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Transitions and paradigms
  1. Leonard Duhl
  1. Correspondence to:
 Professor L Duhl
 School of Public Health, University of California at Berkeley, 410 Warren Hall, Berkeley 94720-7360, USA;

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“Poverty is the inability to command events that affect our lives.”

At this important time of crisis, I am reminded of the work of three of my good friends: Jonas Salk, Ernest Callenbach, Tarzie Vittachi. Each has contributed something very important in trying to understand the future.

Jonas Salk, involved with bacteriology, chose as a metaphor the S shaped curve. In this curve, he states that when resources are infinite the growth of bacteria is rapid. There is competition, a self concern, and a preoccupation with growth. Later, when the resources become diminished, there is a need to replace competition with collaboration, the birth rate slows down, and a completely new value system emerges. The period between the two curves he calls a transition period. This is a transition between what he calls epoch A and epoch B. He believes that we are now in the midst of that transition. Transitions are uncomfortable and often chaotic. Time is required, and as the Bible relates going from Egypt to the Promised Land took 40 years. One might say it took that long for the old people and the ideas to be replaced by new ones.

Ernest Callenbach has written a book called Ecotopia. This book, although a novel, tries to create an area where new values are supreme. The values that he considers important are sustainability of the environment, a happy life, living with the natural world, and living collaboratively. This is more like Jonas Salk’s epoch B. We are obviously not there, it is important to have a vision of the world we would like to have. To understand Callenbach’s views one has to live in a world of systems and ecology. One must also understand that the systems are constantly changing in their relationships and we must constantly adapt to these changes. It also implies a set of values that puts psychological, social, biological, and other humanistic needs above economic ones. Bean counters are less loved in this world, than those involved in process, human relations, networking, and community.

Tarzie Vittachi, the former deputy director of Unicef always reminded us, that “the news behind the news” was more important than the news itself. To me this forces a look not at the symptoms, but the underlying complex processes behind the event. Much of our current response in health and otherwise is to deal with the symptoms and to ignore the underlying complex processes that appear chaotic. Most policy responds in this manner: medicines to cure disease, military action to respond to social unrest, and arresting the local drug provider. In each of these cases looking at the underlying issues is fraught with danger, as it raises questions about our values. It forces us to question authority, common knowledge, and the accepted way of doing things.

Those of us who have been involved in Healthy Cities are part of the experimental group looking to a new paradigm. But, we are not alone. People concerned with the environment, education, transportation, housing, and even the law are becoming increasingly aware, and using these new paradigms. Although the thoughts about the ecological and systems models of health and cities have been with us since the 1960s, it is only now that the Institute of Medicine in Washington has called for it ecological look at medical care and health.

Health is important in leading the way to the future. As we struggle with finding answers to the meaning of health, such as in the Ottawa Charter, and others, we are contributing to understanding how to look differently at the world.

What I want to do is to place Healthy Municipalities (Cities), in the context of the changing American world. My basic position is that we are in the midst of a major change in society, with health leading the way. The changes are of course world wide; geographical to a virtual world, increased participation of the civic sector, and the fact that issues cannot be dealt with in isolation. The Healthy Cities point of view is the anticipation of major changes, in many other fields. Pattern changes are obvious all over the Western hemisphere.

The Americas are rapidly changing their process of governance from an authoritarian hierarchical model, to an increasingly democratic, participatory one. With large migrations of populations, decentralisation from national power, and collaboration between countries, critical to each, yet part of a larger issue, new ways of funding are gradually being looked at, as is taxation, the building of community power, and maintaining the individuality of these diverse populations. The increased diversity of population, the vast movement to urbanisation, and the communications revolution are refining problems, as a set of complex interrelated ever changing systems.

In planning, the processes involved are as important as the data, the question more important than the answer. Rather than defining health as medical care alone, Healthy Cities has lead the way to seeing that health promotion, involving all sectors of our communities, is central to the processes of solution.

The symptoms of both the failure of old solution and the emerging change are widespread—poverty, inadequate housing, drugs, corruption, environmental pollution, emerging and new patterns of illness, and more. Hitherto, we have used the provisions of services as the solution. Now, in contrast, we are seeing those persons concerned central to its solution. Our focus on development has been primarily economic. It is clear both in Healthy Cities communities, and in the UNDP reports that the quality of life is more critical than increasing the gross national product. City report cards are beginning to serve as guides to the processes of change.

That, Healthy Cities focus, is on the whole community—because it emphasises active participation of all sectors, and focuses upon achieving equity, and building personal and social competence to deal with issues has been its main attraction to Latin Americans. New programmes outside of Healthy Cities have used similar principles. Environmental concerns, central to health are leading the change towards achieving sustainable communities. New programmes for local food production, new education and schooling, transportation models, land ownership, housing and social services are the areas where this is happening. The solutions are not governmental alone. It will involve the business section, communities, separate interests, the faith community and more, to make the process work.

These processes are not all working well, however, those that are, are leading the changes in health. Rather that the medical profession and its immediate allies being the ones responsible for health, it is gradually becomes that of the people itself. “Poverty is the inability to command events that affect our lives.” Thus learning those skills is central to solutions.

Healthy Municipalities had led the way, to new health.

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