Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Reexamination of the Concept of ‘Health Promotion’ through a Critique of the Japanese Health Promotion Policy

Reexamination of the Concept of ‘Health Promotion’ through a Critique of the Japanese Health... Abstract This article presents a critique of the health promotion policy of Japan, which is based on an examination of the social importance of and justification for health promotion. This is done to suggest the proper direction that the future Japanese policy could take, and to question the adequacy of the term of ‘health promotion’. We find the ‘social progress’ characterization of the ‘Second Term of National Health Promotion Movement in the Twenty-First Century - Health Japan 21 (The Second Term)’ to be problematic. While there are clear restraints found in terms of social costs related to the policy, the aims toward social justice provided by the policy are not clear. Considering the social importance and justification of health promotion, and the present conditions seen in Japan, we believe that it is necessary clearly to position health promotion as a form of social justice. Having said this, the term ‘health promotion’ is in itself misleading and can belie the range of activities required to action these policies. Therefore, we propose considering the selection of a different and more appropriate term for health promotion that concretely defines policies that actively work toward definitive health equity. Criticism of the Concept of ‘Health Promotion’: Definitions, Social Importance and Justifications Necessity of the Critique of Health Promotion: Uncertainty Surrounding the Concept Since the 1970s, activities based on the concept ‘health promotion’ have come to occupy a central position in the public health policies of developed countries. Early policies that drew on this concept include ‘A new perspective on the health of Canadians’ called the ‘Lalonde report’ from Canada (Lalonde, 1981); ‘Healthy people’ of the USA (US Department of Health, Education, and Welfare, 1979); ‘the Ottawa Charter’ (WHO, 1986), and the ‘Bangkok Charter’ (WHO, 2005) provided by World Health Organization (WHO). In Japan, health promotion activities began in the latter half of the 1970s. After 2000, health promotion was maintained through laws and with policies established; activities were able to move into higher gears. Global knowledge on the harms of smoking and measure for reducing the numbers of smokers in a society have had impact in Japan. Since 2008, monitoring and intervention of obesity measures have been undertaken, and these draw on an understanding of the illness as a ‘metabolic syndrome’. The sub-leader of the current Japanese administration stated that ‘it is exasperating’ that people develop diabetes by neglecting their health because they in turn let others bear excessive medical costs (Tokyo Newspaper, 2013). Movements based on health promotion have influence on people’s lifestyles and the way societies conceptualize and evaluate them. However, many comment that there is difficulty associated with defining health promotion (Cribb, 2007: 549–551, 2013: 63–67; Holland, 2008: 87–110; Dawson and Grill, 2012; Dawson, 2014: 2663–2664). The difficulty appears in the ‘open-endedness’ (Cribb, 2007: 549) or ‘boundlessness’ (Cribb, 2013: 66) of the concept. ‘Health promotion’ is usually distinguished from ‘disease prevention’ (Dawson, 2014). The main factor that affects the limitlessness of the definition is the conceptualization of ‘health’ that is the ultimate goal of these efforts. ‘Health’ is conceptualized in two ways: negatively as a state absent of disease, and positively as exemplified by the WHO definition of health (Nordenfelt, 2007; Holland, 2008: 90–96). Since health promotion is distinguished from disease prevention, it seems that the provision of improving health is a positive aspect of the approach. It then, however, becomes challenging to distinguish the promotion of ‘health’ from the promotion of ‘well-being’ (Cribb, 2007: 550). When we adopt a definition, such as the one presented by WHO, as a health concept in public health, it becomes difficult to keep any distinctive interest in dimensions of human well-being that are not reduced to health (Powers and Feden, 2006: 17). If the conceptualization of ‘health’ is limited to physical and mental health that is defined through the biological or organic functioning of the body, events that are related to changes in health conditions as an outcome can be seen in every life scenario. The continuation of health issues being addressed within the concept of ‘health promotion’ has developed useful strategies of public health. ‘Health promotion’, in addressing the physical and mental health of the individual, has evoked the idea that change measures are needed not only in the transformation of individual behavior but also in the broader social environment and system design. WHO’s ‘Health in All Policies (HiAL)’ can be seen as one of the determining thought leaders of the health promotion movement (WHO, 2013). The broadness of health promotion should be evaluated positively. However, since a state performs the advocacy for health promotion and mobilizes citizen and private sectors toward the achievement of these policies while using national budgets, it is necessary to establish the limitations contained in the contents of the concept. Unless the aims, range of activities and limitations or boundaries that apply to a concept are defined, it becomes impossible to evaluate whether interventions were effective or in fact necessary. The necessity and the effectiveness of the measures must not be ignored as long as a state intervenes into the daily life of citizens (Childress et al., 2002: 173). In addition, it may evoke an excessive canonicalization that is represented by terms such as ‘healthism’ (Wikler, 2000: 13), which advocate the concept of ‘health promotion’ as a limitless policy. Therefore, when a state provides the policy of health promotion to citizens, it is necessary to make the meaning of the contents of the concept clear and distinct so that the evaluation of using limited resources of the public budget show that this is being done effectively. Evaluations should also limit unnecessary intervention and ensure that canonicalization in civic everyday life is evaded, and allow citizens to control public health activities. This article presents an examination of the social importance of and justification for health promotion as some limitations of health promotion activities and a critique of the health promotion policy of Japan based on the examination. Moreover, this article suggests the proper direction that future Japanese policy could take and question the adequacy of the term of ‘health promotion’. The Social Importance of and Justification for Health Promotion Health promotion as social justice and social investment While attaining a clear definition of health promotion is challenging, our description of the concept agrees that social importance constitutes a component of the concept, to an extent, and we elaborate on the political, philosophical and ethical justifications that motivate the adoption of health promotion policies by the state. The Ottawa Charter presented by WHO is the first agreed description of the social importance of health promotion (Dawson and Grill, 2012: 101). Health is seen as a resource for everyday life, not the objective of people’s lives, and therefore health promotion should also aim to address the social environment so that people themselves are able to control their health. The Ottawa Charter was presented for action to achieve ‘Health for All’ by the year 2000 and beyond. This shows that social justice and equity form the basis of the ideas that constitute the charter. Therefore, ‘equity in health’ should be considered as the main purpose of health promotion. Another important purpose of health promotion relates to the recognition of health and its maintenance as a major social investment and challenge. This idea is more clearly articulated in the beginning of the Lalonde report. The Lalonde report states that ‘Good health is the bedrock on which social progress is built’ (Lalonde, 1981). From this perspective, health is an important element of social progress, and this explains why health promotion is an important investment to achieve social progress. Health promotion is therefore represented by those activities that concern social justice which aim to achieve equity in health, as well as those that relate to social investment in working toward social progress. Based on this framework of ethics and political philosophy, health promotion includes the perspectives of both social justice and utilitarianism. This framework can also more generally be applied to overall public health efforts and initiatives (Powers and Feden, 2006: 80–87). The basis of justifications for health promotion Although the perspective of social justice and utilitarianism is adopted in providing the grounds to justify health promotion interventions undertaken by the state, social justice is considered the proper framework of the ethical argument for health promotion in particular (Goldberg, 2012: 106–108). The sufficiency model of social justice by Powers and Faden seems to be an appropriate model of social justice, which justifies public health activities including health promotion. According to this model, justice ‘requires ensuring for everyone a sufficient amount of each of the essential dimensions of well-being, of which health is one’ (Powers and Feden, 2006: 9) where ‘a sufficient amount’ is what contributes to a good life for everyone (Powers and Feden, 2006: 55). The sufficiency model of social justice also requires a commitment to policing ‘densely-woven patterns of disadvantage’, which makes it difficult to ensure a sufficient amount of well-being for members of some clusters (Powers and Feden, 2006: 81). According to this model of social justice, the moral function of public health including health promotion is ‘to monitor the health of those who are experiencing systematic disadvantage as a function of group membership, to be vigilant for evidence of inequalities relative to those in privileged social groups, and to intervene to reduce these inequalities insofar as possible’ (Powers and Feden, 2006: 88). Therefore, attention needs to be given to health inequalities and the groups that are forced to be in a vulnerable situation, indicating the possibility of unjust practices. In particular, the dimension of health during childhood requires more attention because of its impact later in life (Powers and Feden, 2006: 93). The Nuffield Council in the UK provides the ‘stewardship model’ as a specific example of a social justice model that definitively describes state responsibility for public health mainly involving health promotion. Based on this model, a state has responsibility for undertaking action to address health inequalities, such as special protection for people who are vulnerable and for those who face limitations in controlling their own health, such as children. It is this description, ‘any policy, including a policy to “do nothing,” [that] implies value judgments’ (Nuffield Council on Bioethics, 2007: xvi), where the thought to request the state to actively intervene with health inequalities is particularly well expressed. To leave health inequalities unsolved means that a state does not merely intervene but also ignores or, moreover, actively participates in some kind of injustice. Therefore, the purpose of health promotion is to reduce health inequalities through all related activities, and this serves as the moral justification for the approach, combined with the necessity of these interventions for groups who face difficulties in providing health care for themselves (Dawson, 2014: 2663). The social importance of the health promotion is also related to the social investment required by the policies as proposed by a utilitarian perspective. Social progress is promoted through health promotion, as the population becomes healthier, and this contributes to the justification for implementing these measures. However, unlike infectious diseases, there is not a matter of clear harm to the population that prompts the adoption of health promotion activities, and this presents a limitation for a utilitarian justification to make state responsibility clear, except in the matter of passive smoking. In addition, when health promotion is recognized as social investment, the goal of health promotion activities tends to be limitless. From the necessity for limitations of health promotion, the recognition of social investment is not appropriate. Having said this, there are arguments and justifications for health promotion, such as smoking and obesity prevention measures, that are more positively based on the harm principle. This perspective argues that intervention by the state is justified because obese individuals are harming others in society. ‘The combination of prevalence of overweight or obese [people] and costs (financial, social and medical) of obesity constitutes a harm that justifies the introduction of coercive public health measures’ (Callahan, 2013: 36). There is a similar argument applied in the case of smoking called the ‘restoration argument’. From this perspective, individuals who perform the act that leads to smoking-related illness as an autonomous behavior and who depend on public medical health care more than the others who do not smoke should also have their qualification for receiving a health care service reduced. Alternatively, these individuals should be made to contribute to a special fund for medical costs by having an applicable disease (Wilkinson, 1999: 256–257). These arguments regard illness brought on by smoking and obesity as harmful and as a burden to public cost, which in turns justifies intervention by the state in this regard. There are three criticisms of arguments that justify health promotion in term of the harm principle. First, the argument that smoking and obesity place a burden on medical costs is in itself baseless. A representative argument that is based on data shows that smokers are more likely to die young and, as old people are more dependent on health care services as their age increases, smokers arguably depend on the health care service less than nonsmokers as a result (Barendregt et al., 1997). In Japan, a similar survey found that smokers do not necessarily depend on medical services significantly more than nonsmokers (Hayashida et al., 2012). Similar arguments are found in relation to the costs of obesity (van Ball et al., 2008; Anomaly, 2012). Second, it is problematic to consider medical cost burdens to be the resultant harm of personal acts. This critique is against methodological individualism that considers risk behavior to be based solely on personal autonomy and mainly involves intervention of personal lifestyles (Goldberg, 2012; Mayes, 2015). This methodological individualism constitutes a ‘narrow’ model of health promotion compared to a ‘broad’ model such as the Ottawa Charter, requiring commitment to improve health and well-being through societal change (Raphael, 2011: 97). Goldberg identifies three ethical deficiencies in methodological individualism of the narrow model (Goldberg, 2012). First, based on the epidemiologic results that show that social determinants greatly influence heath issues such as smoking behavior or obesity, methodological individualism will be ineffective (Goldberg, 2012: 108). Second, because methodological individualism is more ineffective in disadvantaged groups, it will increase health inequalities (Goldberg, 2012: 109). Third, because the methodological individualism emphasis on individual choices and responsibility on health-related behavior would increase health inequalities, it will in turn intensify stigmatization of the most marginalized groups (Goldberg, 2012: 110). Therefore, methodological individualism and interventions based on the harm principle, rather than helping, might instead produce adverse effects and further damage to health, that is harm, by emphasizing personal responsibility and disregarding the influence of social determinants and stigmatization thereof (O’Hara and Gregg, 2006; Mayes, 2015). Finally, interventions that are based on mitigating the harm principle might be limitless in the extent of their scope. Interventions that are considered to include hard paternalism, such as enforcing the wearing of the seat belt, are legitimate because such interventions reduce the death rate and can make the entire society prosperous through extension of life; therefore, each individual belonging to the society can enjoy broader liberty (Gostin and Gostin, 2009). This could, in theory, correspond to an argument supported by utilitarianism. However, Gostin et al. present the criticism that the justification based on the harm principle in terms of the burden of social and economic costs may be linked to any cases where individuals engage in activities that put themselves at risk of injury or disease and broader economic costs for the society. Such scenarios could lead to ceaseless state interventions (Gostin and Gostin, 2009: 216). Once limitless intervention is justified, it can threaten broader liberty, which contradicts the ultimate purpose of promoting social progress through health promotion. As discussed above, there is lack of clarity surrounding the use of the harm principle in justifying targeted health promotion efforts for health issues that present heavy public medical cost burdens. Epidemiologic evidence supports the mandate to carry out health promotion as a means of countering health inequalities through addressing the social determinants of health and illness, rather than through measures that narrowly focus on personal lifestyles. Such a narrow model of health promotion has other ethical deficiencies, thereby increasing health inequalities and intensifying stigmatization. Moreover, even if based on the argument that attaches great importance to social progress, such an argument also proffers the criticism that interventions based on the harm principle become all-encompassing and obstruct the freedom of individuals. Therefore, it would be unjustifiable to use the harm principle in this regard for health promotion. Social justice should be considered of prime social importance and grounds for justifying health promotion efforts, and on this basis, we should regard measures to curtail health inequalities as centrally linked to the activities of health promotion. A description of health promotion that is similar to ours is found frequently in the ‘Ottawa Charter’, the ‘Bangkok Charter’ and the ‘Healthy People of the US’ agreement (2010). Criticism of Japan’s Main Health Promotion Policy Japan’s Main Health Promotion Policy The ‘1st National Health Promotion Measures of 1978’ were followed by the ‘21st Century Measures for National Health Promotion’ (also called ‘Healthy Japan 21’). It was with this iteration in the ‘3rd National Health Promotion Measures, 2000’ that the health promotion movement in Japan became fully active. Following the measurements found in ‘Healthy People of the US’, numerical targets were introduced and used in health promotion policy for the first time in Japan. The Health Promotion Act was established in 2002, and responsibility for health promotion was prescribed by law to a citizen, a local government and the state. ‘Healthy Japan 21’ was legally established through the Health Promotion Act as the basic policy of health promotion in Japan. Simultaneously to this process, environmental maintenance to prevent passive smoking in society was prescribed. The concept of ‘metabolic syndrome’ was introduced into ‘Healthy Japan 21’ in 2008 and medical insurers were obliged to provide health checks and health guidance which focused on metabolic syndrome among insured persons aged between 40 and 74. The second term of ‘Health Japan 21’ was presented in 2012. For this article, we have focused on ‘Health Japan 21 (the second term)’ (Ministry of Health, Labour and Welfare, 2012) and ‘Reference materials about the promotion of Health Japan 21 (the second term)’ (Committee on Regional Public Health, Health Promotion and Nutrition, and Expert Committee on Next Term National Health Promotion Measures Planning 2012). The latter document was included in our critique because it explains the content of the former document in more detail. Social Importance of Japanese Health Promotion Policy: Sustainability of the Social Security System ‘Health Japan 21 (the second term)’ first describes Japan’s necessity for health promotion which builds on findings from the first term document. An aging population and falling birthrates are listed as justifications for adoption of health promotion measure, along with transitions in disease structure. Furthermore, there are concerns expressed for the social security budget mentioned in the main policy and in the reference document. These concerns specifically refer to medical costs, which are emphasized as a justification for health promotion efforts, as it is thought that the increases to the social security budget are already problematic and will worsen as the population ages. In this way, measures to mitigate public costs increased by low birthrate and an aging population are clearly presented in terms of the main social importance of Japanese health promotion. It seems that this is articulated more strongly in the second term than in the first term. Changes in the preamble from the first term to the second term can be observed in the description of health promotion aiming toward a sustainable society in the first term document with the second term document outlining that government is ‘aiming [for the] social security system to become sustainable’ (Ministry of Health, Labour and Welfare, 2012: 1). Here, health promotion policy that based on interest in public cost that also includes medical cost is presented more clearly. Japan’s aging rate at 2014 was 26.0% and is the highest in the world. This trend is expected to progress further in the future. The social security budget payment costs continued to increase too, and the ratios for this expense within national incomes increased from 5.8% in 1970 to 30.9% in 2012. In addition, the ratio of costs for elderly person-related payments accounted for in welfare benefit costs was 68.3% in 2012 (Cabinet Office, 2015). This is evidence of the problems faced in sustaining a social security system in the context of an aging population with falling birthrates in Japan. Health Inequalities Mitigation Measures in Japanese Health Promotion Policy One of the biggest changes observed between the first and second terms of ‘Health Japan 21’ was that terms of measures to address health inequalities were described as ‘reduction of health disparities’ into the ‘Basic goals’ section of the policy. Income inequality in Japan is above the Organisation for Economic Co-operation and Development average and increased since the mid-1980s. Rising income inequality among the working-age population is related to the increasing share of nonregular workers. Their share in employment doubled since 1990, up to almost 34% in 2012 (OECD, 2015). Therefore, social inequality related to income disparities is a problem that cannot be ignored and should be included alongside low birthrate and aging as issues that confront Japan. In addition, many studies have indicated the correlation of the socioeconomic status (SES) with risk-taking behavior (Fukuda et al., 2005; Miyaki et al., 2013) and health conditions (Oshio and Kobayashi, 2009; Kondo, 2012) in terms of disease prevalence in Japan, like other foreign countries. It seems that the aim of ‘reduction of health disparities’ was introduced into the second term document based on this background. The revision to the policy in this regards is positive as it links Japan’s understanding of health promotion more closely to the model of social justice shown in the Ottawa Charter and confirms Japan’s current conditions. However, there is uncertainty about whether the real description that definitely prescribes the reduction of health disparities is actually based on social justice. The definition of the reduction of health disparities in ‘Basic goals’ is as follows: ‘[the] gap in health status between the groups, [and is] created by difference in community or socioeconomic status’ (Ministry of Health, Labour and Welfare, 2012: 2). This surely includes the concept of SES. ‘The consideration to various mediums such as the poverty and the reduction of the health disparities’ is a description also found in the reference materials (Committee on Regional Public Health, Health Promotion and Nutrition and Expert Committee on Next Term National Health Promotion Measures Planning, 2012: 15). However, the description of the numerical target and plan for health promotion state that, ‘targets for achieving reduction of health disparities’ are concerned with how to put measures into practice, the definition of ‘reduction of health disparities’ as shown by indicators is ‘[the] gap among prefectures in average period of time spent without limitation in daily activities’ (Ministry of Health, Labour and Welfare, 2012: 17). The meaning of ‘health disparities’ has changed from indicating SES and communities solely to denoting administrative divisions such as prefectures too. The target is expressed as the ‘reduction in [the] gap among prefectures’ and it follows that ‘each prefecture should aim to extend their healthy life expectancy with the longest healthy life expectancy among all prefectures being the target’. Therefore, this is promoting competition among the prefectures in terms of improving average healthy life expectancy. This extension of healthy life expectancy is implemented for the community as a whole, while also prescribing the reduction of health disparities. The interest in health inequalities becomes equated to social progress for all, rather than being focused on social justice for people in the community who are vulnerable or fall within a certain SES. This matter is discussed in a description of interventions in the social environment found in the reference materials. The importance of the intervention toward the reduction of health disparities is found in the fact that ‘it can contribute to improvement of the health condition of the whole country’ (Committee on Regional Public Health, Health Promotion and Nutrition and Expert Committee on Next Term National Health Promotion Measures Planning, 2012: 84). Powers and Faden’s model of social justice requires to be vigilant about densely woven patterns of disadvantage and needs to prioritize the measures against systematic patterns of disadvantage. It means that such a model of social justice requires us to monitor social conditions of those who suffer from health issues. Compared to this model of social justice, the reduction of health disparities is not clearly defined as social justice in the current Japanese health promotion policy. This is proved by the use of such words as ‘reduction of health disparities’ instead of ‘reduction of inequity or inequalities of health’. The word ‘disparity’ does not definitively mean ‘inequity’, while the meanings of ‘inequity’ and ‘inequality’ are more apparent. It is in fact recognized by the committees concerned with the development of the policy that the current indicator of the reduction of health disparities is insufficient. This is depicted in a statement in the reference material that states ‘it is necessary to think about grasping health disparities from a different perspective than the healthy life expectancy in future’ (Committee on Regional Public Health, Health Promotion and Nutrition and Expert Committee on Next Term National Health Promotion Measures Planning, 2012: 31). Suggestions for the Future Direction of Japanese Health Promotion Policy and the Reexamination of the Term ‘Health Promotion’ The Main Ethical Agenda of Current Japanese Health Promotion Policy Although a measure based on social justice has begun to be adopted in Japanese health promotion policy, this is still indistinct in comparison with the description of social investment. Having said this, the inclusion of the general extension of healthy life expectancy as a central goal in the policy and the expectation that the social security system will become more sustainable through health promotion shows that current Japanese policy seems to emphasize the social importance as social investment of the policy rather than aiming for social justice. In fact, maintenance of social security is an indispensable matter for social justice efforts. However, in a health promotion policy, it seems inappropriate to emphasize the importance of social security maintenance and the problem of increases in social cost without clarity on the detailed description of health inequalities based on social justice. Moreover, in the second term of ‘Health Japan 21’, the main diseases targeted for prevention in Japan are cancer, cardiovascular disease, diabetes and chronic obstructive pulmonary disease (COPD) which are audaciously described in the Japanese original concept of ‘lifestyle-related diseases’ (Ministry of Health, Labour and Welfare, 2012: 2). Internationally, these four diseases are regarded as noncommunicable diseases, and the lack of continuity between the global perception and Japanese perception of these conditions is problematic. The Japanese interpretation of the concept can give rise to methodological individualism and the narrow model that is based on personal lifestyle interventions. This approach is criticized for being an inappropriate methodology for implementing health promotion by Goldberg and others. It may be said that the description of current policy, adopting the concept of ‘lifestyle-related diseases’ that gives rise to methodological individualism and emphasizing on sustainability of social security, is open to misunderstanding. Suggestion: Clarification of Health Promotion as Social Justice As mentioned above, income inequality is developing in Japan just like in other foreign countries. There are studies that show an indicated correlation between SES and the rate of health risk behavior and disease prevalence increases. Studies show that the state ought to take measures as matters of equity for all, and show that this is necessary to achieve health promotion. The state should not be allowed to disregard these findings. Following the statements promoted by the Nuffield Council, we should consider that ‘any policy, including a policy to “do nothing,” implies value judgments’ on the part of the state and society. The progression of an aging population with falling birthrates in Japan means that it is impossible to ignore the fact that maintenance of social security systems is one of the most important issues facing Japan today. However, there is uncertainty about the costs that can be restrained through health promotion efforts. More certain measures should be considered for addressing the specific issues related to social security maintenance. Therefore, we think that Japanese health promotion policy should be presented definitively from the approach of social justice, which primarily aims to directly address health inequalities or inequity. The concept of health inequity should be described in addition to health disparities, as seen in the US policy ‘Healthy People 2020’. Although earlier, only the concept of health disparities had been described in the ‘Healthy People 2010’ policy, the term ‘health inequity’ was later added. It is additionally important to ensure that the indexes used to measure health inequalities reflect the present conditions in detail and as precisely as possible. For instance, the categories found in ‘Healthy People 2020’ that are used to assess health inequity, such as ‘race/ethnicity, gender, socioeconomic status, disability status, sexuality, and geography’ (Office of Disease Prevention and Health Promotion, 2014), require measurement alongside the current healthy life expectancy scenario. Health issues specifically faced by the community that correspond to the categories of ‘Healthy People 2020’ are similarly reported in Japan. For instance, with respect to sexuality, it is reported in Japan that the rate of attempted suicide is significantly associated with being homosexual (Hidaka et al., 2008). We think that Japanese health promotion policy should prioritize the measures for ‘densely-woven pattern of disadvantage’ and the broad model of health promotion based on social justice. In particular, stronger vigilance regarding the circumstances of children is required. Indeed, the investigation and measurement of health inequalities will be extremely difficult to conduct because the measures deeply affect the social environment. Such measures will need to question the overall way of the society as a whole. Public health including health promotion should always include a vision of how society should be (Carter, 2014). The reason Powers and Faden insist on social justice as a moral foundation of public health is that ‘just as public health has an obligation to call attention to any aspect of the social structure that has a significant effect on health, so too must public health evaluate the impact of its policies and practices, not only on health, but on all dimensions of well-being’ (Powers and Feden, 2006: 83). Thus, ‘public health professionals’ such as epidemiologists ‘who, by virtue of their professional roles, are in a position to know when injustices with respect to health are occurring and why, have at very least a duty to share that knowledge with others’ (Powers and Feden, 2006: 86). In this way, we insist that public health activities that mainly involve epidemiology acting as a form of ‘whistle-blower’ should expose inveterate inequity contained in society to others firstly as a health issue, and then as prompter to rouse action from the entire society. Therefore, because required activities cannot remain in the inside of so-called realm of public health, it will be assumed that public health activities essentially collaborate with other activities while bearing an important part of the policy development for the entire society. The concept of health promotion that is open-ended or boundless and positive (rather than being limited to disease prevention) has played a large role in allowing for the clarification of the social importance and responsibility that public health has carried for the state. However, by observing the present situation of economic inequalities that have progressed worldwide, including in Japan, and the studies of health inequalities based on SES that report with numbers, shows we cannot ignore the necessity of health promotion performing the functions of social justice. It is important to clarify the role of health promotion, and for the approach to be clearly defined within the aims of social justice. The term ‘health promotion’ is misleading in this regard because it does not allow easy imaging of the activities related to social justice. We feel that it is necessary to move toward a term that definitively expresses the face that health equity itself is the agenda as a suggested substitute for ‘health promotion’. Funding This work was supported by the Japan Society for the Promotion of Science KAKENHI (grant numbers 24616024 and 26502004). References Anomaly J. ( 2012 ). Is Obesity a Public Health Problem? . Public Health Ethics , 5 , 216 – 221 . Google Scholar Crossref Search ADS WorldCat Barendregt J. J. , Bonneux L., van der Maas P. J. ( 1997 ). The Health Care Costs of Smoking . New England Journal of Medicine , 337 , 1052 – 1057 . Google Scholar Crossref Search ADS PubMed WorldCat Cabinet Office, Government of Japan . ( 2015 ). Cabinet Office, Annual Report on the Aging Society: 2015 Summary, available from: http://www8.cao.go.jp/kourei/english/annualreport/2015/pdf/c1-1.pdf [accessed 10 May 2016]. Callahan D. ( 2013 ). Obesity: Chasing an Elusive Epidemic . Hastings Center Report , 43 , 34 – 40 . Google Scholar Crossref Search ADS PubMed WorldCat Carter S. M. ( 2014 ). Health Promotion: An Ethical Analysis . Health Promotion Journal of Australia , 25 , 19 – 24 . Google Scholar Crossref Search ADS PubMed WorldCat Childress J. F. , Faden R. R., Gaare R. D., Gostin L. O., Kahn J., Bonnie R. J., Kass N. E., Mastroianni A. C., Moreno J. D., Nieburg P. ( 2002 ). Public Health Ethics: Mapping the Terrain . Journal of Law, Medicine and Ethics , 30 , 170 – 178 . Google Scholar Crossref Search ADS WorldCat Committee on Regional Public Health, Health Promotion and Nutrition, Health Science Council of the Ministry of Health, Labour and Welfare (Koseikagaku Shingikai Chiikihoken Kenkouzousin Eiyou Bukai), and Expert Committee on Next Term National Health Promotion Measures Planning (Jiki Kokumin Kenkouzukuriundou Puran Sakutei Iinkai) . ( 2012 ). Reference Materials about the Promotion of Health Japan 21 (The Second Term), available from: http://www.mhlw.go.jp/bunya/kenkou/dl/kenkounippon21_02.pdf [accessed 10 May 2016]. (in Japanese) Cribb A. ( 2007 ). Health Promotion, Society and Health Care Ethics. In Richard E., Ashcroft A., Dawson H., Draper J., McMillan R. (eds), Principles of Health Care Ethics , 2nd edn. West Sussex : John Wiley and Sons , pp. 549 – 555 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Cribb A. ( 2013 ). Health and the Good Society: Setting Healthcare Ethics in Social Context . Oxford : Oxford University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Dawson A. ( 2014 ). Public Health. In Jennings B. (ed.), Bioethics , 4th edn. USA : Macmillan Reference , pp. 2661 – 2665 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Dawson A. , Grill K. ( 2012 ). Health Promotion: Conceptual and Ethical Issues . Public Health Ethics , 5 , 101 – 103 . Google Scholar Crossref Search ADS WorldCat Fukuda Y. , Nakamura K., Takano T. ( 2005 ). Socioeconomic Pattern of Smoking in Japan: Income Inequality and Gender and Age Differences . Annals of Epidemiology , 15 , 365 – 372 . Google Scholar Crossref Search ADS PubMed WorldCat Goldberg D. S. ( 2012 ). Social Justice, Health Inequalities and Methodological Individualism in US Health Promotion . Public Health Ethics , 5 , 104 – 115 . Google Scholar Crossref Search ADS WorldCat Gostin L. O. , Gostin K. G. ( 2009 ). A Broader Liberty: JS Mill, Paternalism and the Public's Health . Public Health , 123 , 214 – 221 . Google Scholar Crossref Search ADS PubMed WorldCat Hayashida K. , Murakami G., Takahashi Y., Tsuji I., Imanaka Y. ( 2012 ). Lifetime Medical Expenditures of Smokers and Nonsmokers [in Japanese] . Nihon eiseigaku zasshi (Japanese Journal of Hygiene) , 67 , 50 – 55 . Google Scholar Crossref Search ADS PubMed WorldCat Hidaka Y. , Operario D., Takenaka M., Omori S., Ichikawa S., Shirasaka T. ( 2008 ). Attempted Suicide and Associated Risk Factors Among Youth in Urban Japan . Social Psychiatry and Psychiatric Epidemiology , 43 , 752 – 757 . Google Scholar Crossref Search ADS PubMed WorldCat Holland S. ( 2008 ). Public Health Ethics . Cambridge : Polity . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Kondo N. ( 2012 ). Socioeconomic Disparities and Health: Impacts and Pathways . Journal of Epidemiology , 22 , 2 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat Lalonde M. ( 1981 ). A New Perspective on the Health of Canadians, available from: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/1974-lalonde/lalonde-eng.pdf [accessed 10 May 2016]. Mayes C. ( 2015 ). The Harm of Bioethics: A Critique of Singer and Callahan on Obesity . Bioethics , 29 , 217 – 221 . Google Scholar Crossref Search ADS PubMed WorldCat Ministerial Notification No. 430 of the Ministry of Health, Labour and Welfare . ( 2012 ). The second term of National Health Promotion Movement in the Twenty First Century (Health Japan 21 (The Second Term)), available from: http://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000047330.pdf [accessed 10 May 2016]. Miyaki K. , Song Y., Taneichi S., Tsutsumi A., Hashimoto H., Kawakami N., Takahashi M., Shimazu A., Inoue A., Kurioka S., Shimbo T. ( 2013 ). Socioeconomic Status is Significantly Associated with Dietary Salt Intakes and Blood Pressure in Japanese Workers (J-HOPE Study) . International Journal of Environmental Research and Public Health , 10 , 980 – 993 . Google Scholar Crossref Search ADS PubMed WorldCat van Ball P. H. M. , Pieter H. M., Polder J. J., de Wit G. A., Hoogenveen R. T., Feenstra T. L., Boshuizen H. C., Engelfriet P. M., Brouwer W. B. F. ( 2008 ). Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure . PLoS Med , 5 , e29. Google Scholar Crossref Search ADS PubMed WorldCat Nordenfelt L. ( 2007 ). The Concepts of Health and Illness. In Richard E., Ashcroft A., Dawson H., Draper J., McMillan R. (eds), Principles of Health Care Ethics , 2nd edn. West Sussex : John Wiley and Sons , pp. 537 – 542 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Nuffield Council on Bioethics . ( 2007 ). Public Health: Ethical Issues . Cambridge : Cambridge Publishers . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Organisation for Economic Co-operation and Development (OECD) . ( 2015 ). In It Together: Why Less Inequality Benefits All, in Japan, available from: http://www.oecd.org/japan/OECD2015-In-It-Together-Highlights-Japan.pdf [accessed 10 May 2016]. O'Hara L. , Gregg J. ( 2006 ). The War on Obesity: A Social Determinant of Health . Health Promotion Journal of Australia , 17 , 260 – 263 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Oshio T. , Kobayashi M. ( 2009 ). Income Inequality, Area-level Poverty, Perceived Aversion to Inequality, and Self-rated Health in Japan . Social Science and Medicine , 69 , 317 – 326 . Google Scholar Crossref Search ADS PubMed WorldCat Powers M. , Faden R. R. ( 2006 ). Social Justice: The Moral Foundations of Public Health and Health Policy . Oxford : Oxford University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Raphael D. ( 2011 ). The Political Economy of Health Promotion: Part 1, National Commitments to Provision of the Prerequisites of Health . Health Promotion International , 28 , 95 – 111 . Google Scholar Crossref Search ADS PubMed WorldCat Tokyo Newspaper . ( 2013 ). I Feel anger against medical cost caused by those who neglect their own health [Husesseisya no Iryouhi Hutan Hara ga Tatsu] (in Japanese), 25 April 2013. U. S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion . ( 2014 ). Healthy People 2020: Brochure, available from: https://www.healthypeople.gov/sites/default/files/HP2020_brochure_with_LHI_508_FNL.pdf. [accessed 10 May 2016]. United States. Office of the Assistant Secretary for Health, and Surgeon General . ( 1979 ). Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. US Dept. of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretary for Health and Surgeon General: for sale by the Supt. of Docs., US Govt. Print. Off. Wikler M. ( 2000 ). Personal Responsibility for Health: Contexts and Controversies. In Callahan D. (ed.), Promoting Healthy Behavior: How Much Freedom? Whose Responsibility? Washington, DC : George Town University Press , pp. 1 – 22 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Wilkinson S. ( 1999 ). Smokers' Rights to Health Care: Why the ‘Restoration Argument’ is a Moralising Wolf in a Liberal Sheep's Clothing . Journal of Applied Philosophy , 16 , 255 – 269 . Google Scholar Crossref Search ADS PubMed WorldCat World Health Organization . ( 1986 ). Ottawa Charter for Health Promotion . Ottawa : World Health Organization, Health and Welfare Canada, Canadian Public Health Association . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC World Health Organization . ( 2005 ). The Bangkok Charter for Health Promotion in a Globalized World . Bangkok : World Health Organization . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC World Health Organization . ( 2013 ). Helsinki Statement on Health in All Policies . Helsinki : World Health Organization . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC © The Author 2016. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Public Health Ethics Oxford University Press

Reexamination of the Concept of ‘Health Promotion’ through a Critique of the Japanese Health Promotion Policy

Loading next page...
 
/lp/oxford-university-press/reexamination-of-the-concept-of-health-promotion-through-a-critique-of-RVc8vhPD2i

References (25)

Publisher
Oxford University Press
Copyright
© The Author 2016. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org
ISSN
1754-9973
eISSN
1754-9981
DOI
10.1093/phe/phw043
Publisher site
See Article on Publisher Site

Abstract

Abstract This article presents a critique of the health promotion policy of Japan, which is based on an examination of the social importance of and justification for health promotion. This is done to suggest the proper direction that the future Japanese policy could take, and to question the adequacy of the term of ‘health promotion’. We find the ‘social progress’ characterization of the ‘Second Term of National Health Promotion Movement in the Twenty-First Century - Health Japan 21 (The Second Term)’ to be problematic. While there are clear restraints found in terms of social costs related to the policy, the aims toward social justice provided by the policy are not clear. Considering the social importance and justification of health promotion, and the present conditions seen in Japan, we believe that it is necessary clearly to position health promotion as a form of social justice. Having said this, the term ‘health promotion’ is in itself misleading and can belie the range of activities required to action these policies. Therefore, we propose considering the selection of a different and more appropriate term for health promotion that concretely defines policies that actively work toward definitive health equity. Criticism of the Concept of ‘Health Promotion’: Definitions, Social Importance and Justifications Necessity of the Critique of Health Promotion: Uncertainty Surrounding the Concept Since the 1970s, activities based on the concept ‘health promotion’ have come to occupy a central position in the public health policies of developed countries. Early policies that drew on this concept include ‘A new perspective on the health of Canadians’ called the ‘Lalonde report’ from Canada (Lalonde, 1981); ‘Healthy people’ of the USA (US Department of Health, Education, and Welfare, 1979); ‘the Ottawa Charter’ (WHO, 1986), and the ‘Bangkok Charter’ (WHO, 2005) provided by World Health Organization (WHO). In Japan, health promotion activities began in the latter half of the 1970s. After 2000, health promotion was maintained through laws and with policies established; activities were able to move into higher gears. Global knowledge on the harms of smoking and measure for reducing the numbers of smokers in a society have had impact in Japan. Since 2008, monitoring and intervention of obesity measures have been undertaken, and these draw on an understanding of the illness as a ‘metabolic syndrome’. The sub-leader of the current Japanese administration stated that ‘it is exasperating’ that people develop diabetes by neglecting their health because they in turn let others bear excessive medical costs (Tokyo Newspaper, 2013). Movements based on health promotion have influence on people’s lifestyles and the way societies conceptualize and evaluate them. However, many comment that there is difficulty associated with defining health promotion (Cribb, 2007: 549–551, 2013: 63–67; Holland, 2008: 87–110; Dawson and Grill, 2012; Dawson, 2014: 2663–2664). The difficulty appears in the ‘open-endedness’ (Cribb, 2007: 549) or ‘boundlessness’ (Cribb, 2013: 66) of the concept. ‘Health promotion’ is usually distinguished from ‘disease prevention’ (Dawson, 2014). The main factor that affects the limitlessness of the definition is the conceptualization of ‘health’ that is the ultimate goal of these efforts. ‘Health’ is conceptualized in two ways: negatively as a state absent of disease, and positively as exemplified by the WHO definition of health (Nordenfelt, 2007; Holland, 2008: 90–96). Since health promotion is distinguished from disease prevention, it seems that the provision of improving health is a positive aspect of the approach. It then, however, becomes challenging to distinguish the promotion of ‘health’ from the promotion of ‘well-being’ (Cribb, 2007: 550). When we adopt a definition, such as the one presented by WHO, as a health concept in public health, it becomes difficult to keep any distinctive interest in dimensions of human well-being that are not reduced to health (Powers and Feden, 2006: 17). If the conceptualization of ‘health’ is limited to physical and mental health that is defined through the biological or organic functioning of the body, events that are related to changes in health conditions as an outcome can be seen in every life scenario. The continuation of health issues being addressed within the concept of ‘health promotion’ has developed useful strategies of public health. ‘Health promotion’, in addressing the physical and mental health of the individual, has evoked the idea that change measures are needed not only in the transformation of individual behavior but also in the broader social environment and system design. WHO’s ‘Health in All Policies (HiAL)’ can be seen as one of the determining thought leaders of the health promotion movement (WHO, 2013). The broadness of health promotion should be evaluated positively. However, since a state performs the advocacy for health promotion and mobilizes citizen and private sectors toward the achievement of these policies while using national budgets, it is necessary to establish the limitations contained in the contents of the concept. Unless the aims, range of activities and limitations or boundaries that apply to a concept are defined, it becomes impossible to evaluate whether interventions were effective or in fact necessary. The necessity and the effectiveness of the measures must not be ignored as long as a state intervenes into the daily life of citizens (Childress et al., 2002: 173). In addition, it may evoke an excessive canonicalization that is represented by terms such as ‘healthism’ (Wikler, 2000: 13), which advocate the concept of ‘health promotion’ as a limitless policy. Therefore, when a state provides the policy of health promotion to citizens, it is necessary to make the meaning of the contents of the concept clear and distinct so that the evaluation of using limited resources of the public budget show that this is being done effectively. Evaluations should also limit unnecessary intervention and ensure that canonicalization in civic everyday life is evaded, and allow citizens to control public health activities. This article presents an examination of the social importance of and justification for health promotion as some limitations of health promotion activities and a critique of the health promotion policy of Japan based on the examination. Moreover, this article suggests the proper direction that future Japanese policy could take and question the adequacy of the term of ‘health promotion’. The Social Importance of and Justification for Health Promotion Health promotion as social justice and social investment While attaining a clear definition of health promotion is challenging, our description of the concept agrees that social importance constitutes a component of the concept, to an extent, and we elaborate on the political, philosophical and ethical justifications that motivate the adoption of health promotion policies by the state. The Ottawa Charter presented by WHO is the first agreed description of the social importance of health promotion (Dawson and Grill, 2012: 101). Health is seen as a resource for everyday life, not the objective of people’s lives, and therefore health promotion should also aim to address the social environment so that people themselves are able to control their health. The Ottawa Charter was presented for action to achieve ‘Health for All’ by the year 2000 and beyond. This shows that social justice and equity form the basis of the ideas that constitute the charter. Therefore, ‘equity in health’ should be considered as the main purpose of health promotion. Another important purpose of health promotion relates to the recognition of health and its maintenance as a major social investment and challenge. This idea is more clearly articulated in the beginning of the Lalonde report. The Lalonde report states that ‘Good health is the bedrock on which social progress is built’ (Lalonde, 1981). From this perspective, health is an important element of social progress, and this explains why health promotion is an important investment to achieve social progress. Health promotion is therefore represented by those activities that concern social justice which aim to achieve equity in health, as well as those that relate to social investment in working toward social progress. Based on this framework of ethics and political philosophy, health promotion includes the perspectives of both social justice and utilitarianism. This framework can also more generally be applied to overall public health efforts and initiatives (Powers and Feden, 2006: 80–87). The basis of justifications for health promotion Although the perspective of social justice and utilitarianism is adopted in providing the grounds to justify health promotion interventions undertaken by the state, social justice is considered the proper framework of the ethical argument for health promotion in particular (Goldberg, 2012: 106–108). The sufficiency model of social justice by Powers and Faden seems to be an appropriate model of social justice, which justifies public health activities including health promotion. According to this model, justice ‘requires ensuring for everyone a sufficient amount of each of the essential dimensions of well-being, of which health is one’ (Powers and Feden, 2006: 9) where ‘a sufficient amount’ is what contributes to a good life for everyone (Powers and Feden, 2006: 55). The sufficiency model of social justice also requires a commitment to policing ‘densely-woven patterns of disadvantage’, which makes it difficult to ensure a sufficient amount of well-being for members of some clusters (Powers and Feden, 2006: 81). According to this model of social justice, the moral function of public health including health promotion is ‘to monitor the health of those who are experiencing systematic disadvantage as a function of group membership, to be vigilant for evidence of inequalities relative to those in privileged social groups, and to intervene to reduce these inequalities insofar as possible’ (Powers and Feden, 2006: 88). Therefore, attention needs to be given to health inequalities and the groups that are forced to be in a vulnerable situation, indicating the possibility of unjust practices. In particular, the dimension of health during childhood requires more attention because of its impact later in life (Powers and Feden, 2006: 93). The Nuffield Council in the UK provides the ‘stewardship model’ as a specific example of a social justice model that definitively describes state responsibility for public health mainly involving health promotion. Based on this model, a state has responsibility for undertaking action to address health inequalities, such as special protection for people who are vulnerable and for those who face limitations in controlling their own health, such as children. It is this description, ‘any policy, including a policy to “do nothing,” [that] implies value judgments’ (Nuffield Council on Bioethics, 2007: xvi), where the thought to request the state to actively intervene with health inequalities is particularly well expressed. To leave health inequalities unsolved means that a state does not merely intervene but also ignores or, moreover, actively participates in some kind of injustice. Therefore, the purpose of health promotion is to reduce health inequalities through all related activities, and this serves as the moral justification for the approach, combined with the necessity of these interventions for groups who face difficulties in providing health care for themselves (Dawson, 2014: 2663). The social importance of the health promotion is also related to the social investment required by the policies as proposed by a utilitarian perspective. Social progress is promoted through health promotion, as the population becomes healthier, and this contributes to the justification for implementing these measures. However, unlike infectious diseases, there is not a matter of clear harm to the population that prompts the adoption of health promotion activities, and this presents a limitation for a utilitarian justification to make state responsibility clear, except in the matter of passive smoking. In addition, when health promotion is recognized as social investment, the goal of health promotion activities tends to be limitless. From the necessity for limitations of health promotion, the recognition of social investment is not appropriate. Having said this, there are arguments and justifications for health promotion, such as smoking and obesity prevention measures, that are more positively based on the harm principle. This perspective argues that intervention by the state is justified because obese individuals are harming others in society. ‘The combination of prevalence of overweight or obese [people] and costs (financial, social and medical) of obesity constitutes a harm that justifies the introduction of coercive public health measures’ (Callahan, 2013: 36). There is a similar argument applied in the case of smoking called the ‘restoration argument’. From this perspective, individuals who perform the act that leads to smoking-related illness as an autonomous behavior and who depend on public medical health care more than the others who do not smoke should also have their qualification for receiving a health care service reduced. Alternatively, these individuals should be made to contribute to a special fund for medical costs by having an applicable disease (Wilkinson, 1999: 256–257). These arguments regard illness brought on by smoking and obesity as harmful and as a burden to public cost, which in turns justifies intervention by the state in this regard. There are three criticisms of arguments that justify health promotion in term of the harm principle. First, the argument that smoking and obesity place a burden on medical costs is in itself baseless. A representative argument that is based on data shows that smokers are more likely to die young and, as old people are more dependent on health care services as their age increases, smokers arguably depend on the health care service less than nonsmokers as a result (Barendregt et al., 1997). In Japan, a similar survey found that smokers do not necessarily depend on medical services significantly more than nonsmokers (Hayashida et al., 2012). Similar arguments are found in relation to the costs of obesity (van Ball et al., 2008; Anomaly, 2012). Second, it is problematic to consider medical cost burdens to be the resultant harm of personal acts. This critique is against methodological individualism that considers risk behavior to be based solely on personal autonomy and mainly involves intervention of personal lifestyles (Goldberg, 2012; Mayes, 2015). This methodological individualism constitutes a ‘narrow’ model of health promotion compared to a ‘broad’ model such as the Ottawa Charter, requiring commitment to improve health and well-being through societal change (Raphael, 2011: 97). Goldberg identifies three ethical deficiencies in methodological individualism of the narrow model (Goldberg, 2012). First, based on the epidemiologic results that show that social determinants greatly influence heath issues such as smoking behavior or obesity, methodological individualism will be ineffective (Goldberg, 2012: 108). Second, because methodological individualism is more ineffective in disadvantaged groups, it will increase health inequalities (Goldberg, 2012: 109). Third, because the methodological individualism emphasis on individual choices and responsibility on health-related behavior would increase health inequalities, it will in turn intensify stigmatization of the most marginalized groups (Goldberg, 2012: 110). Therefore, methodological individualism and interventions based on the harm principle, rather than helping, might instead produce adverse effects and further damage to health, that is harm, by emphasizing personal responsibility and disregarding the influence of social determinants and stigmatization thereof (O’Hara and Gregg, 2006; Mayes, 2015). Finally, interventions that are based on mitigating the harm principle might be limitless in the extent of their scope. Interventions that are considered to include hard paternalism, such as enforcing the wearing of the seat belt, are legitimate because such interventions reduce the death rate and can make the entire society prosperous through extension of life; therefore, each individual belonging to the society can enjoy broader liberty (Gostin and Gostin, 2009). This could, in theory, correspond to an argument supported by utilitarianism. However, Gostin et al. present the criticism that the justification based on the harm principle in terms of the burden of social and economic costs may be linked to any cases where individuals engage in activities that put themselves at risk of injury or disease and broader economic costs for the society. Such scenarios could lead to ceaseless state interventions (Gostin and Gostin, 2009: 216). Once limitless intervention is justified, it can threaten broader liberty, which contradicts the ultimate purpose of promoting social progress through health promotion. As discussed above, there is lack of clarity surrounding the use of the harm principle in justifying targeted health promotion efforts for health issues that present heavy public medical cost burdens. Epidemiologic evidence supports the mandate to carry out health promotion as a means of countering health inequalities through addressing the social determinants of health and illness, rather than through measures that narrowly focus on personal lifestyles. Such a narrow model of health promotion has other ethical deficiencies, thereby increasing health inequalities and intensifying stigmatization. Moreover, even if based on the argument that attaches great importance to social progress, such an argument also proffers the criticism that interventions based on the harm principle become all-encompassing and obstruct the freedom of individuals. Therefore, it would be unjustifiable to use the harm principle in this regard for health promotion. Social justice should be considered of prime social importance and grounds for justifying health promotion efforts, and on this basis, we should regard measures to curtail health inequalities as centrally linked to the activities of health promotion. A description of health promotion that is similar to ours is found frequently in the ‘Ottawa Charter’, the ‘Bangkok Charter’ and the ‘Healthy People of the US’ agreement (2010). Criticism of Japan’s Main Health Promotion Policy Japan’s Main Health Promotion Policy The ‘1st National Health Promotion Measures of 1978’ were followed by the ‘21st Century Measures for National Health Promotion’ (also called ‘Healthy Japan 21’). It was with this iteration in the ‘3rd National Health Promotion Measures, 2000’ that the health promotion movement in Japan became fully active. Following the measurements found in ‘Healthy People of the US’, numerical targets were introduced and used in health promotion policy for the first time in Japan. The Health Promotion Act was established in 2002, and responsibility for health promotion was prescribed by law to a citizen, a local government and the state. ‘Healthy Japan 21’ was legally established through the Health Promotion Act as the basic policy of health promotion in Japan. Simultaneously to this process, environmental maintenance to prevent passive smoking in society was prescribed. The concept of ‘metabolic syndrome’ was introduced into ‘Healthy Japan 21’ in 2008 and medical insurers were obliged to provide health checks and health guidance which focused on metabolic syndrome among insured persons aged between 40 and 74. The second term of ‘Health Japan 21’ was presented in 2012. For this article, we have focused on ‘Health Japan 21 (the second term)’ (Ministry of Health, Labour and Welfare, 2012) and ‘Reference materials about the promotion of Health Japan 21 (the second term)’ (Committee on Regional Public Health, Health Promotion and Nutrition, and Expert Committee on Next Term National Health Promotion Measures Planning 2012). The latter document was included in our critique because it explains the content of the former document in more detail. Social Importance of Japanese Health Promotion Policy: Sustainability of the Social Security System ‘Health Japan 21 (the second term)’ first describes Japan’s necessity for health promotion which builds on findings from the first term document. An aging population and falling birthrates are listed as justifications for adoption of health promotion measure, along with transitions in disease structure. Furthermore, there are concerns expressed for the social security budget mentioned in the main policy and in the reference document. These concerns specifically refer to medical costs, which are emphasized as a justification for health promotion efforts, as it is thought that the increases to the social security budget are already problematic and will worsen as the population ages. In this way, measures to mitigate public costs increased by low birthrate and an aging population are clearly presented in terms of the main social importance of Japanese health promotion. It seems that this is articulated more strongly in the second term than in the first term. Changes in the preamble from the first term to the second term can be observed in the description of health promotion aiming toward a sustainable society in the first term document with the second term document outlining that government is ‘aiming [for the] social security system to become sustainable’ (Ministry of Health, Labour and Welfare, 2012: 1). Here, health promotion policy that based on interest in public cost that also includes medical cost is presented more clearly. Japan’s aging rate at 2014 was 26.0% and is the highest in the world. This trend is expected to progress further in the future. The social security budget payment costs continued to increase too, and the ratios for this expense within national incomes increased from 5.8% in 1970 to 30.9% in 2012. In addition, the ratio of costs for elderly person-related payments accounted for in welfare benefit costs was 68.3% in 2012 (Cabinet Office, 2015). This is evidence of the problems faced in sustaining a social security system in the context of an aging population with falling birthrates in Japan. Health Inequalities Mitigation Measures in Japanese Health Promotion Policy One of the biggest changes observed between the first and second terms of ‘Health Japan 21’ was that terms of measures to address health inequalities were described as ‘reduction of health disparities’ into the ‘Basic goals’ section of the policy. Income inequality in Japan is above the Organisation for Economic Co-operation and Development average and increased since the mid-1980s. Rising income inequality among the working-age population is related to the increasing share of nonregular workers. Their share in employment doubled since 1990, up to almost 34% in 2012 (OECD, 2015). Therefore, social inequality related to income disparities is a problem that cannot be ignored and should be included alongside low birthrate and aging as issues that confront Japan. In addition, many studies have indicated the correlation of the socioeconomic status (SES) with risk-taking behavior (Fukuda et al., 2005; Miyaki et al., 2013) and health conditions (Oshio and Kobayashi, 2009; Kondo, 2012) in terms of disease prevalence in Japan, like other foreign countries. It seems that the aim of ‘reduction of health disparities’ was introduced into the second term document based on this background. The revision to the policy in this regards is positive as it links Japan’s understanding of health promotion more closely to the model of social justice shown in the Ottawa Charter and confirms Japan’s current conditions. However, there is uncertainty about whether the real description that definitely prescribes the reduction of health disparities is actually based on social justice. The definition of the reduction of health disparities in ‘Basic goals’ is as follows: ‘[the] gap in health status between the groups, [and is] created by difference in community or socioeconomic status’ (Ministry of Health, Labour and Welfare, 2012: 2). This surely includes the concept of SES. ‘The consideration to various mediums such as the poverty and the reduction of the health disparities’ is a description also found in the reference materials (Committee on Regional Public Health, Health Promotion and Nutrition and Expert Committee on Next Term National Health Promotion Measures Planning, 2012: 15). However, the description of the numerical target and plan for health promotion state that, ‘targets for achieving reduction of health disparities’ are concerned with how to put measures into practice, the definition of ‘reduction of health disparities’ as shown by indicators is ‘[the] gap among prefectures in average period of time spent without limitation in daily activities’ (Ministry of Health, Labour and Welfare, 2012: 17). The meaning of ‘health disparities’ has changed from indicating SES and communities solely to denoting administrative divisions such as prefectures too. The target is expressed as the ‘reduction in [the] gap among prefectures’ and it follows that ‘each prefecture should aim to extend their healthy life expectancy with the longest healthy life expectancy among all prefectures being the target’. Therefore, this is promoting competition among the prefectures in terms of improving average healthy life expectancy. This extension of healthy life expectancy is implemented for the community as a whole, while also prescribing the reduction of health disparities. The interest in health inequalities becomes equated to social progress for all, rather than being focused on social justice for people in the community who are vulnerable or fall within a certain SES. This matter is discussed in a description of interventions in the social environment found in the reference materials. The importance of the intervention toward the reduction of health disparities is found in the fact that ‘it can contribute to improvement of the health condition of the whole country’ (Committee on Regional Public Health, Health Promotion and Nutrition and Expert Committee on Next Term National Health Promotion Measures Planning, 2012: 84). Powers and Faden’s model of social justice requires to be vigilant about densely woven patterns of disadvantage and needs to prioritize the measures against systematic patterns of disadvantage. It means that such a model of social justice requires us to monitor social conditions of those who suffer from health issues. Compared to this model of social justice, the reduction of health disparities is not clearly defined as social justice in the current Japanese health promotion policy. This is proved by the use of such words as ‘reduction of health disparities’ instead of ‘reduction of inequity or inequalities of health’. The word ‘disparity’ does not definitively mean ‘inequity’, while the meanings of ‘inequity’ and ‘inequality’ are more apparent. It is in fact recognized by the committees concerned with the development of the policy that the current indicator of the reduction of health disparities is insufficient. This is depicted in a statement in the reference material that states ‘it is necessary to think about grasping health disparities from a different perspective than the healthy life expectancy in future’ (Committee on Regional Public Health, Health Promotion and Nutrition and Expert Committee on Next Term National Health Promotion Measures Planning, 2012: 31). Suggestions for the Future Direction of Japanese Health Promotion Policy and the Reexamination of the Term ‘Health Promotion’ The Main Ethical Agenda of Current Japanese Health Promotion Policy Although a measure based on social justice has begun to be adopted in Japanese health promotion policy, this is still indistinct in comparison with the description of social investment. Having said this, the inclusion of the general extension of healthy life expectancy as a central goal in the policy and the expectation that the social security system will become more sustainable through health promotion shows that current Japanese policy seems to emphasize the social importance as social investment of the policy rather than aiming for social justice. In fact, maintenance of social security is an indispensable matter for social justice efforts. However, in a health promotion policy, it seems inappropriate to emphasize the importance of social security maintenance and the problem of increases in social cost without clarity on the detailed description of health inequalities based on social justice. Moreover, in the second term of ‘Health Japan 21’, the main diseases targeted for prevention in Japan are cancer, cardiovascular disease, diabetes and chronic obstructive pulmonary disease (COPD) which are audaciously described in the Japanese original concept of ‘lifestyle-related diseases’ (Ministry of Health, Labour and Welfare, 2012: 2). Internationally, these four diseases are regarded as noncommunicable diseases, and the lack of continuity between the global perception and Japanese perception of these conditions is problematic. The Japanese interpretation of the concept can give rise to methodological individualism and the narrow model that is based on personal lifestyle interventions. This approach is criticized for being an inappropriate methodology for implementing health promotion by Goldberg and others. It may be said that the description of current policy, adopting the concept of ‘lifestyle-related diseases’ that gives rise to methodological individualism and emphasizing on sustainability of social security, is open to misunderstanding. Suggestion: Clarification of Health Promotion as Social Justice As mentioned above, income inequality is developing in Japan just like in other foreign countries. There are studies that show an indicated correlation between SES and the rate of health risk behavior and disease prevalence increases. Studies show that the state ought to take measures as matters of equity for all, and show that this is necessary to achieve health promotion. The state should not be allowed to disregard these findings. Following the statements promoted by the Nuffield Council, we should consider that ‘any policy, including a policy to “do nothing,” implies value judgments’ on the part of the state and society. The progression of an aging population with falling birthrates in Japan means that it is impossible to ignore the fact that maintenance of social security systems is one of the most important issues facing Japan today. However, there is uncertainty about the costs that can be restrained through health promotion efforts. More certain measures should be considered for addressing the specific issues related to social security maintenance. Therefore, we think that Japanese health promotion policy should be presented definitively from the approach of social justice, which primarily aims to directly address health inequalities or inequity. The concept of health inequity should be described in addition to health disparities, as seen in the US policy ‘Healthy People 2020’. Although earlier, only the concept of health disparities had been described in the ‘Healthy People 2010’ policy, the term ‘health inequity’ was later added. It is additionally important to ensure that the indexes used to measure health inequalities reflect the present conditions in detail and as precisely as possible. For instance, the categories found in ‘Healthy People 2020’ that are used to assess health inequity, such as ‘race/ethnicity, gender, socioeconomic status, disability status, sexuality, and geography’ (Office of Disease Prevention and Health Promotion, 2014), require measurement alongside the current healthy life expectancy scenario. Health issues specifically faced by the community that correspond to the categories of ‘Healthy People 2020’ are similarly reported in Japan. For instance, with respect to sexuality, it is reported in Japan that the rate of attempted suicide is significantly associated with being homosexual (Hidaka et al., 2008). We think that Japanese health promotion policy should prioritize the measures for ‘densely-woven pattern of disadvantage’ and the broad model of health promotion based on social justice. In particular, stronger vigilance regarding the circumstances of children is required. Indeed, the investigation and measurement of health inequalities will be extremely difficult to conduct because the measures deeply affect the social environment. Such measures will need to question the overall way of the society as a whole. Public health including health promotion should always include a vision of how society should be (Carter, 2014). The reason Powers and Faden insist on social justice as a moral foundation of public health is that ‘just as public health has an obligation to call attention to any aspect of the social structure that has a significant effect on health, so too must public health evaluate the impact of its policies and practices, not only on health, but on all dimensions of well-being’ (Powers and Feden, 2006: 83). Thus, ‘public health professionals’ such as epidemiologists ‘who, by virtue of their professional roles, are in a position to know when injustices with respect to health are occurring and why, have at very least a duty to share that knowledge with others’ (Powers and Feden, 2006: 86). In this way, we insist that public health activities that mainly involve epidemiology acting as a form of ‘whistle-blower’ should expose inveterate inequity contained in society to others firstly as a health issue, and then as prompter to rouse action from the entire society. Therefore, because required activities cannot remain in the inside of so-called realm of public health, it will be assumed that public health activities essentially collaborate with other activities while bearing an important part of the policy development for the entire society. The concept of health promotion that is open-ended or boundless and positive (rather than being limited to disease prevention) has played a large role in allowing for the clarification of the social importance and responsibility that public health has carried for the state. However, by observing the present situation of economic inequalities that have progressed worldwide, including in Japan, and the studies of health inequalities based on SES that report with numbers, shows we cannot ignore the necessity of health promotion performing the functions of social justice. It is important to clarify the role of health promotion, and for the approach to be clearly defined within the aims of social justice. The term ‘health promotion’ is misleading in this regard because it does not allow easy imaging of the activities related to social justice. We feel that it is necessary to move toward a term that definitively expresses the face that health equity itself is the agenda as a suggested substitute for ‘health promotion’. Funding This work was supported by the Japan Society for the Promotion of Science KAKENHI (grant numbers 24616024 and 26502004). References Anomaly J. ( 2012 ). Is Obesity a Public Health Problem? . Public Health Ethics , 5 , 216 – 221 . Google Scholar Crossref Search ADS WorldCat Barendregt J. J. , Bonneux L., van der Maas P. J. ( 1997 ). The Health Care Costs of Smoking . New England Journal of Medicine , 337 , 1052 – 1057 . Google Scholar Crossref Search ADS PubMed WorldCat Cabinet Office, Government of Japan . ( 2015 ). Cabinet Office, Annual Report on the Aging Society: 2015 Summary, available from: http://www8.cao.go.jp/kourei/english/annualreport/2015/pdf/c1-1.pdf [accessed 10 May 2016]. Callahan D. ( 2013 ). Obesity: Chasing an Elusive Epidemic . Hastings Center Report , 43 , 34 – 40 . Google Scholar Crossref Search ADS PubMed WorldCat Carter S. M. ( 2014 ). Health Promotion: An Ethical Analysis . Health Promotion Journal of Australia , 25 , 19 – 24 . Google Scholar Crossref Search ADS PubMed WorldCat Childress J. F. , Faden R. R., Gaare R. D., Gostin L. O., Kahn J., Bonnie R. J., Kass N. E., Mastroianni A. C., Moreno J. D., Nieburg P. ( 2002 ). Public Health Ethics: Mapping the Terrain . Journal of Law, Medicine and Ethics , 30 , 170 – 178 . Google Scholar Crossref Search ADS WorldCat Committee on Regional Public Health, Health Promotion and Nutrition, Health Science Council of the Ministry of Health, Labour and Welfare (Koseikagaku Shingikai Chiikihoken Kenkouzousin Eiyou Bukai), and Expert Committee on Next Term National Health Promotion Measures Planning (Jiki Kokumin Kenkouzukuriundou Puran Sakutei Iinkai) . ( 2012 ). Reference Materials about the Promotion of Health Japan 21 (The Second Term), available from: http://www.mhlw.go.jp/bunya/kenkou/dl/kenkounippon21_02.pdf [accessed 10 May 2016]. (in Japanese) Cribb A. ( 2007 ). Health Promotion, Society and Health Care Ethics. In Richard E., Ashcroft A., Dawson H., Draper J., McMillan R. (eds), Principles of Health Care Ethics , 2nd edn. West Sussex : John Wiley and Sons , pp. 549 – 555 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Cribb A. ( 2013 ). Health and the Good Society: Setting Healthcare Ethics in Social Context . Oxford : Oxford University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Dawson A. ( 2014 ). Public Health. In Jennings B. (ed.), Bioethics , 4th edn. USA : Macmillan Reference , pp. 2661 – 2665 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Dawson A. , Grill K. ( 2012 ). Health Promotion: Conceptual and Ethical Issues . Public Health Ethics , 5 , 101 – 103 . Google Scholar Crossref Search ADS WorldCat Fukuda Y. , Nakamura K., Takano T. ( 2005 ). Socioeconomic Pattern of Smoking in Japan: Income Inequality and Gender and Age Differences . Annals of Epidemiology , 15 , 365 – 372 . Google Scholar Crossref Search ADS PubMed WorldCat Goldberg D. S. ( 2012 ). Social Justice, Health Inequalities and Methodological Individualism in US Health Promotion . Public Health Ethics , 5 , 104 – 115 . Google Scholar Crossref Search ADS WorldCat Gostin L. O. , Gostin K. G. ( 2009 ). A Broader Liberty: JS Mill, Paternalism and the Public's Health . Public Health , 123 , 214 – 221 . Google Scholar Crossref Search ADS PubMed WorldCat Hayashida K. , Murakami G., Takahashi Y., Tsuji I., Imanaka Y. ( 2012 ). Lifetime Medical Expenditures of Smokers and Nonsmokers [in Japanese] . Nihon eiseigaku zasshi (Japanese Journal of Hygiene) , 67 , 50 – 55 . Google Scholar Crossref Search ADS PubMed WorldCat Hidaka Y. , Operario D., Takenaka M., Omori S., Ichikawa S., Shirasaka T. ( 2008 ). Attempted Suicide and Associated Risk Factors Among Youth in Urban Japan . Social Psychiatry and Psychiatric Epidemiology , 43 , 752 – 757 . Google Scholar Crossref Search ADS PubMed WorldCat Holland S. ( 2008 ). Public Health Ethics . Cambridge : Polity . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Kondo N. ( 2012 ). Socioeconomic Disparities and Health: Impacts and Pathways . Journal of Epidemiology , 22 , 2 – 6 . Google Scholar Crossref Search ADS PubMed WorldCat Lalonde M. ( 1981 ). A New Perspective on the Health of Canadians, available from: http://www.hc-sc.gc.ca/hcs-sss/alt_formats/hpb-dgps/pdf/pubs/1974-lalonde/lalonde-eng.pdf [accessed 10 May 2016]. Mayes C. ( 2015 ). The Harm of Bioethics: A Critique of Singer and Callahan on Obesity . Bioethics , 29 , 217 – 221 . Google Scholar Crossref Search ADS PubMed WorldCat Ministerial Notification No. 430 of the Ministry of Health, Labour and Welfare . ( 2012 ). The second term of National Health Promotion Movement in the Twenty First Century (Health Japan 21 (The Second Term)), available from: http://www.mhlw.go.jp/file/06-Seisakujouhou-10900000-Kenkoukyoku/0000047330.pdf [accessed 10 May 2016]. Miyaki K. , Song Y., Taneichi S., Tsutsumi A., Hashimoto H., Kawakami N., Takahashi M., Shimazu A., Inoue A., Kurioka S., Shimbo T. ( 2013 ). Socioeconomic Status is Significantly Associated with Dietary Salt Intakes and Blood Pressure in Japanese Workers (J-HOPE Study) . International Journal of Environmental Research and Public Health , 10 , 980 – 993 . Google Scholar Crossref Search ADS PubMed WorldCat van Ball P. H. M. , Pieter H. M., Polder J. J., de Wit G. A., Hoogenveen R. T., Feenstra T. L., Boshuizen H. C., Engelfriet P. M., Brouwer W. B. F. ( 2008 ). Lifetime Medical Costs of Obesity: Prevention No Cure for Increasing Health Expenditure . PLoS Med , 5 , e29. Google Scholar Crossref Search ADS PubMed WorldCat Nordenfelt L. ( 2007 ). The Concepts of Health and Illness. In Richard E., Ashcroft A., Dawson H., Draper J., McMillan R. (eds), Principles of Health Care Ethics , 2nd edn. West Sussex : John Wiley and Sons , pp. 537 – 542 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Nuffield Council on Bioethics . ( 2007 ). Public Health: Ethical Issues . Cambridge : Cambridge Publishers . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Organisation for Economic Co-operation and Development (OECD) . ( 2015 ). In It Together: Why Less Inequality Benefits All, in Japan, available from: http://www.oecd.org/japan/OECD2015-In-It-Together-Highlights-Japan.pdf [accessed 10 May 2016]. O'Hara L. , Gregg J. ( 2006 ). The War on Obesity: A Social Determinant of Health . Health Promotion Journal of Australia , 17 , 260 – 263 . Google Scholar PubMed OpenURL Placeholder Text WorldCat Oshio T. , Kobayashi M. ( 2009 ). Income Inequality, Area-level Poverty, Perceived Aversion to Inequality, and Self-rated Health in Japan . Social Science and Medicine , 69 , 317 – 326 . Google Scholar Crossref Search ADS PubMed WorldCat Powers M. , Faden R. R. ( 2006 ). Social Justice: The Moral Foundations of Public Health and Health Policy . Oxford : Oxford University Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Raphael D. ( 2011 ). The Political Economy of Health Promotion: Part 1, National Commitments to Provision of the Prerequisites of Health . Health Promotion International , 28 , 95 – 111 . Google Scholar Crossref Search ADS PubMed WorldCat Tokyo Newspaper . ( 2013 ). I Feel anger against medical cost caused by those who neglect their own health [Husesseisya no Iryouhi Hutan Hara ga Tatsu] (in Japanese), 25 April 2013. U. S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion . ( 2014 ). Healthy People 2020: Brochure, available from: https://www.healthypeople.gov/sites/default/files/HP2020_brochure_with_LHI_508_FNL.pdf. [accessed 10 May 2016]. United States. Office of the Assistant Secretary for Health, and Surgeon General . ( 1979 ). Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. US Dept. of Health, Education, and Welfare, Public Health Service, Office of the Assistant Secretary for Health and Surgeon General: for sale by the Supt. of Docs., US Govt. Print. Off. Wikler M. ( 2000 ). Personal Responsibility for Health: Contexts and Controversies. In Callahan D. (ed.), Promoting Healthy Behavior: How Much Freedom? Whose Responsibility? Washington, DC : George Town University Press , pp. 1 – 22 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Wilkinson S. ( 1999 ). Smokers' Rights to Health Care: Why the ‘Restoration Argument’ is a Moralising Wolf in a Liberal Sheep's Clothing . Journal of Applied Philosophy , 16 , 255 – 269 . Google Scholar Crossref Search ADS PubMed WorldCat World Health Organization . ( 1986 ). Ottawa Charter for Health Promotion . Ottawa : World Health Organization, Health and Welfare Canada, Canadian Public Health Association . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC World Health Organization . ( 2005 ). The Bangkok Charter for Health Promotion in a Globalized World . Bangkok : World Health Organization . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC World Health Organization . ( 2013 ). Helsinki Statement on Health in All Policies . Helsinki : World Health Organization . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC © The Author 2016. Published by Oxford University Press. Available online at www.phe.oxfordjournals.org

Journal

Public Health EthicsOxford University Press

Published: Nov 1, 2017

There are no references for this article.