Global health promotion in the era of ‘galloping populism’

The European Union Commission President, Jean-Claude Juncker, warned of the perils of ‘galloping populism’ in his State of the Union speech in September 2016 (http://www.cnbc.com/2016/09/14/europe-faces-galloping-populism-juncker-warns-in-state-of-the-union-address.html). Juncker was referring not only to the shift to the right and towards nationalism exemplified by Brexit and the election of Trump as President of the United States. He was also concerned with the appeal of reactionary populism closer to home in various parts of Europe, most notably in Hungary, Italy, France and Austria. However, populism is not only on the rise in Europe and the United States. It is alive and well throughout Latin America where both left and right wing populism have prevailed for decades. The Chinese, Russian, Turkish, Egyptian, Indian and Syrian regimes, among many others, have shown recent signs of escalated response to nationalist and populist sentiments no matter the costs to international reputations. North Korea continues on its separatist nationalistic path, populism and nationalism are thriving in the Philippines under President Rodrigo Duterte and the Australian and New Zealand governments are proposing and enacting reactionary legislative changes in response to rising xenophobia. The antipodean version of right wing populism is most poignantly exemplified in the April 2017 simultaneous New Zealand and Australian government crackdowns on skilled work visas in the ‘Kiwi first’ and ‘Australia first’ initiatives which mirror the ‘United States first’ restrictions to H1B non-immigrant visas, designed to maximize job opportunities for Americans. In Australia, this trend to respond to popular reactionary sentiment was also reflected in attempts by the federal government to water down Part 18C of the Anti-Discrimination Act. This proposal, which would have decriminalized many acts of discrimination, was ultimately defeated in the Senate. Roth (2017) from Human Rights Watch agrees with many analysts (https://ecpr.eu/Events/PanelDetails.aspx?PanelID=4237&EventID=102) that the key reason behind the current unprecedented wave of populism, across the world, is unchecked economic globalization. He argues that the political fall-out from the uncertainty and inequality produced from unbridled globalization has been ‘mounting public discontent over the status quo’ and a growing ‘sense that governments and the elite ignore public concerns’. The nuanced arguments presented for this popular discontent and disillusionment in the Western context are that ‘many people feel left behind by technological change, the global economy, and growing inequality’. In addition, Roth argues, ‘horrific incidents of terrorism generate apprehension and fear’ which ultimately lead to suspicion of societies, and public organizations, that encourage ethnic, religious and racial diversity (https://www.hrw.org/world-report/2017/country-chapters/dangerous-rise-of-populism). Key explanations for non-Western populism also address economic crisis, the negative effects of economic, social and cultural aspects of globalization and inability of weak governance systems to rein in widespread corruption. However, as with Western explanations for the lurch to the right, increasing inequality and loss of trust and confidence in politicians and the public sector are at the heart of the discontent leading to the appeal of populist leaders. The structural, social, political, economic and cultural consequences of this shift in popular thinking, for all sectors of society, both in countries regarded as a part of the cradle of modern democracy and in new world countries which have been critical to the rise of the civil rights movement and progressive thinking, is somewhat ambiguous. Moffitt (2017) points to the contradictory imperatives and outcomes of rising populism arguing that ‘whether on the left or the right, populism has both democratic and anti-democratic tendencies’ which ‘often manifest simultaneously, making populism quite difficult to assess’. This problem with gauging the effect of various dimensions of populism, on societies at different stages of economic and social development, is well exemplified in the health promotion movement. If we consider the impact of the rise of right wing populism and nationalism on adherence to universal principles of human rights, especially in countries at an early stage of implementing human rights legislation and initiatives, the implications for any rights based global movement, including health promotion, are vast. The key mantra for health promotion since 1986 has been ‘Think globally, act locally’ and nationalism and right wing populism tend to ignore both the local and the global in favour of national interests yet the provenance of the concept of populism is ‘people power’. This is the dilemma for health promotion. Populism literally refers to championing the concerns of ordinary people and if this is all that is implied in a populist movement its mission has great merit. However, right wing populism is reactive to the baser motivations of ordinary people including privileging laissez-faire approaches to all spheres of life, anti-intellectualism, xenophobia and ethnocentrism. The ‘common good’, religious tolerance, multiculturalism and a sense of shared humanity become casualties in the tyranny of exalted ordinariness. The privileging of the concept of ‘ordinariness’ and ‘common sense’ is certainly not part of the history of health promotion, despite the movement’s emphasis on inclusive consultation. The Ottawa Charter (1986) was far from an ‘ordinary’ response to the health challenges of the late twentieth century. As de Leeuw and Harris-Roxas (2016, p. 2) argue, the 1986 ‘meeting in Ottawa was the culmination of a deliberate effort that had taken considerable time and strategy’ to develop. The recommendations of the Ottawa Charter required an imaginative collective conceptual leap out of the culture of medicine based on top down, downstream, individual, disease focussed, exclusive, curative, allopathic and heroic approaches to health, which privileged germ theory and pharmaceutical intervention. In contrast, the health intervention proposed by the Ottawa Charter was bottom up, upstream, public, society focussed, inclusive, inter-sectoral, empowering for the population, contextual, preventive and addressed social determinants of health. Thirty years on, with the benefit of hindsight, it could be argued that some of the wording of the action areas of the Ottawa Charter could have been more clearly spelled out and more strongly advocated. de Leeuw and Harris-Roxas (2016:1) suggest that ‘two of its action areas. (have) failed to show real evidence of success’, namely ‘the call to build healthy public policy and the need to reorient health services for health promotion’ (de Leeuw and Harris-Roxas, 2016, p. 1). One solution offered to put the Ottawa Charter back on track, and into practice, is to encourage the ‘global health promotion community to embrace a health political science’ (de Leeuw and Harris-Roxas, 2016, p. 1). However, the question remains, how would this global cooperation be possible in an era of populism and nationalistic focus in all fields of endeavour where public bodies and intellectual debate are viewed with suspicion and contempt? The concept of global human rights is under threat, especially in attitudes towards migrants and refugees across the globe, and the neoliberal approaches to all social issues provide little room for ‘higher causes’ and vision. The lack of trust and confidence in the public arena flows over into rejection of public health bodies, public health services and academics researching in public universities, as exemplified in climate change denial and the anti-immunization movements. Even the Sustainable Development Goals (SDGs), which represent the most recent global attempt to monitor world progress across 17 goals, are unable to follow through on a visionary health promotion approach to health and to building healthy public policy. This is exemplified in the traditional epidemiological indicators used to measure progress in health and well-being for SDG3 by 2030 (Eckermann, 2016). No attempt is made to incorporate the research and mindset change developed in the early years of the twenty-first century by the OECD, the quality of life movement and the Stiglitz–Sen–Fitoussi Commission (2014) (and as initially championed by the World Health Organization in 1947), on the meaning of well-being as distinct from the absence of disease. On the 30th anniversary of the Ottawa Charter, the Shanghai Declaration on Health Promotion and the Shanghai Consensus on Healthy Cities were negotiated at the 9th Global Conference on Health Promotion in Shanghai in November 2016. This global forum was designed to dovetail into the SDGs and examine the health promotion dimensions of the 17 SDGs. Although the wording of the two documents reflects emerging twenty-first century challenges for health promotion, the spirit of the Ottawa Charter with its emphasis on global human rights is retained. However, there is limited evidence of attempts to address the unfulfilled agendas from the Ottawa Charter, especially since health is portrayed in the Transforming our World document (United Nations 2015) in traditional epidemiological terms. This is the challenge for the global health promotion community. The germ of commitment to health rights, and a motivation to reorient health services to health promotion and public policy, remains on the health promotion agenda as evidenced by the debates of the Shanghai Conference. However, a return to the activist role this community played at the end of the twentieth century appears essential if health promotion is to progress in an environment of popular cynicism and mistrust of public initiatives. As de Leeuw and Harris-Roxas (2016, p. 4) recommend, getting health promotion back on track will require ‘courage and leadership’ in addition to ‘scholarship and activism’. Subsequent issues of the journal will provide overviews of the Shanghai Declaration of Health Promotion and the Shanghai Consensus on Healthy Cities. The Consensus document emphasizes the need to incorporate ‘communities’ views, voices and needs’ and one of its governance principles is to ‘promote strong community engagement’ and this is the positive side of populism referred to above but at the same time the importance of equity and fairness, ‘especially for women, children and other potentially vulnerable populations’ is stressed and this cannot be achieved under a laissez-faire approach. One of the five Healthy Cities governance principles refers to ‘Reorient (ing) health and social services towards equity’. Such a task requires strong leadership which at times involves unequal allocation of resources and services to redress imbalances rather than the blanket one size fits all approach proposed by many twenty-first century populists. Mayors, from 100 countries, at the Shanghai Global Health Conference in 2016, saw working towards Universal Health coverage, which at times may involve unpopular skewing of resource allocation, as part their leadership roles in adhering to the five principles for ‘good governance for health’ in line with the Sustainable Development Goals. Another of the five principles emphasizes the need to ‘integrate health as a core consideration in all policies’ which requires strong leadership and coordination rather than relying on the invisible hand of market forces. Similarly, ‘address(ing) all social, economic and environmental determinants of health’, and ‘assess(ing) and monitor(ing) wellbeing, disease burden and health determinants’ demands more than knee jerk reactions by atomized individuals to perceptions of centralized public policy agencies. The theme of equity and fairness in health outcomes and access to health services is alive and well in the global health promotion research community as evidenced by many of the papers in this issue. Salmi evaluates the effectiveness of interventions dealing with health inequalities in Europe, which is timely given huge political and economic change in many parts of Europe which may further exacerbate inequity, especially for migrants and refugees. Mohindra engages with the research on health inequities between Indigenous and non-Indigenous communities in low and middle income countries and McIver proposes a comprehensive healthy islands framework to deal with global health inequities resulting from inevitable climate change in vulnerable islands in the Pacific. In terms of equitable access to health services, Morrison addresses equity and access issues for disabled women attending community women’s groups in rural Nepal and Liu asks why informally employed Chinese women avoid visiting medical practitioners. Health literacy as a resource empowering communities to reduce health knowledge inequities is addressed by Schrauben in a health literacy assessment program in Zambia and by Aponte in her research using electronic health literacy among older Hispanics with diabetes. Empowerment is also the underlying principle of Brandsetter’s study of healthy nutrition initiatives in several German communities and Clarke’s study on headteacher perspectives on obesity prevention in English primary schools. Cauchi focuses on the health outcomes of television food advertising for children in Malta and the theme of media influence is repeated in Albalawi’s analysis on the influence of Twitter on health promotion in Saudi Arabia. Opportunities to enhance the health promotion potential within hospital setting are identified by Rothlin and barriers to promoting cardiovascular health in community pharmacy settings are reviewed by Alonso-Perales. Commercial gay businesses in Japan are identified by Sherriff as a plausible setting for applying international HIV prevention approaches and Knibbe proposes poor Dutch neighbourhoods as settings to engage cultural resources to promote mental health. Mihic assesses the quality of mental health promotion and prevention initiatives in Istria in Croatia, Torres proposes innovative approaches to developing tools and processes that favour new practices in professional development programs for health promotion and Encarnacao examines faith as a resource from a nursing perspective. Health Promotion International remains a fertile avenue for keeping alive the debates about equity in health access and outcomes and their relationship to economic, social and cultural capital, especially in the current volatile geopolitical, and economic global environment. The journal provides a space for imaginative approaches to health promotion research, tools and practice, and creative approaches to old problems such as mental health, obesity and cardiovascular health. It also acts as a forum for new, emerging and escalating global issues such as the health effects of climate change, populism, mass migration and racial and religious marginalization.