The Ottawa Charter at 25.

Hancock, Trevor

On November 21, 2011, the Ottawa Charter for Health Promotion turns 25 (1)--a quarter of a century, an entire generation old! The Canadian Public Health Association (CPHA) paid tribute to this important document, the International Conference that gave rise to it, and some of the key people behind it at the Association's annual Awards ceremony in June. It is perhaps hard now to recognize just how dramatic and significant the Ottawa Charter was at the time of its creation, both for the values it espoused and the ideas it presented. It strengthened Canada's position internationally as a leader in what was then--and many would argue is still--an emerging field. And it placed on the agenda for health promotion and public health a set of issues and challenges that to this day we are a long way from fully addressing.

I place health promotion and public health together deliberately here because it is worth recalling that the subtitle of the 1986 International Conference was "The move towards a new public health" and the Charter states right at the outset that the conference was "a response to growing expectations for a new public health movement around the world". So why a 'new' public health? What was wrong with the 'old' one?

Many of us at the time were reacting to a model of public health that we saw as based too much on the medical model, too oriented toward infectious disease (still the case to date), too focused on the individual and on behavioural change, too timid in the face of environmental, social and economic challenges to health, and too politically neutered. The Charter was intended to be--and was--a radical departure from this 'old' public health, but at the same time it was in many ways a hearkening back to an even older tradition of public health in the 19th and early 20th century which was seen as more publicly and politically active, and more committed to addressing the root causes of ill health. Victorian public health and urban health pioneers such as John Snow, Edwin Chadwick, Benjamin Ward Richardson and Ebenezer Howard were heroes to me, as were Charles Hastings, Medical Officer of Health in Toronto from 1910-1921, and Charles Hodgett, Secretary to the Public Health Committee of the Federal Commission on Conservation at about the same time; the latter body was integrating health, environmental sustainability and urban planning more than 50 years before we rediscovered these ideas in the 1970s and 1980s!

Rereading its four short but intense pages 25 years later, one finds the Charter still refreshingly and excitingly relevant to our work today; in fact perhaps even more so, as I think in recent years we have seen both a tendency--certainly in the public's mind and among our political leaders--to move back to a medical model, a focus on lifestyles and personal responsibility and on infectious disease, and an unwillingness to confront political and social forces that harm health.

Among the key ideas and values that were central to the Charter and that have guided my life's work, as I am sure they have for many health promotion and public health practitioners, are the following:

* Peace: In the rather short list of prerequisites for health in the Charter, peace comes first, and I like that. We do not discuss this enough as a determinant of health, yet peace (as opposed to violence and abuse) in our homes, schools, workplaces, hockey rinks and communities, as well as internationally, is indeed a fundamental determinant of health. And of course, it is very Canadian--peace, order and good government lie at the heart of our founding document, the British North America Act, and our Constitution.

* Social justice and equity: Recognized as a fundamental prerequisite for health, the Charter defined health promotion policy as "coordinated action that leads to health, income and social policies that foster greater equity" and the participants pledged "to respond to the health gap within and between societies, and to tackle the inequities in health produced by the rules and practices of these societies."

* Ecosystem health: The Charter was the first WHO document to recognize "a stable ecosystem (and) sustainable resources" as fundamental determinants of health, noting that "(T)he inextricable links between people and their environment constitutes the basis for a socio-ecological approach to health"; participants pledged to address a wide range of environmental issues that affect health and "to address the overall ecological issue of our ways of living."

* Empowerment: If there is one central theme that runs throughout the Charter, it is this. Health promotion itself is defined as "the process of enabling people to increase control over, and to improve, their health." Note that the word 'people' here is (perhaps deliberately) ambiguous; it could be people as individuals or as a collective--the people. Empowerment of people and communities and participation in the decisions that affect their health are a constant refrain, and personal skills for health are seen as including lifeskills that enable people to exert more control over their lives and their environments.

* 'Whole of government' and 'whole of community/society': There is an implicit hierarchy in the Charter's recommended approach, with governments at all levels, and communities and society as a whole, having a particular responsibility to ensure the conditions for good health. This can be seen in the order in which a variety of factors that can affect health are listed in the section on advocacy ("Political, economic, social, cultural, environmental, behavioural and biological") and in the order of what we now usually call the health promotion strategies: Healthy public policy, supportive environments, strengthened community action, personal skills and reoriented health services. It is also important to note that there is a section on advocacy, and that participants pledged "to advocate a clear political commitment to health and equity in all sectors."

* The settings approach: The Charter notes that "Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love." The Ottawa Charter helped put in place this approach, which has blossomed in Canada and around the world as Healthy Schools, Healthy Workplaces, Healthy Hospitals, Healthy Markets in Asia and Africa, Healthy Communities in Canada, Healthy Villages in EMRO, Healthy Municipalities in PAHO and Healthy Cities in Europe. The Charter marks an important shift in our contemporary understanding and practice of public health. It is a landmark document that, as Michel O'Neill and colleagues noted in 2007, has variously been called "a reference framework; a philosophy; a set of ideas, of orientations, of directions, of guidelines; a vision; a manifesto; and even ... a Bible!" (2) I believe it is all of those.

The Charter cannot be separated from the people behind its creation, and there were of course many who made significant contributions but who will go unheralded here. However, two of them stand out, and both have been honoured by CPHA (which, incidentally, under the leadership of Gerry Dafoe, played a vital role in co-sponsoring and organizing the 1986 Conference).

* Ron Draper: My late and great friend Ron Draper was at the time Director-General of the Health Promotion Directorate at what was then called Health and Welfare Canada. He had led the creation of this Directorate, which itself was a result of another landmark Canadian publication, the Lalonde report. (3) Ron completely understood the fundamental principles--and the fundamental importance--of health promotion and had the bureaucratic skills to make it happen. He was the consummate 'guerrilla in the bureaucracy' who established dramatically different approaches to supporting community actions for health; created, under Irv Rootman's leadership, the first national Health Promotion Survey; and successfully led the development of the Epp report, (4) Canada's version of the Charter, which was released at the Ottawa Conference. Among other things, this involved persuading a Conservative Minister to endorse concepts such as reducing inequalities in health, healthy public policy and community empowerment! And of course, he and Ilona Kickbusch found in each other the intellectual and ideological partners whose chemistry and magic gave us the Charter.

* Ilona Kickbusch: Like Ron, Ilona was not a public health professional by training, nor even a health professional (which should give us some pause for thought!). Her PhD was in political science and she had a strong interest in feminist issues and thus in women's health. She came to the attention of WHO in the early 1980s and was hired as the first Health Promotion Officer for WHO Europe. She began bringing together thought leaders in the nascent 'health promotion' field in Europe, and during that process connected with Ron, presumably because of the intellectual and organizational leadership of Canada at that time, a legacy of the Lalonde report. Ilona visited Canada in the early 1980s; I recall first meeting her in Toronto when Ron brought her to visit us at the Health Advocacy Unit, and meeting again when Ron brought her to our 1984 "Beyond Health Care" Conference on Healthy Public Policy5 (which he had co-funded and which is also where the seeds were sown for the WHO Healthy Cities project). Ilona embraced the settings approach and led the creation of the Healthy Cities, Healthy Schools and Healthpromoting Hospitals networks in Europe, and organized a set of important follow-up health promotion conferences around the world. She would go on to be Director of Health Promotion globally at WHO in Geneva before becoming a consultant and academic based in Switzerland.

Of course, I would not wish to imply that the Ottawa Charter is perfect, or that health promotion is a perfect approach that is being implemented perfectly. Far from it: the Charter and the practice of health promotion have been subjected to plenty of criticism, and rightly so.

Nonetheless, flawed though it might be in some respects, I believe the Ottawa Charter has withstood the test of time and remains a vital guide to the philosophy and practice of public health today. Without doubt, the Charter and the whole development of health promotion in Canada and around the world could not have happened without the partnership of Ron and Ilona, so it is only fitting that in Ron's absence I give the final word to Ilona:

"The generation that developed the Ottawa Charter for Health Promotion set out to classify what it takes to address public health in modern societies, not only in the 20th but even more so in the health society of the 21st century. I still maintain that the document was very much ahead of its time and that its full importance and potential has not yet been fully realized." (6)

And in reference to her students, many of whom, she noted, were not yet in primary school when the Charter was created, Ilona concluded:

"The future of the Ottawa Charter lies with them--in my view it has not yet really come."

So, to the generation that comes after us, I say--here, catch! And do a better job than we have done in realizing the ideals of the Ottawa Charter.

Conflict of Interest: None to declare.

REFERENCES

(1.) World Health Organization. The Ottawa Charter for Health Promotion. Copenhagen: WHO, Health Canada, CPHA, 1986.

(2.) O'Neill M, Dupere S, Pedneault E, Perreault K, Forster M, Roberge N, et al. The 'Montreal message': The Ottawa Charter for Health Promotion is still useful for today's public health practice. PromotEduc 2007;14:31-32.

(3.) Health and Welfare Canada. A New Perspective on the Health of Canadians (Lalonde Report) Ottawa, ON: Health & Welfare Canada, 1974.

(4.) Health and Welfare Canada. Achieving Health for All: A Framework for Health Promotion (Epp Report). Ottawa: Health and Welfare Canada, 1986.

(5.) Beyond Health Care: Proceedings of a Working Conference on Healthy Public Policy. Can J Public Health 1985;76(Suppl. 1):1-104.

(6.) Kickbusch I. The move towards a new public health. Promot Educ 2007;14:9.

Correspondence: Dr. Trevor Hancock, Professor and Senior Scholar, School of Public Health and Social Policy, University of Victoria, PO Box 1700, STN CSC, Victoria, BC V8W 2Y2, Tel: 250-472-5374, E-mail: [email protected]

Trevor Hancock, MB,BS, MHSC

Author Affiliations

Professor and Senior Scholar, School of Public Health and Social Policy, University of Victoria, Victoria, BC