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Sundsvall Statement on Supportive Environments For Health

3rd International Conference on Health Promotion (Sundsvall, Sweden, June 1991)


The Third International Conference on Health Promotion: Supportive Environments for Health - the Sundsvall Conference - fits into a sequence of events which began with the commitment of WHO to the goals of Health For All (1977). This was followed by the UNICEF/WHO International Conference on Primary Health Care, in Alma-Ata (1978), and the First International Conference on Health Promotion in Industrialized Countries (Ottawa 1986). Subsequent meetings on Healthy Public Policy, (Adelaide 1988) and a Call for Action: Health Promotion in Developing countries, (Geneva 1989) have further clarified the relevance and meaning of health promotion. In parallel with these developments in the health arena, public concern over threats to the global environment has grown dramatically. This was clearly expressed by the World Commission on Environment and Development in its report Our Common Future, which provided a new understanding of the imperative of sustainable development.

Third International Conference on Health Promotion: Supportive Environments for Health - the first global conference on health promotion, with participants from 81 countries - calls upon people in all parts of the world to actively engage in making environments more supportive to health. Examining today's health and environmental issues together, the Conference points out that millions of people are living in extreme poverty and deprivation in an increasingly degraded environment that threatens their health, making the goal of Health For All by the Year 2000 extremely hard to achieve. The way forward lies in making the environment - the physical environment, the social and economic environment, and the political environment - supportive to health rather than damaging to it.

The Sundsvall Conference identified many examples and approaches for creating supportive environments that can be used by policy-makers, decision-makers and community activists in the health and environment sectors. The Conference recognized that everyone has a role in creating supportive environments for health.


This call for action is directed towards policy-makers and decision-makers in all relevant sectors and at all levels. Advocates and activists for health, environment and social justice are urged to form a broad alliance towards the common goal of Health for All. We Conference participants have pledged to take this message back to our communities, countries and governments to initiate action. We also call upon the organizations of the United Nations system to strengthen their cooperation and to challenge each other to be truly committed to sustainable development and equity.

A supportive environment is of paramount importance for health. The two are interdependent and inseparable. We urge that the achievement of both be made central objectives in the setting of priorities for development, and be given precedence in resolving competing interests in the everyday management of government policies.

Inequities are reflected in a widening gap in health both within our nations and between rich and poor countries. This is unacceptable. Action to achieve social justice in health is urgently needed. Millions of people are living in extreme poverty and deprivation in an increasingly degraded environment in both urban and rural areas. An unforeseen and alarming number of people suffer from the tragic consequences for health and well-being of armed conflicts. Rapid population growth is a major threat to sustainable development. People must survive without clean water, adequate food, shelter or sanitation.

Poverty frustrates people's ambitions and their dreams of building a better future, while limited access to political structures undermines the basis for self-determination. For many, education is unavailable or insufficient, or, in its present forms, fails to enable and empower. Millions of children lack access to basic education and have little hope for a better future. Women, the majority of the world's population, are still oppressed. They are sexually exploited and suffer from discrimination in the labour market and many other areas, preventing them from playing a full role in creating supportive environments.

More than a billion people worldwide have inadequate access to essential health care. Health care systems undoubtedly need to be strengthened. The solution to these massive problems lies in social action for health and the resources and creativity of individuals and their communities. Releasing this potential requires a fundamental change in the way we view our health and our environment, and a clear, strong political commitment to sustainable health and environmental policies. The solutions lie beyond the traditional health system.

Initiatives have to come from all sectors that can contribute to the creation of supportive environments for health, and must be acted upon by people in local communities, nationally by government and nongovernmental organizations, and globally through international organizations. Action will predominantly involve such sectors as education, transport, housing and urban development, industrial production and agriculture.


In a health context the term supportive environments refers to both the physical and the social aspects of our surroundings. It encompasses where people live, their local community, their home, where they work and play. It also embraces the framework which determines access to resources for living, and opportunities for empowerment. Thus action to create supportive environments has many dimensions: physical, social, spiritual, economic and political. Each of these dimensions is inextricably linked to the others in a dynamic interaction. Action must be coordinated at local, regional, national and global levels to achieve solutions that are truly sustainable.

The Conference highlighted four aspects of supportive environments:

1. The social dimension, which includes the ways in which norms, customs and social processes affect health. In many societies traditional social relationships are changing in ways that threaten health, for example, by increasing social isolation, by depriving life of a meaningful coherence and purpose, or by challenging traditional values and cultural heritage.

2. The political dimension, which requires governments to guarantee democratic participation in decision-making and the decentralization of responsibilities and resources. It also requires a commitment to human rights, peace, and a shifting of resources from the arms race.

3. The economic dimension, which requires a re-channelling of resources for the achievement of Health for All and sustainable development, including the transfer of safe and reliable technology.

4. The need to recognize and use women's skills and knowledge in all sectors - including policy-making, and the economy - in order to develop a more positive infrastructure for supportive environments. The burden of the workload of women should be recognized and shared between men and women. Women's community-based organizations must have a stronger voice in the development of health promotion policies and structures.


The Sundsvall Conference believes that proposals to implement the Health for All strategies must reflect two basic principles:

1. Equity must be a basic priority in creating supportive environments for health, releasing energy and creative power by including all human beings in this unique endeavour. All policies that aim at sustainable development must be subjected to new types of accountability procedures in order to achieve an equitable distribution of responsibilities and resources. All action and resource allocation must be based on a clear priority and commitment to the very poorest, alleviating the extra hardship borne by the marginalized, minority groups, and people with disabilities. The industrialized world needs to pay the environmental and human debt that has accumulated through exploitation of the developing world.

2. Public action for supportive environments for health must recognize the interdependence of all living beings, and must manage all natural resources, taking into account the needs of future generations. Indigenous peoples have a unique spiritual and cultural relationship with the physical environment that can provide valuable lessons for the rest of the world. It is essential, therefore, that indigenous peoples be involved in sustainable development activities, and negotiations be conducted about their rights to land and cultural heritage.


A call for the creation of supportive environments is a practical proposal for public health action at the local level, with a focus on settings for health that allow for broad community involvement and control. Examples from all parts of the world were presented at the Conference in relation to education, food, housing, social support and care, work and transport. They clearly showed that supportive environments enable people to expand their capabilities and develop self-reliance. Further details of these practical proposals are available in the Conference report and handbook.

Using the examples presented, the Conference identified four key public health action strategies to promote the creation of supportive environments at community level.

1. Strengthening advocacy through community action, particularly through groups organized by women.

2. Enabling communities and individuals to take control over their health and environment through education and empowerment.

3. Building alliances for health and supportive environments in order to strengthen the cooperation between health and environmental campaigns and strategies.

4. Mediating between conflicting interests in society in order to ensure equitable access to supportive environments for health.

In summary, empowerment of people and community participation were seen as essential factors in a democratic health promotion approach and the driving force for self-reliance and development.

Participants in the Conference recognized, in particular, that education is a basic human right and a key element in bringing about the political, economic and social changes needed to make health a possibility for all. Education should be accessible throughout life and be built on the principle of equity, particularly with respect to culture, social class and gender.


People form an integral part of the earth's ecosystem. Their health is fundamentally interlinked with the total environment. All available information indicates that it will not be possible to sustain the quality of life, for human beings and all living species, without drastic changes in attitudes and behaviour at all levels with regard to the management and preservation of the environment.

Concerted action to achieve a sustainable, supportive environment for health is the challenge of our times.

At the international level, large differences in per capita income lead to inequalities not only in access to health but also in the capacity of societies to improve their situation and sustain a decent quality of life for future generations. Migration from rural to urban areas drastically increases the number of people living in slums, with accompanying problems - including lack of clean water and sanitation.

Political decision-making and industrial development are too often based on short-term planning and economic gains which do not take into account the true costs to people's health and the environment. International debt is seriously draining the scarce resources of the poor countries. Military expenditure is increasing, and war, in addition to causing deaths and disability, is now introducing new forms of ecological vandalism.

Exploitation of the labour force, the exportation and dumping of hazardous substances, particularly in the weaker and poorer nations, and the wasteful consumption of world resources all demonstrate that the present approach to development is in crisis. There is an urgent need to advance towards new ethics and global agreement based on peaceful coexistence to allow for a more equitable distribution and utilization of the earth's limited resources.


The Sundsvall Conference calls upon the international community to establish nw mechanisms of health and ecological accountability that build upon the principles of sustainable health development. In practice this requires health and environmental impact statements for major policy and programme initiatives. WHO and UNEP are urged to strengthen their efforts to develop codes of conduct on the trade and marketing of substances and products harmful to health and the environment.

WHO and UNEP are urged to develop guidelines based on the principle of sustainable development for use by Member States. All multilateral and bilateral donor and funding agencies such as the World Bank and International Monetary Fund are urged to use such guidelines in planning, implementing and assessing development projects. Urgent action needs to be taken to support developing countries in identifying and applying their own solutions. Close collaboration with nongovernmental organizations should be ensured throughout the process.

The Sundsvall Conference has again demonstrated that the issues of health, environment and human development cannot be separated. Development must imply improvement in the quality of life and health while preserving the sustainability of the environment.

The Conference participants therefore urge the United Nations Conference on Environment and Development (UNCED), to be held in Rio de Janeiro in 1992, to take the Sundsvall Statement into account in its deliberations on the Earth Charter and Agenda 21, which is to be an action plan leading into the 21st century. Health goals must figure prominently in both. Only worldwide action based on global partnership will ensure the future of our planet.

Copyright by World Health Organization, Division of Health Promotion, Education and Communication,
CH-1211 Geneva 27, Switzerland

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