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People empowerment vs. social capital.
From health promotion to social marketing.

Rosmarie Erben, Peter Franzkowiak & Eberhard Wenzel

Paper presented to the 11th National Health Promotion Conference
"Building social capital in the 21st century"
23-26 May 1999, Perth, WA

Last updated:  19 May 1999

Beware of the health educator
who ignores the political reality,
for he is the fool's twin (Mohan Sing)
http://www.ldb.org/mohan/maxim38.htm


Introduction

New concepts are introduced to social science on a regular basis. In relation to their conceptual and strategic development, health promotion and public health are customers of social, behavioral and other sciences. One of the latest concepts creating some waves among health promotors is called social capital. As we can see with the theme of this conference, it has finally reached conference status. Social capital is no longer just the flavor of the month, it has grown into a concept seriously adopted by health promotion and public health alike. How has that happened and why was health promotion so easily infected?

In this paper we argue that the philosophy, on which social capital is based, is incompatible with the basic philosophy of health promotion as expressed in the Ottawa Charter. While social capital assumes that all of us sit in one boat aiming at the same objectives with the same strategies in mind, the Ottawa Charter clearly states that we live in a world of different cultures, interests, values, and beliefs, and that health promotion means struggle and dealing with conflicting interests. The philosophical difference between social capital and health promotion lies in the difference of social harmony and social conflicts.

In order to be able to understand the differences between the concepts, we need to step back and look at their origins. This is particularly important in the case of social capital because the concept has become rather fuzzy, since it has been adopted by social and behavioral sciences in the past few years.


Health promotion

Health promotion according to the Ottawa Charter (WHO 1986), is supposed to initiate and drive processes of social change aiming at the improvement of living and working conditions conducive to health. Guided by three principles, i.e. enabling, mediating and advocating, health promotion activities are grouped into five areas:

  • building healthy public policies
  • creating supportive environments
  • strengthening community action
  • developing personal skills, and
  • reorienting health services.
All of these areas, and particular regarding the guiding principles of action, demonstrate that health promotion aims at levels of collective action with regard to the improvement of individual and collective health conditions.


Empowerment

The key strategic concept guiding the Ottawa Charter is empowerment (Rappaport et al. 1984), a concept developed in the context of social work and community organization. Empowerment is defined in different ways (Rappaport et al. 1984), but there are some common elements to all definitions:

  • empowerment aims at the improvement of individual and collective skills to regain control over living and working conditions and their impact on well-being (Henderson & Thomas 1987)
  • empowerment is the aim and the means of community organization (Minkler 1997)
  • empowerment refers to a constant process of enabling individuals and groups to take part in collective action (Daly & Cobb 1994).
Empowerment refers to processes of social interaction of individuals and groups, which aim at enabling people to enhance their individual and collective skills and the scope and range of controlling their lives in a given community. Empowerment happens while people interact in ways of mutual respect, tolerance and social support.


Social capital

The concept of social capital has emerged from sociological analyses concerning the quality of social relations and their impact on the lives of their participants. Social capital was seen by the late James S. Coleman as an ingredient of the functioning of social relations among individuals (Coleman 1990). Participants of these relations demonstrated trust and confidence in each other, which helps enabling them as a social group to become successful in social, cultural, and political terms. Social capital according to Coleman's analysis refers to sociability and consequently to social status of the individual, which are seen to provide the main foundations for successful social relations.

Robert D. Putnam (1994) re-defined social capital by referring to social organizations and institutions in Italy and the ways and means how they collaborate in common projects. He found that trust and confidence are major ingredients of successful performance of these organizations when it comes to political and governmental reform. Trust and confidence are results of historical processes in which these organizations have been taken part, and not just outcomes of spontaneous developments in relation to specific political topics.

Social capital refers to the macro-level of the analysis of social systems thereby looking into mechanisms of cooperation and conflict between social sectors. It assumes that cooperation between sectors generates a stock of social capital, i.e. the essential resource enabling agencies to further cooperate because of the benefits this cooperation generates for all participants. Behind the concept of social capital lies the idea of a well-balanced social system, which favors mutual collaboration between social agencies and sectors for the sake of the sustainability of this system itself.

In other words: social capital refers to benefits generated by collaboration between established social organizations.1) These benefits particularly require generating trust and confidence between organizations in relation to further projects of collaboration. Like monetary capital, social capital becomes a resource to exercise power vis--vis those who have only limited or even no access to this resource.


Homo oeconomicus sanitatis

The essential idea behind the concept of social capital in the context of public health is the homo oeconomicus sanitatis. That is, human beings, who

  • view themselves primarily as actors aiming at gaining maximum benefits from their investment in themselves;
  • calculate their behavior according to individual risk assessment, whereby risks are interpreted in monetary and social costs;
  • direct their action towards the generation of power, influence and "trust" in order to become accepted partners within relationships aiming at the provision of equal benefits for all partners involved.
In the context of public health and health promotion, social capital refers to the health entrepreneur, that is the individual who sees health as a powerful ingredient for improving their chances in the market of social opportunities. The individual becomes the entrepreneur responsible for his/her own social life. In other words, humans become the subject of economic calculations aiming at improving benefits from whatever social action is taken. Following this conceptualization, life degenerates to a market-place characterized by economic calculation and control of risks, profits and losses.


Empowerment vs. social capital

Health promotion aims at improving living and working conditions conducive to health. We know from numerous studies that the socio-economic conditions of a society present the major influence on public health and consequently on the quality of life of the people (Wilkinson 1996). Socio-economic conditions refer to employment and unemployment, level of education, income, occupational position and others. Quality of life is related to the biological, physical, social, cultural, and political environment in which people live. Both conditions, the socio-economic and the environmental, are beyond the individual's control. They form parts of society, which impact on individuals' development and growth. This does not mean that these conditions cannot be changed. But it is a fact that an individual alone may not able to change them according to her/his preferences.

Societies are subject to constant change because they are generated every day through human interaction in public places, social institutions, and every social sector being part of the particular society. As much as societies can be seen as constant collective processes, they also provide boundaries for these processes in terms of institutions and organizations, and through norms and values guiding social interaction. When individuals and groups intend to bring about social change in the five activity areas of the Ottawa Charter, they will be confronted with different interests and priorities among the stakeholders in these areas. For example, the re-orientation of the health care system has not taken place in any of the so-called developed countries. On the contrary, we seem to witness a re-medicalization of health promotion and public health (Wenzel 1997).

Empowerment is the aim of social interaction in the context of public health. The Ottawa Charter suggests that people need to gain control over their living and working conditions in order to be able to develop lifestyles conducive to health. People need to form alliances in order to gain political strength and power necessary to support their causes. Alliance refers to individuals, groups and/or organization cooperating with regard to a specific topic and providing mutual assistance and support. Alliances are not partnerships, but political frames of cooperation within a defined time spectrum. They are strategic in nature, and they do not necessarily mean that the parties share common interests, values and beliefs other than in the particular case of the alliance.

However, the social capital concept suggests that individuals, groups, and organizations sit in one boat and need to collaborate in "partnership" to achieve the objectives of health promotion. "Partnerships" are defined by the Oxford English Dictionary as "an association of two or more persons for the carrying on of a business, of which they share the expenses, profit and loss". Social capital assumes that all members of the partnership have equal interests and equal access to all resources needed for this collaboration, and in addition it assumes that all players will equally benefit from the collaboration. These assumptions seem to be unrealistic given the vast inequalities in health in all countries of the world (WHO 1999). Their major cause lies in the unequal distribution of wealth (income), and consequently in inequalities regarding education, employment, and access to social, political, and economic resources.

Change will not come automatically, it needs to be struggled and striven for by those who wish to see more equality in society than currently exists. The Ottawa Charter offers a strategic frame of reference for health promotion. This frame has not been put into practice to the extent that we would be able to decide upon its appropriateness and suitability. Instead of implementing what we have promised some 13 years ago, we hop from declaration to declaration and in-between we introduce new "concepts". In this intellectual exercise we seem to have forgotten that health promotion supposedly links to real people living under real living conditions which in most cases are not conducive to their health.

"Partnerships in health", as suggested by the Jakarta Declaration on Health Promotion into the 21st century (WHO 1997), are an ideological metaphor, covering up differences in health and wealth, rather than disclosing ways and means how to overcome inequalities in health. The individual health worker in Australia may sit in the same boat with a company like Johnson & Johnson, but that does not mean that both have the same capacities when it comes to shaping social, cultural, political, environmental, and economic living and working conditions and their impact on health. We feel it is unethical to propagate ways and means of collaboration between "partners", who may not have more in common than a general interest in health, but are different as regards access to all resources relevant to bring about social change in favor of living and working conditions conducive to health. Among others, these resources are power, money, expertise, and media and they are distributed unequally between socio-economic, ethnic, age, and gender groups in any given society.

If health promotion would work with the concept of social capital it will degenerate to an ideology in praise of social marketing. Social marketing does not reflect on issues like community participation or community involvement, but presents a formula by which messages can be transmitted to "target audiences" (Kotler & Roberto 1989). The idea is that people listen to these messages and if they are developed to perfection, people may adopt them and change the related aspects of their lives accordingly. In other words: social marketing is about persuasion and it provides the "psychological technology" to develop and transmit messages accordingly. Social change will become a matter of rhetoric.

In contrast, empowerment refers to social change in societies characterized by conflicting interests of different groups and organizations, and realized in social action. It acknowledges that health promotion and public health are topics, which need to be put on political agendas and be included in budgets in order to provide opportunities and resources for practical change. This can only happen when people form alliances and subsequently engage in social action to bring about substantial changes of their living and working conditions.

Footnote

1 Further enlightening studies on the origins and meanings of social capital are provided, for example, by Boix & Posner (1998), Edwards & Foley (1998), Journal of Interdisciplinary History (1999), Rico et al. (1998), Sullivan & Transue (1999), Wallis et al. (1998).
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References

Boix, C. & Posner, D.N. (1998), Social capital: explaining its origins and effects on government performance. In: British Journal of Political Science, Vol. 28, No. 4, 686-693

Coleman, J.S. (1990), Foundations of social theory. Cambridge, Mass. (Harvard University Press)

Daly, H.E. & Cobb, J.B. (1994), For the common good. Redirecting the economy toward community, the environment, and a sustainable future. Updated and expanded edition. Boston (Beacon Press)

Edwards, B. & Foley, M.W. (1998), Civil society and social capital beyond Putnam. In: American Behavioral Scientist, Bol. 42, No1, 124-140

Henderson, P. & Thomas, D.N. (1987), Skills in neighborhood work. Second edition. London/New York (Routledge)

Journal of Interdisciplinary History (1999), Patterns of social capital: Stability and change in comparative perspective. Part 2. (Vol. 29, Issue 4, Spring 1999). Boston (MIT Press)

Kotler, P. & Roberto, E.L. (1989), Social marketing. Strategies for changing public behavior. New York (The Free Press)

Minkler, M. (ed.) (1997), Community organizing and community building for health. New Brunswick (Rutgers University Press)

Putnam, R.D. (1994), Making democracy work. Civic traditions in modern Italy. Princeton, NJ (Princeton University Press)

Rappaport, J., Swift, C. & Hess, R. (eds.) (1984), Studies in empowerment. Steps toward understanding and action. New York (Haworth Press)

Rico, A., Fraile, M. & Gonzales, P. (1998), Regional decentralisation of health policy in Spain: social capital does not tell the whole story. In: West European Politics, Vol. 21, No. 4, 180-

Sullivan, J.L. & Transue, J.E. (1999), The psychological underpinnings of democracy: A selective review of research on political tolerance, interpersonal trust, and social capital. In: Annual Review of Psychology, 625-650

Wallis, A., Crocker, J.P. & Schlechter, B. (1998), Social capital and community building, part 1. In: National Civic Review, Vol. 87, No. 3, 253-271

Wenzel, E. (1997), Environment, development and health. Ideological metaphors of post-traditional societies? In: Health Education Research, Vol. 12, No 4, 403-418

WHO (1986), Ottawa Charter of Health Promotion. Geneva (WHO)

WHO (1997), Jakarta Declaration on Health Promotion into the 21st century. Geneva (WHO)

WHO (1999), World Health Report 1999: Making a difference. Geneva (WHO) http://www.who.int/whr/1999/

Wilkinson, R.G. (1996), Unhealthy societies. The afflictions of inequality. London/New York (Routledge)




Copyright © by Rosmarie Erben, Peter Franzkowiak and Eberhard Wenzel, 1999