Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Special Centennial Edition
Volume 7, Number 2, 2002

This move toward making health a private, commercial and individual endeavor is an expression of larger trends in modern societies. The wellness revolution places economics as a driving force behind health by making it good business and providing the consumer with products that enhance well-being and quality of life. Unlike industries such as tobacco and alcohol, which require regulation to mitigate their adverse effects on consumers, the new wellness industry fosters a consumer movement toward products and services that create health. As Pilzer suggests, it means we can "fix the problems" using the same entrepreneurial skills that created them.

Yet all this raises serious questions about equity. As the wellness industry booms, the public health sector faces a critical shortage of public funding at the local, national and global levels, and the danger of a widening health gap grows. While the healthy and better off buy an ever-increasing amount of products and services that promote health, cuts in the public sector not only reduce prevention and health education services for the poor (such as nutrition education) but also weaken public safeguards on harmful goods and services (such as access to and advertising of soft drinks and junk food in U.S. schools).

The debates around access to healthy nutrition, on the one hand, and safe food, on the other, in view of rising obesity and increasing food-borne illnesses will be one of the big public health battlegrounds of the future but these will also provide a unique opportunity for combined public and private sector action on health. A key challenge to the future of health promotion will lie in devising strategies for harnessing the private sector for population health without increasing inequalities by making health a strictly individual concern, defined as a private good with no social dimensions or responsibilities.

Health: the ultimate value?
As health has become one of the defining dimensions of modern societies, an increasing number of social issues are being defined in health terms and addressed through the health system. In some areas, such as rape and other types of violence, this is a welcome trend, one that can promote a more victim-friendly response.

But in other areas, the trend is more dangerous, leading us to take a standard medical approach to social adjustment and social functioning, often responding with neuropharmacological solutions. Particularly in the broad area of mental health, the line between prevention and treatment, between social norms and medical prescriptions, is ever more difficult to draw. The extensive use of Ritalin to treat U.S. school-children is a case in point. Even addressing social determinants may take health promotion into the realm of social control. Many public health strategies must constantly strive to achieve a balance between ensuring population health and providing choices. Indeed, the human capabilities approach as advocated by the philosopher Martha Nussbaum states explicitly that the individual must have the freedom to choose not to function.

The larger question, both in the domain of public health and in the health marketplace, will be what social, political and financial price we will be willing to pay for better health, individually and as a community, at both the local and global levels. Although it may seem benign to buy better health by joining a fitness club or choosing nutritional supplements, can the same be said of buying healthier and better children? Although it seems appropriate to strive for more health, should we not also critically consider the limits of this quest? Pilzer's list of the components of the nascent wellness industry includes genetic engineering, under which he classifies sex selection and fertility enhancement.

In his analysis of the consequences of the biotechnology revolution, Francis Fukuyama points out that genetic engineering presents a challenge not only to our assumptions about human nature but also to democracy, which is premised on the notion that all are created equal. What if, in an unregulated marketplace, I have the means to buy my (perhaps sex-selected) child more intelligence through genetic engineering, instead of having her coached by expensive consultants for her college admissions tests? What new inequalities will we add to the great health divide as one part of the world embarks on a trillion-dollar wellness industry while the other cannot afford basic primary care?

These examples indicate that the future of health promotion lies in areas of social, economic and scientific development that the Ottawa Charter was not able to consider. But the charter can bring a vision and orientation to these new debates that is deeply humanitarian and equity oriented, and which is firmly rooted in the U.N. Declaration of Human Rights. Health promotion has always maintained that health is a social concept, a process toward empowerment not an ultimate goal in itself.

The possibilities for improving public health are great as we enter the 21st century. But the task of improving people's control over their health is more difficult and forces us to ask tough ethical questions about health and its role in modern society. The answers will not be obvious or easy under the pressure of new markets and new technologies. Health promotion must be willing to question the value of ultimate health, just as the savage in Aldous Huxley's Brave New World questions the value of a life without disease, death and pain because it would deprive him of compassion, joy and human dignity.

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