Health Promotion in South Africa: An Overview

Historically in SA, as elsewhere in the world there was a conceptual gap in understanding the science and practice of health education and health promotion. Both health education and health promotion were often seen as the same thing, and later on, health education was seen as a contradictory approach whose focus on individual behaviour change placed the responsibility on individuals to make choices that would maintain or improve their health status.

Due to the unfortunate political history of SA, the disease profile now reveals a high rate of infectious diseases ,e.g. diarrhoea, tuberculosis, and HIV/AIDs/ other sexually transmitted diseases and social pathology, e.g. rape, murder, suicide, interpersonal injury and road traffic accidents. Additionally the rate of chronic diseases such as cardiovascular disease, hypertension and diabetes is also on the increase. This social and health profile forced a review of the definition of health promotion in SA.

It therefore became evident that if health promotion was to make a difference to peoples lives, it had to provide strategies that would impact on the political, economic, environmental, social and cultural aspects of all South Africans. Furthermore for these strategies to be implementable, they had to be imbued by a philosophy that supported inter-sectoral collaboration both in terms of sharing resources as well implementation.

The following is an example of a health promotion matrix that enables operationalization of the concept in SA. The Health Promotion programme are planned systematically and are underpinned by research. These programmes also aim to ensure community participation and programme evaluation. The example cited here is tobacco control. However, this model has been used for STD/HIV prevention etc.

The Model of Tobacco Control

This example of Tobacco control is ideal for illustrating the multi-faceted approach required for effective Health Promotion in South Africa. In order to have significant public health impact on Tobacco in South Africa simply providing the public with information on the adverse effects of tobacco use with legislative changes like banning smoking in public places does little to re-inforce the initial intervention. Furthermore, in all Health Promotion activities it is important to recognize the varying levels of behaviour among societies. Programmes need to be streamlined or tailored to meet these needs. The impact of prevention programmes for tobacco use will be limited if it is not augmented by concurrent programmes for current smokers. This matrix serves to highlight the need for an inter-sectoral approach and multiple level of intervention for Health Promotion.

Unravelling Health Promotion: A framework for Action: Tobacco Control
Reddy, SP and Swart D, MRC 1998

Foreign Smokes

In the 10 years since the breakdown of the its communist regime, Romania has been a prime target for sales expansion by TTCs (Transnational Tobacco Companies) After 1989, foreign tobacco manufacturers promoted their products throughout the country, advertising various new cigarette brands. Additionally, Romanian TV channels began to air tobacco advertisements during broadcasts, while newspapers and magazines discovered that tobacco advertising provided an easy way to obtain a significant increase in their revenues.

Prior to 1990 it was very difficult in Romania to buy cigarettes produced by transnational tobacco companies (TTCs), and the typical Romanian smoker could choose only from among 5 or 6 relatively primitive, domestic brands. Today this situation is history. Numerous TTCs have since bought or built factories in Romania. TV programs cover each grand opening celebration and present them as great investments that help the Romanian economy. The Romanian cigarette market is now more than 90% foreign-owned.

The connection between sales of American cigarettes and US foreign policy became especially apparent in 1994, when the US Ambassador, Alfred Moses, addressed an audience at the grand opening of a new American cigarette factory near Bucharest saying in part: "I am sure that Camel and the other splendid products of the RJ Reynolds Tobacco Co. will prosper in Romania."

Packs of Viceroy, Winston, LM, Camel, Marlboro, Kent, and Gauloises sell at prices between 0.5 and 1.0 Euro, and approximately half of all adult Romanians smoke. Considering that 100-150 Euro is the medium monthly income in Romania, we see that at 1-2 packs/day this new ‘liberty’ costs more than 1/3 the total income of a smoker. Moreover, in the 10 years since arrival of TTC cigarette sales in Romania the incidence of smoking has increased dramatically among both children and the adults. A recent study shows that 49% of Romanian men smoke and 36% of women.

Current Challenges

Today the most important problems in Romania are:

• Decreasing of start smoking age
• High prevalence of smoking
• No coherent and global tobacco control legislation
• Aggressive presence of Transnational Tobacco Companies
• Low taxes for tobacco products
• Low prices of cigarettes
• High levels of cigarette smuggling
• Passivity of population in regard to tobacco related problems
• Duplicity of Health Ministry due to cooperation with Tobacco Companies

The Main Players in Romania

Only in the last two years have different active organizations tried to build coalitions in the field of tobacco control. On World No-Tobacco Day, 31 May 2000 the No-Tobacco Partnership was created under the umbrella of the Romanian Health Ministry. In 2000 the main players in Romanian tobacco control in are:

Government organizations:

• Health Ministry
• Institute of Health Services Management
• Public Health Institute

Non-Government organizations:

• Romanian Movement for Defending Nonsmokers Rights - AER PUR
• Health Messengers
• EMASH Romania

Pharmaceutical Companies:

• GlaxoWellcome Romania
• Pharmacia & UPJOHN Romania

Activism

Despite limited financial resources and the few people active in promoting tobacco control, in the last five years some important anti-smoking progress and activism has developed in Romania. AER PUR ROMANIA mounted a vigorous campaign for Romanian adoption of global tobacco control legislation, and organized a Non-smokers Rights Conference. Coalitions of anti-smoking activists have pushed for Quit and Win programs and smoke-free public spaces. Groups, such as EMASH and Health Messengers have been involved in efforts to promote smoke-free hospitals, courses for medical students on smoking cessation, campaigns to prevent childhood smoking, publications, and media outreach.

International Support

An important role in developing these activities has been played by a number of international organizations with representation in Romania, most especially, the World Health Organization, Health Promotion Foundation Poland - Tobacco Control Institute, Public Health Institute - Finland - Quit & Win Campaign, various NGOs, and numbers of tobacco Control Activists.

Cornel Radu-Loghin – GLOBALINK , at the 10 World Conference on Tobacco or Health Beijing 1997

Background

On 24 May 1999, the 191-member World Health Assembly (WHA), the governing body of the World Health Organization (WHO), unanimously backed a resolution calling for work to begin on the Framework Convention on Tobacco Control (FCTC) - a new legal instrument that could address issues as diverse as tobacco advertising and promotion, agricultural diversification, smuggling, taxes and subsidies. A record 50 nations took the floor to pledge financial and political support for the Convention. The list included the five permanent members of the United Nations Security Council, major tobacco growers and exporters, as well as several countries in the developing and developed world, which face the brunt of the tobacco industry's marketing and promotion pitch. The European Union and 5 NGOs also made statements in support of the Convention and the Director-General's leadership in global tobacco control. Subsequently, the Working Group on the WHO Framework Convention on Tobacco Control held its first meeting in Geneva, Switzerland, from 25 to 29 October 1999.

Defining the FCTC

The Framework Convention on Tobacco Control (FCTC) will be an international legal instrument that will circumscribe the global spread of tobacco and tobacco products. This is the first time that the WHO has activated Article 19 of its constitution, which allows the Organization to develop and adopt such a Convention. In fact, WHO argues that the FCTC negotiations and the adoption of the Convention should be seen as a process and a product in service of public health.

The FCTC will be developed by WHO's 191 Member States so that their concerns are adequately reflected throughout the process. The framework convention/protocol approach will allow Member States to proceed with the process of crafting this piece of international legislation in incremental stages, and WHO foresees the adoption of the Framework Convention and possible related protocols by the World Health Assembly no later than May 2003.

Aims of the Framework Convention

The FCTC and related protocols will improve transnational tobacco control and cooperation through the following avenues:

The guiding principles of the Convention may include both national and transnational measures making it clear that: tobacco is an important contributor to inequity in health in all societies. As a result of the addictive nature and health damage associated with tobacco use it must be considered as a harmful commodity. Thus, the public has a right to be fully informed about the health consequences of using tobacco products, and the health sector has a leading responsibility to combat the tobacco epidemic.

Under the Convention, State Parties would take appropriate measures to fulfill the general objectives jointly agreed to. In this respect, the FCTC could include the following general objectives: protecting children and adolescents from exposure to and use of tobacco products and their promotion; preventing and treating tobacco dependence; promoting smoke-free environments; promoting healthy tobacco-free economies, especially stopping smuggling; strengthening women's leadership role in tobacco control; enhancing the capacity of all Member States in tobacco control and improving knowledge and exchange of information at national and international levels; and protecting vulnerable communities, including indigenous peoples.

The protocols could include specific obligations to address inter alia: prices, smuggling, tax-free tobacco products, advertising/sponsorships, Internet advertising/trade, testing methods, package design/labeling, information sharing, and agricultural diversification.

Addressing Economic Concerns

WHO is seeking to address concerns that tobacco-dependent economies will experience loss of revenue related to implementation of the FCTC. WHO notes that the widely held perception that tobacco control will lead to loss of revenues is just that: a perception. In reality, the numbers are heavily in favor of moving away from tobacco cultivation. Recent World Bank analysis show that the social and health costs of tobacco far outweigh the direct economic benefits that may be possible because of tobacco cultivation.

Moreover, though the tobacco industry relies on the argument that there are no real crop or other substitution options, it is reasonable to assume that consumers who stop smoking will reallocate their tobacco expenditure to other goods and services in the economy. Therefore, falling employment in the tobacco industry will be offset by increases in employment in other industries, WHO argues. However, in the short-term, for countries which rely heavily on tobacco exports (i.e. the economy is a net exporter of tobacco), economic/ agricultural diversification will likely entail employment losses.

The FCTC will adopt a long-term view of agricultural diversification. The framework-protocol approach provides for an evolutionary approach to developing an international legal regime for tobacco control, and thus all issues will not need to be addressed at the same time. Further, the need for a multilateral fund to assist those countries which will bear the highest adjustment cost needs to be established. The FCTC will probably be the first instrument seeking global support for tobacco farmers.

A new report on the state of Finnish women’s health by Ansa Ojanlatva concentrates on four aspects: occupational health, maternal health, health education, and the health of elderly women. Special advocacy considerations are discussed, including gender-sensitive approaches and the effects of career advancement on women’s health.

In regard to this latter issue, Ojanlatva reports that roughly 70% of Finnish women work, mostly in full-time employment though often acting in substitute positions or holding short term contracts (20% women, 11% men). The report also notes studies showing that education and degrees have not contributed to equality in salaries for any professional group of women with women generally earning 80% of man's salary, and 75% or less for highly-educated women. An unexplained 8% bonus for male workers has been discovered in the banking business. Additionally, though about 40% of the doctoral degrees have been granted to women, they have been appointed to only 18% of the professorships.

Ojanlatva also notes that studies show that Finnish women's work is different from men's work and equate women's work with interpersonal relationships requiring communication skills. This sets a person up for potential preference, discrimination, and harassment. Women sense mental cruelty such as harassment and intimidation more easily than men do, and many have been objects of bullying.

According to this same study, life and lifestyle issues (smoking, alcohol use, long working days, rapid work) are more problematic for Finnish women today than 50 years ago, and it is suggested that today's woman is not healthier than a woman of the middle of the twentieth century because life style issues are compounded by family responsibilities. Public policies favor women's activities but the everyday life is still another matter.

South Africa To Adopt Strict Smoking Controls

The regulations establishing where South Africans will and will not be able to smoke are expected to be finalized this year according to the health department. The department intends to amend tobacco legislation with the aim of preventing harmful effects of tobacco products in South African population. The act is aimed at limiting tobacco advertising, protecting children from tobacco, protecting the rights and health of non-smokers, banning sports sponsorships by companies of tobacco products and regulating and reducing nicotine and tar content in tobacco products.

If the bill is passed in parliament, from 31 December, 2000, cigarettes sold in South Africa will not contain more than 1.5mg tar and 1.5-mg nicotine per stick, and from 31 December 2002, cigarettes will not contain more than 1.2-mg tar and 1.2-mg nicotine per stick. These aims will be achieved by creating smoke free public places. The legislation stipulates that public places should have smoking and non-smoking areas, and that not more than 25 percent of public places, including workplaces, restaurants, pubs, shebeens or bars, should be allocated for smoking. The act is aimed at ensuring clear terms of enforcement or fines for breaking any of the above legislation. Fines will be enforced on those who do not adhere, with fines of up to 35 US dollars prescribed for smoking in non-smoking area.

The department said a smoke-free environment will limit the number of tobacco related illnesses from which the population suffers and will thus relieve health centres of the responsibility of treating such disease and instead divert those resources to other areas of care. Submissions from the tobacco and hospitality industries, academic institutions, health lobby groups, and a large number of private citizens have been received and the bill will be tabled in April.

Curbing the Epidemic: The World Bank reports on the politics and economics of tobacco control

The World Bank and the World Health Organization have joined forces to produce a new report on the economics and politics of c control. The report argues that if current smoking patterns persist, about 500 million people alive today will eventually be killed by tobacco use, and points out that by 2030, tobacco is expected to be the single biggest cause of death worldwide, accounting for about 10 million deaths per year. By enabling efforts to identify and implement effective tobacco control policies, particularly in children, both the World Bank and WHO would be fulfilling their missions and helping to reduce the suffering and costs of the smoking epidemic.

The report describes tobacco as different from many other health challenges because cigarettes are demanded by consumers and form part of the social custom of many societies. Cigarettes are extensively traded and profitable commodities, whose production and consumption have an impact on the social and economic resources of developed and developing countries alike. The economic aspects of tobacco use are therefore critical to the debate on its control. However, until recently these aspects have received little global attention.

The "Curbing the Epidemic" report aims to help fill that gap. It covers key issues that most societies and policymakers face when they think about tobacco or its control. The report is an important part of the partnership between the WHO and the World Bank. The WHO, the principal international agency on health issues, has taken the lead in responding to the epidemic with its Tobacco Free Initiative. The World Bank aims to work in partnership with the lead agency, offering its particular analytic resources in economics. Since 1991, the World Bank has had a formal policy on tobacco, in recognition of the harm that it does to health. The policy prohibits the Bank from lending on tobacco and encourages control efforts.

The report draws on many productive collaborations that have arisen from such reviews at national and international levels, and it is intended mainly to address the concerns raised by policymakers about the impact of tobacco control policies on economies. The benefits of tobacco control for health, especially for the world's children, are clear. There are, however, costs to tobacco control, and policymakers need to weigh these carefully. In cases where tobacco control policies impose costs on the poorest in society, governments clearly have a responsibility to help reduce these costs through, for example, transition schemes for poor tobacco farmers.

Tobacco is among the greatest causes of preventable and premature deaths in human history. Yet comparatively simple and cost-effective policies that can reduce its devastating impact are already available. For governments intent on improving health within the framework of sound economic policies, action to control tobacco represents an unusually attractive choice.

Argentina is South America’s second largest country with a surface area of 1,073,518 square miles. It has a population of 36 million people of which more than one third live in the metropolitan area of Buenos Aires. The main causes of mortality in Argentina are: a) cardiovascular diseases (31.1%); b) cancer (mostly esophageal cancer and cancer of larynx; both tobacco related cancer); c) infectious diseases (7.2 %); and d) accidents, suicides and homicides (6.3%). Two of the major risk factors are inactivity and smoking. Tobacco smoking is mostly prevalent among men (40 to 50 %). A lack of consciousness about the effects of side-stream smoke, which is correlated with a high risk of acute myocardial infarction, is common in Argentina, as well as of a lack of tough enforcement of tobacco smoking laws inside buildings. Recently, the Argentine newspaper Clarin published a survey conducted in Buenos Aires among high school students. Results showed that 35% were smokers, mostly women, with a starting age of 13 years old. Surveyed teens said that there was not enough education about tobacco smoke at school. Alcohol consumption is also a health problem in Argentina. Recent studies show an increase in economically active males as well as among adolescents. In order to address the problem, some cities and provinces have promulgated their own legislation and the school system has included alcohol use among topics to be covered. Obesity and nutritional disorders have also become a public health concern. Regarding obesity, a study of the children of Rojas City (province of Buenos Aires) showed that 30 % were overweight and so were 12% of children in the surroundings of Buenos Aires (Gran Buenos Aires). Interestingly, Argentina has a high rate of bulimia and anorexia nervosa. ALUBA (Association against Bulimia and Anorexia) has nowadays by itself, 2000 patients in day-centers. Two pieces of legislation are in process in the Congress to declare anorexia a disease.

Research and Education

Health education is part of the curricula of general basic education (EGB) and high school (Polimodal), included in the area of biological sciences. Topics like AIDS prevention, drug abuse, smoking, sexual education and nutrition are covered in forms of workshops for the high school level. However, structures differ among schools. Physical education is also part of the curricula and sports practice promotion is encouraged by the school system through organized competitions in municipal, provincial and national levels. The Federal Education Law added hours of physical education to the curriculum. Private schools, with better economical possibilities offer a variety of activities in the sports field. Research in Argentina in the health field is performed in mostly clinical settings. This is reflected in the 117 health-related journals in which 80% was devoted to clinical research while public health only accounted for 9%.

Current health promotion programs

Argentina is far behind the tobacco control advocacy efforts of other countries but has shown some recent progress. LALCEC is one of the institutions that fight against cancer and addresses this problem. LALCEC’s program is called "Chau Pucho" ("Goodbye cigarette") and consists of self-help groups of smokers and ex-smokers and is free of charge.

Physical activity is finally being recognized as a significant health promotion strategy. Physical activity has become important for the prevention and treatment of hypertension, diabetes, cardiovascular disease, obesity. Construction of worksite fitness centers also show an improvement in this area. For example, Dupont-Argentina is one of the companies that has taken this initiative. In addition, some "obras sociales", which comprises the health care system based upon employer and employee contribution, are offering this service to affiliates.

Other more traditional public health programs include a national program of immunization for measles, tuberculosis, polio, neonatal tetanus and diphtheria, which is being carried on with the support of the provinces. Chagas disease is being controlled nationally, and there are smaller programs intrinsic to some areas. For example, in the province of Santiago del Estero a horizontal program was established educating leaders in different communities to act as transmission agents. AIDS control and prevention is counting on the support of the World’s Bank LUSIDA project. Additionally, local institutions also carry their own programs

Conclusion:

Like other emerging countries, Argentina is faced with a double burden: On one hand, it is similar to developed countries with cardiovascular disease, obesity, inactivity, diabetes, stress, work-site fitness centers. On the other hand, there are health promotion programs seeking to lower under-nutrition in mothers and infants under 5 years old (PROMIN I&II) and increase access to safe water. In addition, eradication of cholera, chagas, tuberculosis, measles, meningitis, (caused by poor environmental conditions and lack of prevention, vaccination and education) is also vital component of the health promotion campaign in Argentina.

"The Role of Physical Activity in the Prevention and Treatment of Cardiovascular Diseases: Biological Mechanisms and Policies at Regional, National and European Level". Hosted by the US Libertas Castagnaro in collaboration with the Castagnaro Municipality, Verona, Italy, October 14, 2000.

The Second International Congress of Quality of Life: From Methodology to Practice in the Corporations. São Paulo, Brazil. October 1-4, 2000.

Global Congress on Mental Health in the Workplace: Workplace Productivity, Wellbeing, Rehabilitation and Risk Management. Geneva, Switzerland. October 9-10, 2000.

Fifth Annual Meeting of the International Institute for Health Promotion (IIHP), American University, Washington, DC, USA, October 18-21, 2000.

European Conference: "Health-Enhancing Physical Activity and Active Living for You and Your Community". Belfast, Northern Ireland, October 22-24, 2000.

5th Annual Meeting of the International Institute for Health Promotion in October

The5th Annual IIHP Meeting will be held from October 18-21 at American University in Washington DC. As a result of the input from IIHP affiliates, the main topic for discussion in the plenary will be "Advocacy for Health Promotion". Many IIHP members are interested in how to garner more support for health promotion from decision-makers in various settings. Convinced of the significance of health promotion and up-to-date with the latest research, we struggle to make an impact in our environment (e.g., university, corporate, government, hospital), because too often we are "pioneers" and

feel that we do not have the tools to influence our superiors. An internationally renowned speaker will introduce this topic and a workshop on tools for advocacy will follow.

The second day of the meeting will be reserved for committee work in the following interest areas:

• training and curriculum
• workplace health promotion
• global fitness test
• advocacy and communication

The third day will feature presentations from the participants on recent health promotion initiatives from throughout the world and close with a discussion on the future of the IIHP.

The preliminary program is the following:

OCTOBER 18

Registration
7:30pm Welcome Ceremony

OCTOBER 19

8:00am Physical Activity
9:00am Official welcome by Bob Karch and University representative
Introduction of participants
10:45am Break
11:00am Presentation on Health Promotion Advocacy
12:30pm Lunch
2:00pm Workshop on Tools for Advocacy
3:30pm Break/activity
3:45pm Summary of IIHP activities '99/00 and WHO Conference in Mexico
5:30pm End of day
8:00pm Optional social activity

OCTOBER 20

8:00am Physical Activity
9:00am Committee introductions:

1. Training/curriculum
2. Workplace health promotion,
3. Global Fitness Testing
4. Advocacy/Communication

10:00am Breakout into four committees until 3:45pm (Lunch at 12:30pm)
3:45pm Report Back from committees
5:30pm End of day
8:00pm Optional social activity

OCTOBER 21

8:00am Physical activity
9:00am Conclusion committee work
10:00am "International Experiences": oral/poster presentations
Q&A session
12:30pm Lunch
2:00pm IIHP issues: committee timelines, future plans/events, next IIHP Meeting, evaluation
3:45pm Open forum or site visit
5:30pm Closure of meeting

Physical Activity Seminar at the Sasakawa Sports Foundation in Tokyo

The Sasakawa Sports Foundation (SSF) hosted a seminar in Tokyo this past June focusing on the relationship of physical activity and health. Wolf Kirsten of American University presented on the global developments on this field and how numerous countries are incorporating physical activity into their national health goals like Healthy Japan 21 or Healthy People 2010. The SSF publishes the "SSF National Sport-Life Data Survey" every two years. The 2000 edition is to be published by the end of this year. For further information please contact the SSF at: info@ssf.or.jp.

Quality of Life/ Health Promotion Training Seminar in São Paulo, Brazil

CPH Technologia em Sáude from São Paulo, Brazil and American University in Washington, DC teamed up to host the 4th Quality of Life/ Health Promotion training seminar from July 10-14 in São Paulo. 45 human resource managers and corporate health professionals from Brazil and Argentina attended the seminar to learn about the latest trends and methods dealing with the management of worksite health promotion programs. Speakers included Bob Karch, Marc Schaeffer, Wolf Kirsten from American University, and Ricardo De Marchi and Ken Burgess from CPH. The participants also visited two state-of-the-art corporate quality of life programs at Siemens and Alcoa, both in São Paulo. The next seminar will take place in São Paulo from December 4-8, 2000.