Health Promotion International, Vol. 29 No. 1 doi:10.1093/heapro/dat052 Advance Access published 14 August, 2013
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After Nairobi: can the international community help to develop health promotion in Africa? RACHAEL DIXEY* Centre for Health Promotion Research, Leeds Metropolitan University, Leeds, West Yorkshire, UK *Corresponding author. E-mail:
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SUMMARY The Nairobi Conference presaged a surge of interest in the development of health promotion in sub-Saharan Africa. A number of Africans have asserted that health promotion is underdeveloped in the continent, with the principles of the Ottawa Charter not widely adopted. This paper does not presume to say how health promotion could be developed in Africa, as that is for Africans to decide for themselves. Rather, it debates some issues which the
international epistemic health promotion community could address in order to work in solidarity with African colleagues in taking forward the health promotion agenda in their continent. These issues include the Eurocentric nature of health promotion discourse, the different disease burden of Africa and the lack of training capacity in African universities.
Key words: Sub-Saharan Africa; health promotion capacity development; Eurocentrism
INTRODUCTION After the Nairobi Conference in 2009, John Catford wrote, ‘We look in eager anticipation to see how Africa moves ahead in closing the implementation gap in health promotion’ and that ‘Although Africa may light the way, the rest of the world will also need to shoulder the task’, [(Catford, 2010), p. 3] implying that there is a role for the international community in moving the ‘least developed’ continent towards ‘closing the gap in a generation’. The Nairobi Call to Action requested all countries to strengthen health promotion, and highlighted Africa’s particular problems, calling for the mainstreaming of health promotion into priorities such as HIV/ AIDS, malaria, tuberculosis, mental health, maternal and child health, violence and injury, neglected tropical diseases and non-communicable diseases (WHO, 2009). This paper hopes to ask: how should the epistemic health promotion community (that is,
those academics and practitioners thinking and writing about health promotion), respond to Africa’s needs, given that historically, Africa has received far too many unwanted interventions and moralizing judgements? Moyo (Moyo, 2009) cogently argues that aid does not provide solutions for Africa, and the paper is written against a background where ‘Africa has suffered two decades of policy implementation associated with the “neoliberal” macroeconomic as well as micro-development paradigm, and the health status of this continent has deteriorated markedly’ [(Bond and Dor, 2003), p. 607]. What right though, do white Europeans have to comment on African affairs? There are moral and political responsibilities carried by anyone concerned with health justice, and as Desmond Tutu has stated, ‘If you are neutral in situations of injustice, you are on the side of the oppressor. If an elephant has its foot on the tail of a mouse and you say you are neutral, the mouse will not appreciate your neutrality’ (in Cahill, 2009). 185
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Further, as providers of postgraduate education, it is essential to consider how to respond to the educational needs of African countries, especially given the northern Universities’ scramble for international fee income. This paper does not intend to debate how health promotion can be repositioned in Africa, as Amuyunzu et al. (Amuyunzu et al., 2009) have already written about that; rather it is a contribution to how health promoters in the global North can respond to African colleagues’ wishes to develop health promotion. Although it is impossible to leave behind ‘whiteness’ and its colonial baggage, it is possible to have a debate about how solidarity can be developed. Wainana (Wainana, 2012), in ‘How not to write about Africa in 2012— a guide’, says that Africa will engage with those who address Africans as equals. Health promotion, given its methods and principles should be capable of developing meaningful partnerships; the attention to cultural sensitivity, respect and trust, equality and empowerment, power differentials and bottom-up approaches mean that we have the skills to avoid some of the unhelpful and inappropriate ‘aid’ efforts of the past. Africa is a huge continent and generalizations about it are unhelpful. What is generally meant here is Anglophone sub-Saharan Africa. African colleagues note the poor state of health promotion (Sanders et al., 2008; Amuyunzu-Nyamongo and Nyamwaya, 2009; Onye, 2009). AmuyunzuNyamongo et al. [(Amuyunzu-Nyamongo et al., 2009), p. 185] comment that, ‘the continent is characterized by a worrying disconnect between policy and implementation, which remains one of the key challenges to the development of health promotion’—governments might be ‘signed up’, but action is not occurring. Amuyunzu-Nyamongo and Nyamwaya (Amuyunzu-Nyamongo and Nyamwaya, 2009) suggest, ‘The most confounding factor to health promotion development in Africa emanates from the fact that health promotion activities are in most cases, planned, managed and controlled exclusively by health staff, mostly from within the ministry of health. The main actors are health workers whose concept of health is based on the conventional public health model and whose focus is on interventions revolving around curative services’ [(Nyamwaya and Amuyunzu-Nyamong, 2009), p. 21]. Nyamwaya (Nyamwaya, 2003, 2005) suggests that health promotion development has accelerated over the last 20 years, but there remains ‘an undeclared war for supremacy among different
practitioners . . . health education practitioners, medical doctors, nurses and professionals from areas such as social mobilization, behaviour change communication and social marketing, who are jostling for niches’. In terms of development of health promotion in Africa, Amuyunzu-Nyamongo et al. (AmuyunzuNyamongo et al., 2009) point to six areas which require attention: to invest in health; to develop more robust health systems; to build capacity in health promotion; to work within traditional and new settings; to cultivate political will; to generate evidence of health promotion effectiveness. Whilst it may be helpful for the international community to consider how they might support African colleagues in giving the desired attention to these six areas, there are other issues, in my view, that non-Africans could reflect on. IMAGES OF AFRICA First is the need to consider the formation of images of Africa. ‘Africa’ is an ideological construction; its description as the ‘dark continent’ still resonates, as do negative views, misperceptions and ‘Afro-pessimism’. Whereas Africa is seen as famine ridden, actually only one of the 20 largest famines of the 20th century, (in terms of lives lost) occurred there (Keneally, 2011). Several African economies are growing at rates higher than those in Europe. Civil wars and large scale political conflict have declined to half their level of the 1990s (Straus, 2012). However, there is a persistent image of Africa as the least ‘developed’ continent, characterized by a high disease burden, large numbers of ‘low-level’ insurgencies and civilian conflicts, corruption and inefficiencies, and high dependency on overseas aid. Collier (Collier, 2007) adopts the term ‘Africaþ’ to describe the ‘bottom billion’—those poorest countries in Africa plus the poorest elsewhere. This use of ‘Africa’ as a pseudonym for poverty, corruption, conflict and marginalization is to be resisted, but there are important questions about why many African countries contain a disproportionate amount of health and development problems. These are emotive, politically laden and difficult questions. Even writers sympathetic to countering these images of Africa, such as Gill (Gill, 2012), who argues against the onedimensional, negative and pessimistic images of Africa promulgated, often unwittingly, by the likes of Live Aid, actually fuels that image of
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Africa in his book on how to change the way journalists report the continent. Understanding the sources of dominant images of Africa and examining one’s own images of ‘Africa’ goes hand in hand with examining ‘whiteness’ as a process and its role in upholding systems of power. Critical race theory has emerged as an effective framework to challenge racism, suggesting that ‘the question is not do we live in a racist society? Rather it is a conclusion: we do live in a racist society and we need to do something about it’ [(Hylton, 2010), pp. 336– 338]. This leads logically into questioning the hegemony of Northern health promotion discourse and examining its Eurocentricity.
EUROCENTRIC THEORY BASE? Postmodernism questions what counts as legitimate knowledge, but the privileging of discourse from the global North remains (Best and Kellner, 1997; Sharp, 2008). Macdonald (MacDonald, 1998) argued that health promotion is a Eurocentric phenomenon and for its theory base to develop, it needs to change this. Airhihenbuwa is critical of how western theoretical models of psychology serve badly those societies not based on individualistic values; he suggests that by emphasizing individual empowerment, rather than understanding the collective and communitarian nature of those societies, health promotion has been mishandled in Africa: ‘Theories based on the individual, which may be effective and meaningful in Western context, have lesser relevance in self-effacing cultures of Asia, Africa, Latin America, and the Caribbean. In these regions, family and community are more central to the construction of health and well-being than the individual . . . It is the state of well-being of family and community that regulates how individuals measure their state of health. Moreover, theories and models based on measuring how the individual feels about himself or herself . . . could never capture the health locus of control in many societies because such control rests somewhere outside the self . . . The professional and cultural partiality of the Westernized approach to the understanding of self renders problematic findings from much social and behavioral science research in Africa, Asia, Latin America, and the Caribbean’. [(Airhihenbuwa and Obregon, 2000), p. 10 and 11]
Implicitly, Northern discourse on empowerment separates individual and collective empowerment,
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but if sub-Saharan societies are based on the concept of ubuntu, a term with no English equivalent but which relates to the centrality of communal life and the realization of oneself through relationships with others (Ramose, 1999), then ‘individual empowerment’ loses its potency. Ubuntu also points to the vital role of participation and harnessing the energies of civil society organizations. Osaghae [(Osaghae, 1995), p. 194] warned of using western theory to analyse civil society, as it fails to appreciate the role of rural, kinship and ethnic based associations—‘there is a clear misrepresentation of the Western connotation of civil society to the African situation’ [(Osaghae, 1995), p. 195]. Konings (Konings, 2009) also argues that existing theorizations of civil society are too Eurocentric to understand African, and specifically Cameroonian, society. There have been calls to develop a critical public health in the global South (Colvin, 2011). Speaking of ‘development’ generally, Bryceson [(Bryceson, 2012), p. 300] argues that, ‘the most effective way of challenging external donors agencies’ misguided influence, Western or indeed also eastern in the near future, is for theoretical agency to be grounded in Africa’. Likewise, it can be argued that for health promotion to develop in Africa, it needs to have an Afro-centric theoretical grounding. Health promotion has strengths that hold promise for the development of Afro-centric perspectives: it places the perspectives of lay people at its core, attempting to understand people’s worldviews and the place of health within that. African worldviews have been well expounded in social science literature and in the wealth of African fiction, theatre and film. This returns to the failure of Western, secular, positivist research paradigms to capture the authentic voice of Africans (Dixey, 1999). Such paradigms have been challenged by numerous African scholars, such as Adamiume’s critique of the sexist and ethnocentric anthropology of European scholars (Amadiume 1987, 1997). Mudimbe and Appiah (Mudimbe and Appiah, 1993) outline African philosophy, and Mkandawire (2001, 2005) describes the contribution of African social sciences. Oyewumi (Oyewumi, 2003, 2010) explores African gender studies and the role of feminism in Africa. There are thus authoritative African scholars writing in the disciplines that feed health promotion. There is no excuse for not using these voices to inform the theoretical base of health promotion. As post-colonial theory points out (McEwan,
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2009), Northern academics need to ‘decentre’ themselves as the ‘experts’. HEALTH PROMOTION IN PRACTICE— EUROCENTRIC? Africans participated in reaching the Galway consensus on skills for health promotion (Allegrante et al., 2009) but in terms of practice, Robins (Robins, 2004) for example argues that tackling the massive AIDS epidemic in South Africa will not be effective using ‘Northern’ approaches and without incorporating local interpretations of HIV. Traditional African concepts and traditions are being used to promote health (Aubel et al., 2004; Omonzejele, 2008). Serpell et al. (Serpell et al., 2011) show how distinctively African values of civic responsibility can be developed through schools in Zambia. Fankanta and Bantaba have entered the health promotion discourse in the Gambia. ‘Fankanta’, a Mandinka word meaning planning for the future, is an acceptable euphemism for family planning. The ‘Bantaba’ approach, derived from the Mandinka word meaning a meeting ground or a ‘community conversation’ (similar to the indaba found elsewhere in Africa), facilitates participation and solution seeking (Dixey and Njai, 2013). There are many examples of using the rich ‘folk’ traditions of Africa to promote health (Mda, 1993) and of challenging instructional, colonializing methods (Shaka, 1999). The epistemic health promotion community has developed a shared values discourse, but even so, certain practices are difficult to discuss across North/South divides, including female genital mutilation, gender-based violence and other practices harmful to women. These are not peculiar to Africa, of course. One sensitive area between many African societies and the global North is the latter’s widespread (though not total) acceptance of homosexuality. Recently, the president of Liberia, Ellen Johnson Sirleaf, has defended a law that criminalizes homosexual acts, saying, ‘We like ourselves just the way we are’ [(Ford and Allen, 2012), p. 19]. Homosexuality remains illegal in 37 African countries and some appear to be strengthening anti-gay legislation. Both US and British foreign ministers have publically supported the push for gay rights, with suggestions that aid will be tied to progress on these rights. Criminalizing homosexuality is illegal under international law, and the Human
Dignity Trust has recently launched a campaign to combat homophobic legislation globally. It includes African rights workers. Epprecht’s (Epprecht, 2011) useful overview of gay rights in Africa shows a large amount of African activitism, and how a tacit approach might be more fruitful than the type of campaigning found in the global North. The role of men who have sex with men (msm) has been argued as the missing factor in understanding the high rates of HIV in Africa (Griensven, 2007; Baral et al., 2009); in one study in Uganda, for example, 90% of the respondents (msm) had (female) wives (Kajubi et al., 2008). OTTAWA CHARTER OR ALMA ATA? The Ottawa Charter, though sacrosanct to health promoters, should be questioned in terms of its global applicability. The Ottawa Conference was aimed at ‘industrialized countries’ in 1986; it intended to inform the strategies of countries such as Canada, which had acknowledged that its health problems could not be tackled by the health sector alone. It was the Alma Ata Declaration that produced the paradigm shift for ‘developing’ countries, radically changing the emphasis from expensive, curative care (WHO, 1978). Although many African countries have based their strategies on it, Baum and Sanders (Baum and Sanders, 1995) argue that universal primary care has been subverted and the original ideals diluted. However, the Alma Ata Declaration did impact, and continues to impact, the health strategies of many African countries, arguably resulting in greater equity (Dixey and Njai, 2013). It can be argued that there is room for both comprehensive primary health care as espoused by the Alma Ata Declaration, and also a need to implement strategies based on the Ottawa Charter, in tackling the emerging ‘double burden’ of non-communicable and communicable disease. The epidemiological and demographic transitions facing African countries produce health problems similar to those in ‘industrialized’ countries. Abubakari [(Abubakari et al., 2009), p. 610] suggest that soon West Africa will have rates of diabetes comparable with industrialized countries. The rising rates (Igene, 2008; Hanna and Kangolle, 2010) and small amount spent on cancer care in Africa have led to a call for action on cancer (Farmer et al., 2010). Obesity
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and coronary heart disease are rising in subSaharan Africa (Mensah, 2008; Onywera, 2010). Amuyunzu-Nyamongo [(Amuyunzu-Nyamongo, 2010), p. 32] has said ‘we cannot afford to wait any longer’ in tackling non-communicable diseases (NCDs), and Lins et al. [(Lins et al., 2010), p. 27] argue that the NCD situation is as ‘equally serious’ as infectious disease. Certainly, the emerging NCDs require urgent attention but still too many children in Africa do not survive long enough to go on to become the adults at risk of NCDs. Diarrhoea, malaria, acute respiratory infections and common childhood diseases such as measles dominate the mortality and morbidity statistics. Many millions do not have safe water and much mortality is associated with poor hygiene, water and sanitation; many do not enjoy the dignity of having adequate toilets (Bartram and Cairncross, 2010). A ‘neglected’ disease such as sleeping sickness affects an estimated 300 000 to 500 000 people in Africa, but only 5– 10% have access to relevant treatments. World health Organization (WHO) estimate that 60 million people in 36 African countries are at risk of developing the disease (WHO, 2002), yet is not high on international priorities. Back in 1999, Gwatkin et al. (Gwatkin et al., 1999) thought that the WHO’s shift away from communicable towards non-communicable diseases would disadvantage poorer countries. The HIV/AIDS epidemic has also, arguably, distorted priorities. Africa experiences the highest rates of HIV, putting huge strains on already stretched health-care services and on the fabric of those societies worst affected. However, there are questions about the ability of some states to absorb the large quantities of money given to ‘fight AIDS’ and also the focus on HIV appears to distract attention from those conditions, which even kill more adults and children than does AIDS. In the midst of the large disease burden, the medical model predominates. Poor health-care services have hindered reorientation of health services and development of clinics and hospitals as healthy settings. Health care is frequently described as severely threatened, with the loss of staff a key contributor to the ‘crisis’ (Dovlo, 2003). Chapter 4 of Zambia’s National Health Strategic Plan 2006– 2010 [(MoH, 2005), p. 15] was titled ‘Human Resource Crisis’ which is ‘significantly undermining the capacity to provide even the most basic health-care services to the people’. Migration and high levels of HIV among
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health workers are blamed. High level international attempts have tried to tackle the issues, such as the AU-EU Tripoli Joint Declaration on Migration and Development, the Oslo Consultation (2005), the Abuja meeting of the High Level Forum on the MDGs (2004) and the work of the Global Health Workforce Alliance (2008). Although ethical recruitment policies (Oulton, 2001) have been implemented in some developed countries, they were undermined for example, by the EU’s Blue Card Scheme, fast-tracking skilled personnel into the European Union (Maru, 2008). The other key tenets of the Ottawa Charter, building healthy public policy, developing supportive environments, building strong communities and developing personal skills show equally mixed fortunes in the African context. Healthy public policy requires strong national and local government structures but local authorities often lack the capacity to deliver effective environmental and public health services, resulting in partnership approaches with the private sector, NGOs and community groups in the case of, for example, solid waste management (Coad and Gonzenbach, 2007). Rather than adopting westernized solutions to these issues, some African countries are adopting the idea of ‘mixed modernities’ (Spaargaren 2005), taking the best of the old whilst incorporating what is appropriate from the new (Tukahirwa, 2011). Creating supportive environments is hindered in resource-poor countries, although attempts to control major killers such as malaria have adopted environmental measures at the community level. Strong cohesive communities do characterize Africa, though it may be necessary to interrogate assumptions in times of rapid change. The final area of the Ottawa Charter, developing personal skills, implies a role for health education, and indications are that health promotion in Africa is dominated by health education. The terms ‘health education’ and ‘health promotion’ are used interchangeably or in conjunction, as in one of the Gambia’s key documents: ‘Health education and promotion, mainstreamed in all health-care programmes is key to the National health-care services delivery. At present there is no Health education and promotion policy to guide the effective dissemination of health messages in the general population. This has led to the current situation of uncoordinated approach to the development and dissemination of comprehensive health messages’. (Department of State for Health and Social Welfare, The Gambia, 2007).
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In policy documents, the concept of IEC—information, education and communication—is often regarded as ‘health promotion’, seen merely as an adjunct to the medical enterprise, encouraging people to make better use of preventive health services and so on. Nigeria’s draft health promotion policy does adopt the Ottawa Charter but adapts it, stating that the five action areas ‘can also be simplified into three basic components . . . The first component is health education with individuals and communities’ [(Federal Ministry of Health, Nigeria, 2006), p. 3]. The policy does provide a sound basis on which to support the development of health promotion, as does the draft policy in Uganda (Government of Uganda, 2009). The latter has a short paragraph on health promotion, which is principally about health education, whereas there is much of the entire document that could be called ‘health promotion’. Nyamwaya and AmuyunzuNyamongo (Nyamwaya and AmuyunzuNyamongo, 2009) provide an overview of which African countries have developed their health promotion strategies but clarification of terminology and concepts is an important task, as there is much occurring in Africa that really is ‘health promotion’ but is not recognized as such. However, robust ‘big picture health promotion’, occurring at a policy level true to the Ottawa Charter—addressing the social determinants of health or concerned with tackling inequalities, empowerment and with people taking control of their health—is relatively lacking. LACK OF TRAINING CAPACITY FOR HEALTH PROMOTION Onye (Onye, 2009) has identified the ‘serious’ lack of training capacity in African health promotion. Outside South Africa (Van den Brouke et al., 2010) the academic infrastructure for health promotion is under-developed, against a background of generally low-level capacity of higher education institutions. In colonial times, (before 1960), only 18 of 48 sub-Saharan countries had a university (Sawyerr, 2002). Since then, African universities are acknowledged to have performed well in producing human resources (Ajayi et al., 1996). However, in the interconnected global knowledge economy of the 21st century, and the marketization trajectory of universities in the global North, African universities face becoming marginalized if they are
unable to compete (Sawyerr, 2002). Moreover, Carrington and Detragiache (Carrington and Detragiache, 1999) asked the question back in the1990s as to whether the universities and training institutions of Africa were servicing the demands of developed countries due to the migration of health professionals trained in Africa. A struggling academic infrastructure impacts on research capacity. Whitworth et al. [(Whitworth et al., 2008), p. 1590] call for a common framework for sustainable research capacity strengthening in Africa: ‘That health research is indispensible for improving health, equity, and development is now widely accepted, yet how sub-Saharan African countries can develop their fragile health systems and their own capacity to do health research is rarely discussed’. The lack of well-developed research infrastructure means that vital issues such as health inequalities (Chopra, 2005), significant causes of ill health such as exposure to pesticides (Kuye et al., 2007; London and Bailie, 2001) or work-related injuries (Culp et al., 2007) are under-researched. Moreover, major gaps remain in evaluating the effectiveness of health promotion interventions, hindering the development of evidence-based practice. Crucially, research helps to establish the Africanist voice: ‘Research, like schooling, once the tool for colonization and oppression, is very gradually coming to be seen as a potential means to reclaim languages, histories and knowledge, to find solutions to the negative impacts of colonialism and to give voice to an alternative way of knowing and of being’ [(Smith, 2005), p. 10]. With a lack of training capacity in Africa, individuals access courses in the global North, which may or may not be appropriate. Educational opportunities represent important aspect of development assistance (Mittelmark, 2003), and although overseas courses can be beneficial, they take workers from their posts, scholarships can be gained unfairly and selection can be gender biased. On-line learning may overcome some of these issues, but an evaluation of e-learning in South Africa suggests that it has its problems (Rohleder et al., 2008), and there is still a significant ‘digital divide’ within and between different countries. Given the lack of capacity, the challenges facing Universities in the global South (Bourne, 2000) and the expense of students accessing courses in the global North, Universities have developed partnerships for infrastructure and capacity building. Jackson et al. (Jackson et al.,
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2007) describe the impressive capacity development work undertaken by Canadian universities and other agencies, in Latin America, Africa and emerging European countries. Leeds Met has been running its MSc Public Health—Health Promotion course in Zambia with a partner college and the Ministry of Health since 2004, to provide more cost-effective education and strengthen health promotion capacity (Dixey and Green, 2009) and in the Gambia, drawing in additional students from Sierra Leone, since 2008. The aim is to create a critical mass in communities of practice, with learning shared in multidisciplinary groups, helping to break down the professional competitiveness highlighted by Nyamwaya (Nyamwaya, 2003). This kind of work is under threat in the current economic climate, with fewer scholarships available and knowledge transfer threatened (Ridde, 2009). COMMENTS ON CHALLENGES FOR THE FUTURE OF HEALTH PROMOTION IN AFRICA Health promotion has increased its presence in Africa after Nairobi, giving timely consideration to what infrastructure is required for sustainable implementation of effective practice. Many Ministries of Health do not have a health promotion structure, even within their Public Health function. They often have an IEC unit, performing traditional health education functions, but these often operate in an uncritical fashion and are not especially tied in to a wider strategy. The ‘implementation gap’ continues and the medical dominance noted above by David Nyamwaya remains; he has ‘established that Africa is still lagging behind in the adoption of health promotion principles and approaches’ [(Hueto and Luwaga, 2009), p. 27]. As noted above, it is not for non-Africans to make prescriptions for how to address this lag. What the following section does is to point to some challenges. Ideas about ‘health’ have moved into concerns with wellbeing, happiness, and how such concepts can be measured. This new discourse is in danger of being a Eurocentric/North Atlantic phenomenon, though for some time ‘Southern’ voices have been calling for a changed conception of ‘development’, with Bhutan leading in switching from measures of economic growth towards measures of happiness. Kwame Nkrumah, the first President of independent Ghana said, ‘We
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shall measure our progress by the improvement in the health of our people. The welfare of our people is our chief pride, and it is by this that (we) ask to be judged’ (Nkrumah, 1957). Sen’s (Sen, 1999) notion of ‘development as freedom’ is based on the idea that development can be measured by the removal of ‘unfreedoms’, those things which leave people with little choice and no ability to exercise their ‘reasoned agency’ (p. xii). Too many Africans do not have the freedom to realize their dreams or to live disease-free, healthy lives. Although the African Development Bank estimates that 34% of the continent’s population are ‘middle class’ (though their definition is questioned), many live on the margins of survival— according to the same report, 66% of Africa’s population lives below the $2 a day poverty line and 44% below $1.25. Critiques of neoliberalism in Africa and its role in perpetuating poverty have been well expounded (Harrison, 2005; Navarro, 2007) and will not be detailed here, though it is useful to repeat the statement made in the Bamako Declaration: ‘. . . the values, practices, structures and institutions of the currently dominant neoliberal order are inimical to and incompatible with the realization of Africa’s dignity, values and aspirations. The Forum rejected neoliberal globalization and further integration of Africa into an unjust system as a basis for growth and development’. [(cited in Bond and Dor, 2003), p. 628]
The causes of global warming originate in the practices of the global North, whereas Africa pays the price—climate change and its attendant health problems are likely to affect Africa more than any other continent. Already coffee growing in east Africa is being threatened, and as much of its power derives from hydroelectricity, more erratic rainfall is an issue. In Africa generally, the geographical range of malaria is set to double, drought and water shortages will become more common and countries that are low lying, such as the Gambia, will be prone to flooding if sea levels rise (UNEP, 2009). Although African economies are growing fast, there is little evidence that this benefits the poorest or influences the social determinants of health. China’s role in Africa has risen monumentally, providing aid and also exploiting resources. Opinion is divided about whether China is Africa’s legitimate new economic partner or its new colonial master, whether it enables growth
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and development or creates tensions and conflict. In Zambia, where the Chinese are investing heavily in copper and other extractive industries, there is no evidence of knowledge transfer or of building African entrepreneurship (Harneit-Sievers et al., 2010). Carmody (Carmody, 2011) queries why Africa is opening itself up to so much foreign investment, and whether this really will bring about increased wellbeing.
CONCLUSION The epistemic health promotion community is keen to support African colleagues in developing health promotion. Those colleagues have identified shortfalls and the future agenda needs to be led by them rather than yet again being the recipients of well meant but inappropriate ‘aid’. Countries of the global North and South differ in key aspects particularly in their individualist/ communitarian orientations; in Airhihenbuwa’s (Airhihenbuwa, 2007) words, the aim must be to develop an Africanist vision for health promotion. This paper has attempted to outline some issues for consideration by the wider health promotion world, such as the Eurocentrism of much health promotion discourse and practice. There are difficulties of getting an accurate picture of ‘Africa’ given the media distortion and colonial legacy. Given the skills embedded in health promotion practice, of partnership development, intersectoral collaboration, empowerment and bottom-up working, colleagues from Africa and from elsewhere should be able to work in solidarity to remedy the implementation gaps. REFERENCES Abubakari, A. R., Lauder, W., Jones, M. C., Kirk, A., Agyemang, C. and Bhopal, R. S. (2009) Prevalence and time trends in diabetes and physical inactivity among adult West African populations: the epidemic has arrived. Public Health, 123, 602–614. African Development Bank (2011) The Middle of the Pyramid: Dynamics of the Middle Class in Africa. Market Briefing April 20. African Development Bank. http://www.afdb.org/ fileadmin/uploads/afdb/Documents/Publications/The% 20Middle%20of%20the%20Pyramid_The%20Middle% 20of%20the%20Pyramid.pdf (last accessed 1 August 2013). Airhihenbuwa, C. O. (2007) 2007 SOPHE Presidential Address: on being comfortable with being uncomfortable: centering an Africanist vision in our gateway to global health. Health Education Behaviour, 34, 31. Airhihenbuwa, C. and Obregon, R. (2000) A critical assessment of theories/models used in health communication
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