals,
political leaders and the private sector. Everyone is beautiful and
everyone is nice and everyone is called to better coordinate their
mutual goodwill according to the wishes expressed by the nice and well
intentioned writers of the Charter ." 
                                       

According to Marzouki, it is unrealistic to think of finding solutions
to health and  social problems by joining together all the various
actors (http://www.rhpeo.org/reviews/2005/27/index.htm). 
For example, sitting the representatives of the tobacco industry at the
same table as the victims of the lung cancer cannot solve the problem
due to the disparity in their interests.
                                           

Dr Laverack, of the University of Auckland, and Dr Ron Labonté, Canada
Research Chair, Globalization/Health Equity at the Institute of
Population Health at the University of Ottawa, formulated their
reaction in an open letter addressed to the general manager of the
World Health Organization (WHO). The first question sets the
tone:  "How do you see the Bangkok Charter's usefulness in terms
of direct (or even indirect) benefits to the people suffering the
consequences of poverty?"
               
They question the steps taken to ensure that the Charter is meaningful
to practitioners and communities dealing with the "burdens of disease";
how  the Charter will actually influence health promotion funders;
how those endorsing the Charter will ensure that these action areas
will be taken seriously by governments; and, finally, what resources
WHO has to back up the implementation of the Charter (https://listserv.yorku.ca/cgi-bin/wa?A2=ind0506&L=CLICK4HP&P=R1495&I=-3).
                                           

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B At the Canadian level

Dr. Ron Labonté, mentioned above, also published a critique emphasizing
the importance governments honouring already existing commitments such
as human rights treaties and covenants and multilateral environmental
agreements. He firmly believes that  governments must re-commit to
the right to health, including access to services (and to related
rights such as the right to food, to water). According to him, the
Charter could also include new rights such as evaluating the impact of
trade on health. He states that certain policies make globalization
health friendlier, giving the example of the trade reform agreements
allowing the underdeveloped countries to economically develop. He also
suggests removing any reference to public-private partnerships. If
there is to be any reference, it should be in order to develop legal
frameworks and regulate them, not to promote them (https://listserv.yorku.ca/cgi-bin/wa?A2=ind0507&L=CLICK4HP&P=R957&I=-3).
               
Michel O' Neil, professor at Université Laval, Québec and
Vice-President for Communications at the  International Union for
Health Promotion and Education (IUHPE), defines the new Charter as
generating values and broad principles as well as noble and generous
suggestions that are increasingly difficult to apply. His analysis of
the success of the Ottawa Charter makes us doubt the impact the Bangkok
Charter will have. The Ottawa Charter is convincing and quite
distinctive ("it was really a charter and not a set of
recommendations"). Its success is based on the historical and political
circumstances which were different form those of the Bangkok Charter:
the inaugurator aspect (a first in history); ten years of preliminary
work, reflections and exchanges; the good credibility and reputation of
the World Health Organization at that time; and the leadership of 
the Scandinavian countries (as opposed to the South-east Asian
countries for the Bangkok Charter).
                                           

In a telephone interview, Suzanne Jackson, director of the Center for
Health Promotion at the University of Toronto, who participated at the
Bangkok Conference, explains where what some note as the authoritative
tone of the Charter comes from. The tone was selected to unite "the
decision makers," it really is a political document and, she says, the
tone was even stronger backstage.  It reiterates the base of
social justice to the Charter, following strong representation of the
underdeveloped countries undergoing the effects of globalization
(personal communication, October 7, 2005).
                                           

Mr. Claude Rocan,  General Director of Centre for Healthy Human
Development at the Public Health Agency of Canada, was another
participant at the Bangkok Conference and states that the Charter is a
gathering force for all actors -- public sector, private sector,
community organizations-- by inviting them to work together towards
progress. Mr. Rocan supports the document and sees repercussions on the
projects and programs of the agency by bringing them to a
conscientisation and a commitment at the local as well as a more global
level (personal communication, October 11, 2005).

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IV  Relevance of the Charter for the Practitioners in the Field
       
The following is reflections are by Sylvie Boulet, (Dt.P, MHSc.),
Health Promotion Consultant with the Stroke Prevention Initiative and
the Canadian Health Network (sylvie@preventstroke.ca
s.boulet@opc.on.ca).
   
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A Opportunities for the populations of the underdeveloped countries

I like the room granted to the underdeveloped countries in the Bangkok
Charter. As mentioned earlier, the Charter clearly supports the
populations of the under-developped countries since we tried to
understand their reality. The presence of most nations, and
particularly those of the underdeveloped countries, is felt from the
first paragraph of the document. For example, the first of four
commitments (make the promotion of health central to the global
development agenda) results in the development of solid
intergovernmental agreements to increase health and the collective
health security and to reduce the gap between rich and poor. The
Charter stipulates firmly that the governments must find global
governance mechanisms to mitigate the harmful effects of  "trade,
products, services and marketing strategies."
                                               

My impression is confirmed by the discussions on CLICK4HP, where 
participant Bernie Marshall, referring to presentations made in
Stockholm, mentions that there was a perception that the underdeveloped
countries had not been involved in the process of the Ottawa Charter.
Then, he says "we needed a new Charter  that is owned by a broader
group of nations" (https://listserv.yorku.ca/cgi-bin/wa?A2=ind0506&L=click4hp&T=0&F=&S=&P=5232).                                           

The Ottawa Charter is known for giving priority to community action. I
keep looking for concepts of social justice, inequality and political
claims and here is what I found in the last paragraph "Call for
international action." This new Charter seems to start where the Ottawa
Charter left off.
                                           

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B From Community action to globalization

The Bangkok Charter suggests the assertion of health according to the
human rights and solidarity, building capacity in terms of policy
development, regulating and legislating and building partnerships and
alliances with various sectors (public, private). A message completely
different from the comfortable arena of the Ottawa Charter.

This Charter raises my awareness about the impact or the consequences
of community action--how does our local work influence what occurs at
the gobal level? Through various interventions, whether it's the
training and support given to multicultural and/or minority groups, the
contacts made with the municipal school and political decision makers,
or the life style changes aiming at a greater comfort, we all influence
the health of an individual, a family, a nation. All these actions are
more or less connected to the conditions of a global reality. Eric's
story, used to show the interdependence of the determinants of health
(Why is Eric at the hospital? http://www.phac-aspc.gc.ca/ph-sp/ddsp/pdf/toward/toward_a_healthy_french.PDF)
can have extensive consequences such as working to eliminate dumps and
to promote recycling. From a global perspective, one can easily see
that a local reality is the consequence of a world transaction by
imagining that for instance, a father looses his job because the
contracts of his factory were transferred to another country.
                                               

Unfortunately, the practitioners in the community do not always have
the time, the energy and the tools to apply this framework. In the
field of health, in a minority context with isolated clients, we're
often busy building the structures and the services, counting the
resources or maintaining the assets. But practitioners can ,on the
other hand, work in the spirit of the Bangkok Charter by making our
clients more particularly aware of their economic power, while
remaining alert of the regroupings on all levels and remaining active
on the local, regional and national policy level.
                                           

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C The reassertion of health promotion

The Bangkok Charter includes the basic concepts of health promotion.
The practitioners on the field can relate to action verbs such as "to
assert, invest, build."  It reminds the reader that  health
promotion works and is followed by a list of effective strategies (http://www.proyectoefectividad.com/archivos/carta_bangkok.doc).
At the bottom of the first page, health promotion is described as being
a fundamental human right that offers a positive and inclusive concept
of health as a determinant of the quality of life... I appreciate even
more the reference to inclusion which is directly related to the lattst
strategies of OPC  (see tools for an inclusive Ontario http://www.opc.on.ca/francais/nosprogrammes/centre/projets/jen_fais_partie/full/index.htm). 
That the four commitments for health begin with "Making health
promotion .... " reinforces the importance of the concept.
                                       

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D The relationship between health and social determinants of health

An anonymous author posted to the SDOH mailing list criticizing one of
the Charter's assertions: "Health determines socioeconomic and
political development."  He reminds us that "the relationship
between health and poverty is two way but it is not symmetric. Poverty
is the single most important determinant of poor health.  But poor
health is very far from being the single most important determinant of
poverty"(https://listserv.yorku.ca/cgi- bin/wa?A2=ind0508&L=SDOH&P=R14036&I=-3).

Several socio-political documents were published to support this
standpoint, stating the relationship between the social determinants
and health, including the Charter of Toronto for a Healthy Canada
conducted in  2002 and ratified by four hundred Canadians from the
social and health policy field. This document confirms the importance
of social determinants of health.
                                           

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E The private sector and its implication

The private sector is mentioned nine times in the six pages of the
Charter. The role granted to the private sector is new compared to the
Ottawa Charter. Discussions on the CLICK4HP and SDOH mailing lists made
me think its inclusion is not unanimously approved.

Experts in health promotion, such as Dr. Ron Labonté, suggest limiting
the partnership of public and private sectors to the development of
legal structures in order to legislate the private sector (https://listserv.yorku.ca/cgibin/wa?A2=ind0507&L=CLICK4HP&P=R957&I=-3).
Another author after presenting a basic argument in terms of the
disparity of interests of the involved parties suggests to seek the
input of groups like the associations of health workers and the unions
or peasant's federations (https://listserv.yorku.ca/cgi-bin/wa?A2=ind0508&L=SDOH&P=R14036&I=-3).
Finally, David Warner states that "the corporations commitment to
equity, public health, and sustainable environment should be voluntary
rather than through strong regulation and democratic process (https://listserv.yorku.ca/cgi-bin/wa?A2=ind0507&L=sdoh&T=0&P=635).

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F Think globally, act locally--health for all: utopia?

The 1986 Charter recommended "`health for all by the year 2000." This
charter brought great initiatives and had a high impact in the
community intervention sector. These official documents are always a
little utopian but make us think.

A support document for the Bangkok Charter states that the adoption of
the Ottawa charter encouraged a certain number of declarations at the
national and global level but the signature of these agreements has yet
to result in concrete actions. The participants of this Bangkok
Conference hope to close this implementation gap for a concrete action
by working at the policy, partnership and political leadership level.
The future will tell us if the citizens will take up the challenge (http://bioethicsanddisability.org/WordPress/?/p=4).
                                               

I see in the Bangkok Charter, a great complementarity with that of
Ottawa. As a speaker, I can relate to the concrete language and
well-defined structure of the Ottawa Charter that allows me to use the
determinants of health as objectives as well as indicators of success.
The Bagkok Charter triggers my reflection, questions my global
commitment, evaluates my social justice actions. This thought leads me
to re-examine my professional implication but also motivates me to
consider the range of local action that could have an international
significance. I just returned from a Santé en français conference where
I could hear the reality of Franco-Canadian of each province. The
richness of the experiments opens doors, builds bridges, makes it
possible to go further. Moreover, one must admit that globalization
opened a door to us on the world.

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G Last reflections: Will the Charter have an impact?

The Ottawa Charter made its mark and remains a difficult point of
comparison for Bangkok:  "the five years following the publication
of the Ottawa Charter were rich in terms of health promotion
activities.  Several federal strategies were created on a large
scale, including  Canada's Drug Strategy, Tobacco Demand Reduction
in Canada, the National AIDS Strategy and the Brighter Futures
Initiative for Children "(Hamilton, 2002, Why evaluate the
effectiveness of health promotion? ).

Several authors including Dr. Labonté, mention the low expectations
they have from these documents and that they would rather give priority
to human rights conventions that bring the mobilisation and the
agitation of the civil society as an effective tool for social change.
                                           

Concretely, what changes does the new Charter bring? How does it
transform the daily activities of practitioners? Let us acknowledge
that this Charter brings a great reflection on our personal actions and
our community interventions and forces us to think more about our
community and its bonds with other communities. Personally, it
motivates me to take a further step, to support the small artisanal
shop that gives part of its profit to the less fortunate and to sign
the petition that advocates for the rights of the homeless throughout
the world.

Let me finish with a inspiring quote of Moncef Marzouki, human rights
advocate: "It is idiotic to want to change the world but criminal not
to try."

So,  see you next time?

Read about the 7th International Conference for health promotion:
Ottawa 1986-Vancouver 2007: should we revise the Ottawa Charter? at http://www.iuhpeconference.org/).