Sandra Carlisle

Do we face a third revolution in human history? If so, how will public health respond?

Background A range of evidence suggests that the dominant culture associated with the economic systems of ‘modern’ societies has become a major source of pressure on global resources and may precipitate a third revolution in human history, with major implications for health and well-being. Objective This paper aims to consider whether there are historical analogies with contemporary circumstances which might help us make connections between past and present predicaments in the human condition; to highlight the underpinnings of such predicaments in the politico-economic and cultural systems found in ‘modern’ societies; to outline questions prompted by this analysis, and stimulate greater debate around the issues raised. Methods We draw on evidence and arguments condensed from complex research and theorizing from multiple disciplines. Results Contemporary evidence suggests that global depletion of a key energy resource (oil), increasing environmental degradation and imminent climate change can be linked to human socio-economic and cultural systems which are now out of balance with their environment. Those systems are associated with Western-type societies, where political philosophies of neo-liberalism, together with cultural values of individualism, materialism and consumerism, support an increasingly globalized capitalist economic system. Evidence points to a decline of psychological and social well-being in such societies. Conclusion We need to work out how to prevent/ameliorate the harms likely to flow from climate change and rising oil costs. Public health professionals face the challenge of preventing adverse health consequences likely to result from continued adherence to the have-it-all mindset prevailing in contemporary Western societies. Equally, we need to seek out the potential health dividends that could be realized in terms of reduced obesity, improved well-being and greater social equity, while not under-estimating the likelihood of profound resistance, from many sectors of society, to unwanted but inevitable change.

The complex territory of well‐being: contestable evidence, contentious theories and speculative conclusions

This paper brings together evidence and theories from a number of disciplines and thinkers that highlight multiple, sometimes incommensurable understandings about well‐being. We identify three broad strands or themes within the literature(s) that frame both the nature of the problem and its potential solutions in different ways. The first strand can be categorised as the ‘hard’ science of wellbeing and its stagnation or decline in modern western society. In a second strand, social and political theory suggests that conceptualisations of well‐being are shaped by aspects of western culture, often in line with the demands of a capitalist economic system. A third theme pursues the critique of consumer cultures influence on well‐being but in the context of broader human problems. This approach draws on ecology, ethics, philosophy and much else to suggest that we urgently need to reconsider what it means to be human, if we are to survive and thrive. Although no uncontroversial solutions are found within any of these themes, all play a necessary part in contributing to knowledge of this complex territory, where assumptions about the nature of the human condition come into question.

Tackling health inequalities and social exclusion through partnership and community engagement? A reality check for policy and practice aspirations from a Social Inclusion Partnership in Scotland.

In the contemporary UK policy context, multisectoral partnership initiatives and community participation are increasingly viewed as appropriate mechanisms for tackling health and social disadvantage. Such initiatives are often put into practice in contexts of industrial and economic decline, fragmented neighbourhoods, hard-pressed public services, and sustained under-investment in voluntary and community sector organisations. This paper draws on ethnographic fieldwork in a Social Inclusion Partnership (SIP) in Scotland to suggest that policy-makers and public health practitioners need a better understanding of the difficulties involved in implementing partnership and participation initiatives in this kind of context. The East Kirkland SIP was set up to tackle social exclusion and health inequalities within the most deprived neighbourhoods of a Scottish town, yet community engagement remained elusive. Partnership proved to be risky territory for all involved, marked by rivalry and suspicion between SIP members, rather than co-operation, whilst health promotion and social inclusion priorities conflicted with those of community development and regeneration. In sum, this paper presents a reality check for some contemporary policy and practice aspirations.

‘Well-being’ as a focus for public health? A critique and defence

The concept of well-being has long attracted attention from multiple academic disciplines and interest has now spilled over into public and political domains in the UK. Yet a number of critical arguments might be made in relation to its utility for public health. For example, subjective well-being is broad and ill-defined, and is associated with contestable, morally laden ideas about happiness and ‘the good life’. Well-being has highly individualistic connotations and buys uncritically into the consumer culture of Western economies. The focus on well-being reinforces personal responsibility whilst intensifying the penetration of the individuals lifeworld by a range of experts or therapies. As a concern of the worried well of wealthy nations, well-being could exacerbate existing inequalities. Well-being may thus present a distraction from efforts to address enduring structural inequalities in health. Nevertheless, arguments can be made in its defence, not least the burgeoning science on the topic, and the suggestion that well-being may be an appropriate measure of what people value in life, and therefore relevant to public health. In this paper, we present a synthesis of favourable and critical perspectives on the topic. This provides the foundation for a critique of the diagnoses and prescriptions found in both positions. More broadly, we highlight doubts about the sustainability of the current, modernist paradigm which has failed to substantially reduce health or other inequalities yet to which contemporary public health efforts apparently remain tied. We suggest that a re-think in public health policy and practice may be required.

Status, taste and distinction in consumer culture: acknowledging the symbolic dimensions of inequality

The relationship between social position and health has been the focus of extensive public health debate. In the UK and elsewhere, most researchers have focused on physical aspects of health, using indicators such as mortality and morbidity to draw a picture of profound and widening social inequalities. This paper draws attention to the (neglected) influence of contemporary culture on wellbeing, arguing that the social meanings created within consumer culture possess symbolic force that can add to wider inequalities. The possession of greater material and cultural resources by people of higher social status enables them to label their preferred forms of consumption and lifestyle as desirable and legitimate, thus conveying messages about superior taste and social distinction. Symbolic rather than material forms of inequality are implicated here, with consequences for the psychological wellbeing of disadvantaged people. This paper argues that analyses of inequality need broadening to include such considerations. However, there are implications for efforts to address health inequalities because this analysis suggests that if some forms of social inequality are removed, elements within society would be motivated to invent new forms to replace them. Therefore, this article suggests processes whereby people can develop the self-awareness needed to resist the glossy illusions of the good life represented by modern consumer capitalism.

A perspective on the future public health: an integrative and ecological framework

Modernity has brought health and social benefits to many societies, not least through the insights of science and technology. Yet, modernity has also been associated with a number of cultural characteristics, such as materialism, individualism, consumerism and an addiction to continuing economic growth, that seem potentially harmful to health and well-being and inimical to social equity. There is an emerging body of evidence that suggests that, in the affluent world, some of our most intractable contemporary health problems are, in fact, the product of modernity. This suggests that the tools of modernity (its science and its technology) are ill suited to finding solutions. This poses a problem for public health, as this discipline is itself a product of modernity and thus appears ill equipped to deal with the conditions and challenges of a rapidly changing and unstable world, one where the very sustainability of human society is now in question. This paper argues that a new paradigm for the future public health is needed. It presents an integrative, ecological framework as a starting point from which public health might grasp the opportunities for change inherent in the ‘modern’ threats we face. It suggests a number of features that will need to underpin such a paradigm shift in thinking and practice. However, as this paper is written from the perspective of an affluent, developed society (albeit from a perspective that is explicitly critical of the goals, trends and values that seem to characterise such societies), other voices from other places need to be heard. We hope that others will want to engage with our arguments and suggestions, whether to challenge and refute these, or to further their development.

Enabling well-being in a time of radical change: Integrative public health for the 21st century.

We live in a rapidly changing world; one where existing models for and approaches to health appear to deliver diminishing returns, whilst new public health challenges emerge. This paper outlines an integrative approach to such challenges. Integral theory suggests that key dimensions of human experience, frequently presented in opposition to each other (e.g. subjective-objective; individual-collective), need to be understood as integral to the whole. This is relevant to the public health community because powerful forces within neglected dimensions can undermine or destroy our efforts in other dimensions. This is illustrated in this paper by focusing on the issue of well-being, which illustrates the interconnected ways in which people in affluent societies can suffer from particular problems arising in such society and contribute to broader, global problems. The integral framework is used to show how a more integrative approach to such challenges can transcend some neglected blind-spots within public health. It is argued that public health leaders and practitioners need to apply integrative forms of thinking to their own practice in order to respond more effectively to the complexity of contemporary public health problems.

Re-orienting public health: rhetoric, challenges and possibilities for sustainability

We make a case in this article for re-orienting public health, based on evidence that societies across the globe are now facing inevitable change for which public health remains insufficiently prepared. We focus on the relationship between different sustainability ideals, displayed through rhetoric and discourse and the reality of a number of challenges in the ‘modern’ world. We briefly describe discernible elements of public and policy rhetoric around sustainability, as an important background for public health efforts, and present two significant public health discourses. We then outline some of the challenges to sustainability; some relate to the powerful social systems and cultural values associated with modernity, while others refer to broader environmental issues. These are not unconnected. We conclude by outlining the possibilities for sustainability, which include a transition to a more sustainable form of society that could lessen global inequalities, combat emerging problems, such as obesity, depression and addictive behaviours, and improve individual and social levels of well-being. We believe that this may well require a change of consciousness for a change of age, so the scope and scale of the required response should not be underestimated.

Investing in lay researchers for community-based health action research: implications for research, policy and practice.

Calls for greater community participation health-related research are increasingly made and, it seems, heeded–albeit to varying degrees. We report here, from the perspective of external evaluators, on practical efforts by the leaders of two community-based health action research projects to enhance such participation still further by employing a small number of local people as lay action researchers within their own community. ‘Action research’ in this context was conceived as an approach by which comparatively small projects, based on partnerships between academics, communities and public sector organisations, could address local issues of health and well-being. The purpose of the paper is to examine project leaders’ initial assumptions and expectations of the lay action research role and to compare these with the actual experience of those researchers. On this basis we consider the value to organisations and communities of the lay action research role for community health development and point out some of the unanticipated risks such individuals may face. We conclude by highlighting implications for future policy and practice in this area.

Is ‘modern culture’ bad for our health and well-being?

Evidence is accumulating that well-being in high-income societies may be static or in decline. One influential theory argues that this is because ‘modern’ societies are influenced by values of materialism, individualism and consumerism. Does this intellectual critique resonate with ordinary people? This article reports on interviews with purposefully selected groups in Scotland, where the relevance of the cultural critique was explored. Participants in the study believed that cultural values such as individualized consumerism do exert a damaging influence on well-being. They suggested that such values are given particular power in the context of widespread social change and increasing inequalities. Nevertheless, they also believed that individuals and communities possess the capacity to resist such trends. This article concludes that efforts to achieve material improvement for disadvantaged people may not suffice in redressing deep-seated inequalities, if the contribution of some subtle but pernicious effects of contemporary culture remains neglected. However, the research does suggest that positive responses are also possible. (Global Health Promotion, 2009; 16(4): pp. 27—34)