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Sustainability and Sustainable Health Promotion

Alf Trojan, Waldemar Süß

(last update 01 March 2015)

The definition of sustainability has a number of facets to it. In the groundbreaking report by Brundtland in 1987 we read the following: “Sustainable development is development that meets the needs of the present without compromising the ability of future generations to meet their own needs.”

A graphic example thereof is the long-term, sustainable supply of energy that eschews the depletion of the Earth´s energy reserves and focuses rather on renewable energy (wind, tides, sun, etc.). Sustainable development does not mean solely being obligated to future generations; it is also a development concept that takes account of the ecological problems caused by previous economic and lifestyle choices made in the industrial countries as well as the needs of Third World countries.

Sustainable development comprises the areas of economic, ecological and social development (3-component model or the agenda trias of the Agenda 21). A “high level of health” is seen as one goal of social development. We would like to emphasize that sustainable development must be understood as a process that is characterized by a broad discourse concerning the goals, standards, indicators and intersectoral strategies. As laid out in the WHO strategy “Health 21,” this process serves to improve the quality of the life and environment of everyone, in the sense of intragenerational and intergenerational justice.

The complete title of the most recent WHO program is “Health 21. Health for All in the 21st Century,” the subtitle being “The health for all policy framework for the WHO European Region.” This title expressly reflects the close relationship of this program to the worldwide program for sustainable development, Agenda 21. The separate areas of “health-promoting lifestyles” and “environment” were combined into a single chapter with the title “Multisectoral Strategies for creating Sustainable Health,” which has as its basic goals the following: “to promote a healthy environment and to enable healthy decisions that create paths to sustainable health.”

The term “sustainable health” appears repeatedly in this report, but in fact is never discussed or defined explicitly. The use of this term is apparently meant to be associated with and remind us of the concept “sustainable development.” Agenda 21, however, does not refer to “sustainable environment,” but rather solely to “sustainable development” (i.e., social development including health, economic and ecological development). One could thus also better speak of the “sustainable promotion of health.”

The WHO glossary includes in its new terms that of “Sustainable Health Promotion Actions” and defines them as follows: “Sustainable health promotion actions are those that can maintain their benefits for communities and populations beyond their initial stage of implementation. Sustainable actions can continue to be delivered within the limits of finances, expertise, infrastructure, natural resources and participation by stakeholders.”

Health promotion comprises a number of key concepts that include sustainability as their goal: capacity building, overall health-promotion policy, the Setting Approach and organizational development. All of these concepts strive to achieve structural changes and thus provide a solution to the widespread disease in health promotion known as “projectitis.”

An empirical study from Australia provides a deeper look at the crucial factors that facilitate sustainable health promotion or health promotion actions. This analysis spans 18 years of experience with projects concerning healthy cities, the primary question being how sustainability emerges in such initiatives. Nine factors were discovered: a social concept of health, leadership, adaptation to the local conditions, balancing the various, sometimes contradictory demands, vigorous support for the work of the community, acknowledgement as a “neutral playing field,” connections to university research, international connections and WHO leadership as well as a successful transition from projects to actual measures of health promotion. Even if these nine factors largely correspond to the normative demands made of such healthy-city projects, they still represent a helpful and empirically proven checklist for designing sustainable health promotion activities.

At least since the 1992 conference of the United Nations in Rio de Janeiro has the concept of sustainable development assumed a firm place in the political, scientific and public discussions on environmental and development policies. Important predecessors were the Stockholm conference of the United Nations with the title “On the Human Environment” (UNEP) some 20 years previously as well as a number of further conferences and the report of the UN World Commission for Environment and Development “Our Common Future” (i.e., the so-called Brundtland Report of 1987). Previous to the 1992 conference in Rio several WHO conferences were held that specifically addressed the relationship between environment and health (e.g., one in 1989 in Frankfurt am Main, resulting in the “European Charta for Environment and Health” and in 1991 in Sundsvall “Supportive Environments for Health,” cf. health promotion I).
Both the program of the UN World Commission and the Agenda 21 of Rio represent the minimal consensus of environmental politicians from the participating governments. The importance of the concept of sustainable development lies above all in sensitizing the public to the complex relationships that exist between the environment and development, and in initiating further programs at the local level (Local Agenda 21) all the way up to the international level (Action Plans for Environment and Health, as discussed at the 3rd European Minister´s Conference in 1999 in London through the 5th Conference in 2010 in Parma). In Germany, the “National Action Plan for Environment and Health,” conceived in 1994, was passed shortly before the conference in 1999.

At the 3rd European Conference in 1999 in London the German Ministry of Health together with the German Ministry for the Environment, Nature Conservation and Nuclear Safety jointly presented the common “Action Program for Environment and Health” (APUG), which is still in force. The expressed goal of this action program is the promotion of the networking of environment and health protection with regard to the sustainable development of the field of “environment and health.” Within the scope of the support for APUG projects, activities at the regional and local levels are gaining in importance.

During the development and (sometimes halting) implementation of this program it became clear how very difficult it is to combine the areas of environment and health. This is all the more surprising since at the international and programmatic level the two concepts of health promotion and sustainable development have become increasingly integrated. The efforts in Germany to establish local action plans for the environment and health are just beginning to take hold or have even come to a standstill. Thousands of individual municipalities have already passed resolutions and implementation plans for the Local Agenda 21, but there is still need for a greater effort. The cooperation between the various projects of the Local Agenda 21 and the movement “Healthy Cities” in Germany has remained sporadic. For this reason, the Healthy City Network put closer cooperation between the projects of sustainable development, health promotion and “social municipal development” on the agenda (local political perspective). The Guideline for Health in Munich, which serves to foster the intersectoral cooperation of the Healthy City Network, the Agenda 21 activities and health promotion in certain districts of the city is a good example. Of major importance for the further development is the concept of ecological health promotion as a go-between the two guidelines and programs.

The idea of sustainable health, as mentioned in the documents published by the WHO, however, has yet to be introduced to the public, scientific and political discourse in Germany. On the other hand, the principle of “sustainable health promotion” - analogous to the principle of “sustainable development” - has become the basic practical and political basis for all setting projects on health promotion according to the setting approach, albeit often in the shortened form of simply “health promotion.”

In order to test whether a policy has been permanently anchored or implemented one may apply four criteria (cf. Table 1):

  • Have the routines become established in all political avenues for determining whether measures and programs conform with health compatibility and form the basis of actions?
  • Are permanent measures and programs in place that work toward reducing health dangers and increasing health resources?
  • Are sustainable structures in place to promote health (as opposed to short-term or limited projects and measures)?
  • Are institutionalized processes and instruments in place for planning, implementing and assessing health-promoting policies, particularly permanent health data collection and assessment of health impact?

Table 1. Criteria for assessing the implementation of sustainable health promotion (own depiction).

All aspects of the concept of sustainable health promotion were treated in an anthology by Göpel (2010) in order to make it more accessible and attractive in both practice and theory.

Baum F et al., What makes for sustainable Healthy Cities initiatives - a review of the evidence from Noarlunga, Australia after 18 years, in: Health Promotion International 21 (4), 2006, 259-265.
Böhme C et al. (Eds.), Handbuch Stadtplanung und Gesundheit, Bern 2012.
Brundtland GH, Unsere gemeinsame Zukunft - Der Brundtland-Bericht der Weltkommission für Umwelt und Entwicklung, 1987.
Fehr R/Neus H/Heudorf U (Eds.), Gesundheit und Umwelt, Ökologische Prävention und Gesundheitsförderung, Bern 2005.
Fehr R, Ökologische Gesundheitsförderung, Bern 2001.
Göpel E (Ed.), Nachhaltige Gesundheitsförderung, Frankfurt am Main 2010.
Smith BJ et al., WHO Health Promotion Glossary: new terms, in: Health Promotion International 21 (4), 2006, 340-34.
Trojan A/Legewie H, Nachhaltige Gesundheit und Entwicklung, Frankfurt am Main 2001.
WHO Euro 1997, City planning for health and sustainable development. Kopenhagen
Wolf U et al., Infoband Agenda 21 und Gesundheit, Fakultät für Gesundheitswissenschaften der Universität Bielefeld und lögd, 2000

Internet addresses:
www.apug.de (Aktionsprogramm Umwelt und Gesundheit)
www.nachhaltigkeitsrat.de (Nachhaltigkeitsrat der Bundesregierung Deutschland)

Links: Setting Approach

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