Enduring principles in a fast-changing world

We are living in a different world, indeed a different planet, from the one in which ‘the Ottawa Conference’ was held, a conference co-hosted by the World Health Organization, through its Regional Office for Europe. The quarter century since then has been marked by a series of qualitative changes, none of which could have been foreseen in 1986.

The world's population has now almost reached seven billion, from the five billion alive at the time of the Conference. These people are ageing at such a rate that soon, for the first time in human history, there will be more people aged over 65 than there are aged below 5. The world's climate is now known to be changing, and the change is attributable to human agency. There are now more people living in cities than in rural areas. In Europe, the early nineties were marked by a dramatic social and economic upheaval with the emergence of new countries and a transition that in many cases was marked by unrest and deep impacts on public health. In recent years, a global economic crisis has emerged, is far from being resolved and is threatening households, health systems and the very viability of countries.

‘The New Public Health’, envisaged in the title of the landmark Ottawa conference, has indeed emerged in many ways that were then unanticipated. The problems of poverty, infectious disease, hunger, maternal mortality and child survival, considered then the problems of the ‘old’ public health, have not disappeared at all and have instead proved remarkably resilient. Indeed, the epidemic of HIV/AIDS acquired global political prominence within a year of the conference (Shilts, 2000), followed by a host of emergent and re-emergent infections. At the same time, the burden of chronic, non-communicable diseases has come to the fore as the predominant public health challenge, even in lower income countries, and it is now recognized that these diseases are linked with poverty and pose a threat to human development (WHO, 2010; United Nations, 2011).

The health promotion movement, born 25 years ago, has grown stronger in the face of these challenges. The Ottawa Charter, celebrated here, is the marker of the birth of that movement. Other papers in this journal examine the relevance and impact of the Charter today. At the same time, it is appropriate to also mark here a lesser-known document that emerged in 1984 from a meeting held in the WHO Regional Office for Europe, affectionately called ‘the yellow document’ in reference to the colour of the paper it was first printed on. This short paper, ‘A discussion document on the concept and principles of health promotion’ (Catford, 1986), defined that health promotion and succinctly laid down the skeleton of what would evolve as the Ottawa Charter. The yellow document reads today as a timely reminder of the foundations of the movement and continues to provide a roadmap for future evolution of the field.

While the context has changed beyond recognition, the principles of health promotion, recorded at the time, provide a solid foundation for action even today. Health promotion continues to call upon practitioners and public health advocates to remain focused on the determinants of health, to work to reduce inequalities and, based on a logic founded on ‘the inextricable link between people and their environment’, to adopt a ‘socio-ecological approach to health’.

It is this logic and these principles that are today driving the development of Health 2020, an overarching health policy for the Region with the concept, principles and values of health promotion at its core (WHO, 2011a). This policy, still in the process of drafting at the time of writing, starts with a broad vision for health in the European Region:

… where all people are enabled and supported in achieving their full health potential and wellbeing, and in which countries, individually and jointly, work towards reducing inequalities in health within the Region and beyond.

The policy has been in development for over a year and will be proposed to the Regional Committee in 2012. In its current form, the document is founded on a positive definition of health and wellbeing, emphasizes citizen participation, proposes a whole-of-society and a whole-of-government approach to health, addresses the structural, environmental and behavioural determinants of health and defines the key role of public health and health systems based on primary health care. A number of reviews and frameworks are feeding into this policy: a review of social determinants of health in Europe (WHO, 2011b), a formal study of health governance (Kickbusch and Gleicher, 2011) and an action framework for public health (WHO, 2011c).

The development of Health 2020 is a practical illustration of the evolution and application of health promotion to policy making in one WHO region. The broad social drivers described above similarly challenge health policy makers across the globe. It is proposed that similar application of the concept and principles of health promotion is appropriate elsewhere. While the changes of the past decades have transformed public health, the concept, principles and the Charter of health promotion have endured. They will remain our guide in the next quarter century.

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