Theory and Policy Innovation for Health: where has the creativity and fun gone?

Recently, I attended one of those weekly research seminars. The presenter was a newly appointed research professor with many competitive grants and international consultancies under his belt. In explaining what had taken him to such leading stature in his field, he proudly announced that he ‘… never let research be clouded by theory.’ I had to think of one of Kurt Lewin's famous maxims, ‘If you want to understand something, try changing it.’ Indeed, action before understanding sometimes is a promising approach to innovation. Yet, the same Lewin also said something about the practicality of theory. As editors of this journal, we are sometimes torn between excellent manuscripts describing a problem, and possibly less brilliant pieces that speculate why something is a problem and how solutions could be sought. The scientific procedures of describing a problem analytically have crystallized into a fabulously powerful toolbox, with the Randomised Controlled Trial emerging as (what some would believe) the ‘Swiss Army Knife’ of empirical understanding. However, approaches towards theorizing and validly speculating about causal, final, normative and other relations often still rely on creativity, lateral thinking and applying wisdoms from alternative disciplines to the health field. Such approaches are less strictly codified, and harder to appraise for us as editors of a journal at the cutting edge of health understanding. The science of innovation in fact finds humour in creativity, one of the greatest assets for change (Land and Jarman, 1993). In this issue of the journal, we are proud to present some of the fabulous creativity and lateral thinking that will take the health promotion field forward, colourfully and sometimes with great wit clouded by theory. In her book ‘Policy Innovation for Health', the Chair of our Editorial Board presents, as always, some challenging thoughts (Kickbusch, 2008). She describes how historically the four domains of health (personal; public; medical; and the health market) have been competing for power over health. Medical health currently seems dominant. At the same time, ‘health’ has escaped from what was historically a contained arena owned by well-defined proprietors. The discourse now has expanded into many other spheres in the last decades. Health is now socially pervasive and penetrates virtually all spheres of public, private and corporate life at any local level. This compelling starting point leads to dramatic new insights. While most of us are still considering our options as a result of the reinvigorated debate around social determinants of health, Kickbusch leads her co-authors beyond these ‘classical'—as she calls them—determinants into a domain where globalization, networked governance and partnerships may work for and against human health. Indeed, the book challenges us all to radically rethink the approaches, structures and geo-political options that are required to deal with health in a changed and ever-changing world. The very practical case that is given is that of obesity as the emblematic disease of the twenty-first century, compared to cholera as the symbol of the nineteenth. With the wisdom of hindsight Thomas McKeown could—applying Sherlock Holmes’ maxim When we have eliminated the impossible, whatever remains, however improbable, must be the truth—start to argue legitimately that it was not medical intervention but social change that brought down the scourge of the urbanizing industrial revolution (McKeown and Record, 1962). Similarly, what new plane of social change, what policy innovation for health and what, quite possibly paradigmatic, shift will make that obesity will not, for the first time in human history, result in decreasing life expectancies at birth (Olshansky et al., 2005)? A dramatic rethink is required. Continuing on the traditional epidemiological path, reductionist behavioural intervention as the pivot of action is not ‘outside the box’ enough. Krieger has already challenged the simplistic, in Kickbusch's terms ‘classical’ view of what causes health (Krieger, 2008). Material like Krieger's, which only a few years ago only might have been published in unconventional yet excessively funny journals such as The Annals of Improbable Research, Null Hypothesis: the Journal of Unlikely Science, the Journal of Irreproducible Results or Rejecta Mathematica, needs to enter mainstream international peer-review journals such as Health Promotion International. Kickbusch's book is both rhetorically and conceptually strong and interesting, and an excellent foundation for a profound conversation on the changing landscape for constructing Healthy Public Policy or Health in All Policy. However, it is weak on theory, and perhaps fun. Only Warner and Gould (Warner and Gould, 2008) devote a substantial discussion to theoretically grounded propositions around network governance for local health policy. Their argument hinges on the theoretical notions that local policy network configurations are indicative of the substance of health policy strategies and thus outcomes. If this is the case, changing network configurations would lead to changing policy substance and ambition, and outcomes. This issue of the journal further contributes to this debate, both in theoretical as well as in conceptual terms. Authors such as Harting et al., Larsen and Stock, Whitehead and Strazdins et al. have identified issues and elements in the health promotion body of knowledge that have been strangely absent from our considerations; for instance, why does virtually not one single policy or planning framework used in our field explicitly conceptualize time as a critical variable? Strazdins et al. provide a review and some first empirical insights. Harting et al. describe an attempt to manipulate local network governance and policy development. In this disciplinary field, Breton and de Leeuw, Bernier and Clavier and Alvaro et al. all discover how health promotion has still so much to learn from the theoretical advances in social science. For example, Breton and de Leeuw show an unexpected dearth of political science applications in our field, and Bernier and Clavier, and Alvaro et al. argue for theoretical and theoretically grounded empirical ways forward. Similar arguments are being made on social marketing and philosophical analysis by Mogford et al., Kemp et al. and Whitehead. We need to innovate for health, and policy innovation would be an important driver. Innovation, however, can be systematically advanced by conscious theoretical interdisciplinary cross-fertilization (and, of course, through the arguments and challenges that extraordinary minds present us with!). This issue of the journal provides ample examples from disciplines within and beyond the health sciences that this innovation is already well under way. We smiled, occasionally. We hope you will, too.