Perspectives of Health Promotion – A Personal View

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While strolling through a book exhibition at Khon Kaen University recently, the title ‘The new world of
health promotion’ drew my attention and I decided to get me the volume. A note on the cover strongly forbid to
sell the book in the USA even it was obviously written for students of public health there and the authors had
been from North America as well. Probably one has to pay more for the book over there in the states. By
seeping through the pages of my newly purchased ‘treasure’, I started to wonder whether it would have been
wise to recommend the text to someone dealing with public health in my ‘country of origin’, which is Germany,
since as major determinants of health, ‘individual behaviors’ and ‘environmental factors’ were highlighted by
the authors. Not that I wouldn’t fully agree to that statement, but while still in office as Professor of Social
Medicine in Central Europe some time ago, I strongly was ad odds with a number of my colleagues because of
fundamental differences between them and me as far as the underlying reasons for morbidity and mortality in
the field of chronic diseases had been concerned. So what is the perception of those, dealing with medical
sociology in a number of Western European countries towards the reason for most of the chronic diseases?
To answer this question I might refer to another statement of my newly purchased book about ‘health
promotion’, mentioning as leading causes of mortality tobacco, physical inactivity and diet. One may add
excessive alcohol consumption to this list as well. The problem is that mainly unhealthy behavior of the
individual is to blame for the highly prevalent chronic diseases such as heart diseases, diabetes mellitus, high
blood pressure, cancer and stroke. Accepting the risk factor model to explain the occurrence of chronic
diseases and to base health promotion on it would require to eat only ‘half of what one wants to eat’, avoid
sweets, exercise instead of watching television, and give up smoking and drinking too much alcohol.
The ultimate consequence of this line of thinking might be that those who are suffering from chronic
diseases are responsible for their illness because of ill behavior and why then the society should cover the
expenses for treatment and care? This aspect is especially important for a society in which more then 95% of
the population is covered by social health insurance and social security. The system requires tremendous
spending of money which also a rich country seems now no longer able to afford. The most radical
consequence to solve the problem would be to give up social health insurance and social security, which of
course is not feasible politically and could destabilize the country.
To avoid even to think along that line of argumentation, means to give up social security, the
advocates of social security in western European countries favor to take the individual out of her or his
responsibility for health and blame the society for unhealthy behavior, pointing towards ‘stress’ as the ultimate
reason for smoking, excessive energy intake, and alcohol consumption. The argumentation is that since the
society is exposing the individual to ‘stress’, thus causing the individual to adopt unhealthy behavior to release
the stress. Since the society is to blame for unhealthy behavior by causing stress consequently should also
shoulder the expenses for treatment and care.
An additional line of argumentation is to blame genetic factors for the occurrence of chronic diseases,
which might explain why ‘academic excellence’ is linked to highly sophisticated and expensive laboratory
investigations. It is almost unnecessary to mention that health promotion in Germany hardly focus on changing
unhealthy behavior.