Ottawa to Bangkok — Health promotion's journey from principles to ‘glocal’ implementation

In 1986, a group of delegates from some 50 countries gathered in Ottawa at the invitation of the World Health Organization, Health Canada and the Canadian Public Health Association to develop and affirm a series of principles and actions framing the value systems and practice of health promotion. The organizers had captured the spirit of the times or ‘Zeitgeist’ with great astuteness and foresight: the Ottawa Charter built effectively on a broad range of insights from governments, academia and communities, identifying key areas of concern and further investment for health. The Ottawa Charter thus became a visionary statement profoundly connected to a chain of events such as the world's reorientation towards Primary Health Care, the WHO strategy for Health for All, and people's movements in areas such as women's health, environmental consciousness and human rights. To many, the Ottawa Charter for Health Promotion became the gospel and foundation stone of a new public health movement (which was, indeed, the subtitle of the statement itself). Further global health promotion conferences in Adelaide, Sundsvall, Jakarta and Mexico City refined the principles and action areas laid out in the original Charter. Its various Statements and Declarations became a powerful force and inspiration for investing in health promotion beyond an individual, disease-oriented, behaviour-change model. Rather it focused attention on work at different levels of society (from the individual, through family and community to national strategies), and in a variety of settings (workplaces, markets, neighbourhoods and cities, schools, etc.). In addition, it more intelligently honed an analytical approach to behavioural, social and environmental determinants of health. In a mere two decades, though, the world has changed fundamentally. In 1986, a nascent internet just started to emerge from the US Defense Advanced Research Projects Agency. Very early adopters could send electronic mail around the globe using systems called bitnet or jnet. Only in 1989, a first world standard for mobile telephony (GSM) was established. This was also the year when the global balance of power between two ideological blocks started to crumble. A machine for gene sequencing only became available in 1995, around the same time that first massive protests against globalization hit the streets. Back in 1986, the United Nations Conference on Environment and Development in Rio de Janeiro (also known as the Earth Summit) was still six years away. Since 1986, urbanization and environmental change have become a legitimate concern of the public health community. Disasters, emergency management and the consequences of various forms of terrorism entered the health promotion remit. World trade and particularly its impact on health have also been put under the blowtorch and is high on the health promotion agenda. Health as a global public good has also increasingly become a focus of the international health promotion community. In less than a generation, both the shape and our understanding of the determinants of the health landscape have changed dramatically. Most current students of health promotion have never lived in a world without internet that allows for high-speed communications on virtually every aspect of human life and its qualities, including health. At the same time, we have become aware of the nexus between poverty, debt and health in a world where health issues transcend the traditional governance systems of nation states. An Ottawa Charter adept, in 1986, may have been struggling to reconcile individual health behaviour change with the need to develop healthy public policy. In 2006, the struggle is now about connecting global phenomena with everyday life. The Ottawa Charter shifted principles for health promotion from individual foci to determinants of health. Although the more proximal determinants of health (those directly impacting on individual and community health) have hardly changed, the patterns of distal determinants of health (those factors that set the parameters for proximal determinants), as outlined above, have. For example, the connection between education and health has never been stronger. But the context in which education is shaped, though, is increasingly determined by multinational publishing corporations, globally operating internet providers, the need to be internationally competitive in tertiary education and international aid requirements. The impact on local health of these global changes is demonstrable: brain drains lead to diminished local capacity for health; ‘one size fits all’ teaching texts ignore unique and valuable local cultural and value systems for health; and globalized communication channels project an unwarranted desirability of ‘western’ lifestyles. To manage the challenges and opportunities of globalization at global, national and local levels, collaboration and engagement of all sectors are required to ensure that the benefits for health from globalization are maximized and equitable, and the negative effects are minimized and mitigated. This has been the remit of the development and acceptance of the Bangkok Charter. Building on the Ottawa Charter, the Bangkok Charter for Health Promotion adds value to health promotion practice worldwide. Four new commitments were identified: 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 practices. The participants of the Sixth Global Conference on Health Promotion also reviewed the original five action areas, and found that building capacity to promote health goes beyond community and skills development, into the generation and sustenance of health promotion capacity in both global and local (‘glocal’) policy, public/community/corporate partnerships and alliances, finance and information systems and trade considerations. The Conference was structured around four thematic tracks: the new context, health-friendly globalization, partners, and sustainability. Each track was introduced through plenary presentations, upon which a series of technical papers was discussed in parallel workshops. In this Special Issue, 10 of these technical papers are published and they can be grouped under three broad categories: challenges in the new context, globalization for health and capacity building for health promotion. In three papers, current and emerging health issues to which health promotion can make considerable contribution are highlighted. McMichael and Butler look at emerging and re-emerging infectious diseases, declining regional life expectancy, global environmental changes and the impact of globalization of trade on health. Östlin and colleagues examine the links between gender differences and causes, consequences and management of diseases and ill health. Sturgeon argues for greater attention for mental health in the field. The articles not only describe what the issues are but also discuss what action can be taken. To harness globalization for health, Lee reviews the initiatives on breast milk substitutes, healthy cities, tobacco control and diet and nutrition. She argues that existing institutions are often unprepared in their capacity to tackle global health issues. She recommends ways for strengthening governance and building effective strategies for global health promotion in terms of the process of enabling people to increase control over, and to improve, their health within an increasingly global context. Fidler explores and substantiates the explicit link between health promotion and foreign policy set out in the Bangkok Charter. This link has been strengthened by the recent UN reform proposals to elevate public health as a foreign policy priority to support the four governance tasks served by foreign policy: security, economic well-being, development and human dignity. The emergence of health as a domain for foreign policy presents opportunities and risks for health promotion that can be managed by emphasizing that public health is a public good that benefits all those governance tasks. Trade liberalization is now at the forefront of debates about globalization. Health services and the diet and nutrition transition in the context of trade liberalization are examined, respectively, by Arunanondchai, and Fink and Rayner and colleagues. Implications for policy development and practice are discussed and recommendations to public health and health promotion practitioners are made. The final three papers lead the way towards making the thrust of the Bangkok Charter a reality. All of these review contemporary health promotion capacity and reframe the resulting evidence in terms of changing global contexts. Jackson et al. looks at the evidence base for the integrated health promotion strategies that the Ottawa Charter has called for. This evidence base, according to the authors, now needs to be transposed to meet more effectively the health promotion challenges in a globalizing world. Eight key lessons from their review are connected to a global context. Raeburn and colleagues look at a critical element of integrated health promotion: community capacity. They provide a truly global review of the literature and case studies and demonstrate that the evidence of effectiveness of community capacity building (CCB) is beyond doubt, and that CCB may well be the only sane way ahead towards a sustainable, equitable and just world. Mittelmark and colleagues, finally, address a range of approaches to mapping national capacity for health promotion. These include reviews of the physical and social infrastructure of countries, their policy-making traditions, institutional designs, training options, and workforce and professionalization issues. Although the different maps that have been produced in different regions and countries seem to yield different types of information, Mittelmark et al. argue that globalization will be able to lend a crucial helping hand to an important endeavour: global networks of health promoters, fast global communications technologies, and advances in software and data management. For the first time in history, these would provide an opportunity to produce maps for health promotion capacity and its development, which are globally valid and comprehensive, yet locally relevant and responsive. The Bangkok Charter provides leadership and directions for the health promotion community worldwide. The focus now is on its implementation. To implement the Bangkok Charter effectively, the participants at the Sixth Global Conference also urged WHO and its Member States, in collaboration with others, to initiate plans of action, monitor performance through appropriate indicators and targets and to report on progress at regular intervals. In response, WHO intends to work with key stakeholders through a global partnership to provide health promotion practitioners at the country and local levels with know-how for implementation of the Charter. An important element in this is the development of a global framework for health promotion strategy to fulfil the commitments and execute the action strategies. The framework will include models and methods for practice among practitioners worldwide and a set of priorities for action, indicators and mechanisms to monitor progress. A key task for the future in implementing the Charter is to build institutional capacity. Not only do health promotion practitioners need to be equipped with the knowledge and skills to tackle the social and economic causes of poor health, the organizations that they work for must also be able to provide a conducive environment. Most importantly practitioners need to be supported with other dimensions of capacity such as information, financing, partnership and policies (Catford, 2006; Tang et al., 2006). The Bangkok Charter and the 10 articles in this volume show that the further development and implementation of health promotion in a global context requires sustainable, resilient and persistent action at all levels—local, regional, national and international. Perhaps, most excitingly, the authors demonstrate that this is not a rhetorical call for action but a journey of ‘glocal’ development that is both feasible and necessary. K. C. Tang is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization. R. Beaglehole is a staff member of the World Health Organization. The author alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

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