An evolving process No one is fully healthy as long as some of us are sick, suffering and dying from causes that could have been prevented. This is one of the forces that have prompted the evolution from disease repair to health promotion by Hakan Hellberg A fter the Second World War a dominating aspect of many human endeavours was the feeling of interdependence , of social relations. This led to the development of social medicine and community health efforts. But the starting point remained the disease- oriented hospital and its profess- ional staff. The emphasis , during these early years of WHO , was on getting the cu- rative services out to the periphery, closer to people in their commu- nities. This was mainly done by professional staff, but in some in- stances it was realised that auxiliary workers with less training , or very little training, had to be used in or- der to ensure a greater spread of the services. It could be described as a centrifugal distribution of hos- pital medicine simplified. The new drugs that gradually became avail- W ORLD HEALTH, Jan ./Feb. 1988 able formed important tools in this development. As this process of decentralising the curative services continued , in many places they were combined Dr Hakan Hellberg, formerly Director of WHO's Division of Public Information and Educa- tion for Health, is now Chief Editor of the newspaper Hufvudstadsbladetin Helsinki, Finland. with preventive measures such as immunization and some degree of health education. Only rarely were these measures aimed at total cov- erage but they did reach those people who lived near the curative satellites. The concept of basic health ser- vices is a good description of this process. Those responsible for it tried to broaden the ·base so that the system of care could reach as many people as possible, but the whole system was determined from the centre and was carried out fun- damentally in terms of the hospital. Little by little some people became dissatisfied with this ap- proach , as they recognised that the reasons that underlay good health and disease in the community were not being given enough emphasis. For instance , it was quite common for the same children to come back again and again for the same treat- ment for the same diseases . Two village communities-one in India, one in Guatemala-build their own water facilities. Photos WHO/P. Larsen and WHO/UN The key role that the environ- ment plays in matters of health was now recognised. This in turn meant the involvement of specialists other than the traditional healing profes- sions ; water, food , housing, sanita- tion and education are all impor- tant prerequisites for health. If they are neglected, curative repair is only partly successful and may even be impossible. It was a short step from this to the concept of intersec- toral and multisectoral action. But the more clearly we recognised the need for such action and cooper- ation , the more the system to be managed became complicated; this is why such coordination and coop- eration, involving different sectors of interest and action, is so difficult. The kind of development that has been sketched here took place in several of the Member States of WHO , including some of the colonies 5 of Member States. The lessons learned were slowly spreading, but the rapid and unprecedented devel- opment of curative capabilities tended to overshadow the overall efforts of intersectoral health development. As usual , the ideology and the concepts developed more rapidly than the practical implementation. One of the reasons for this delay was the slowness and reluctance with which many of the training programmes for health workers ac- cepted change. One might say that all over the world we continued to train "tennis players" when "cross- country runners" or burly " football players " were needed. To perform in neat white clothing within a lim- ited area and according to set rules is all very well , but it can hardly 6 claim to have an effect on the total health situation of people and their communities. The political realities that under- line the prerequisites for health are integral aspects of the "world out there ," where readiness to take part in the rough-and-tumble processes of decision-making and power-sharing is required. The need to get involved in political re- alities was strengthened in WHO and its member countries when the new nations formed from former colo- nies and other parts of the develop- ing world in turn became WHO members. The participation of so- cialist countries and of industrialised countries experiencing rapid social and political change, such as the United Kingdom and the Nordic countries , also helped to change the An evolving process. Left: During the early years of WHO, the em- phasis was on the disease-oriented hos- pital and itsprofessional staff. Tubercu- losis patients in an old-style sanatorium in Europe. Right: In the early 1970s primary health care was born, and with it the concept of bringing health to all people. A commu- nity health worker on his house rounds in Nepal. Photos WHO and WHOff. Farkas international health scene , and the very issue of participation itself began to be felt in the field of health systems and health policy. Since the health needs in many countries were far greater than the resources available, particularly where people were living in a state of chronic crisis, it became neces- sary to consider carefully how exist- ing resources were to be spent. A number of different technical and systemic solutions for improving health and various models of plan- ning and decision-making made their appearance. They were devel- oped as appropriate solutions for different situations rather than just being copied without regard for their relevance. In WHO terminol- ogy, the slogan was " adapt don't adopt. " W ORLD HEALTH. Jan./Feb. 1988 Under the influence of all these factors, it was obvious that a new concept was emerging, and in the early 1970s primary health care was born. The Alma-Ata Declaration of 1978 incorporated all the ele- ments mentioned above. The con- ference on primary health care and the Declaration brought together the developments of several de- cades, and can be seen today as an important milestone for inter- national health. The business of putting into effect the noble ideas and practical concepts enshrined in the Declaration was and still is hampered by the fact that coun- tries move forward at a different pace and under the influence of various "cocktails" of forces all trying to influence the develop- ment process. WoRLD HEALTH, Jan./Feb. 1988 Even before the Alma-Ata Con- ference, the Member States of WHO had adopted the concept of Health for all by the year 2000. Specifically, this means the attainment by all cit- izens of the world by the year 2000 of a level of health that will permit them to lead a socially and econom- ically productive life. This there- fore goes further than the follow-up of Alma-Ata itself. In the Alma- Ata documents all the ingredients for a total new health understand- ing are there but, both at the con- ference and later during the imple- mentation, the focus was and still is too much on the medical and health care systems themselves. Certainly this is an important aspect but it also limits the perspective on health and the development of people's health in its totality. The Alma-Ata Declaration en- dorses and emphasises people's right to participation in matters concerning their own health. But it is not possible to introduce a special health democracy separate from the overall democratic processes in any given country, province or state. The overall process of pri- mary health care is slowed down as long as feudal or authoritarian models prevail. This is not only true in respect of the political systems but also within the hierarchies of the medical and health professions. To be willing to take each other se- riously, and to consider every per- son as a resource for his/her health as well as that of the community, requires a commitment to demo- cratic processes that is only gradu- ally taking root. 7 An evolving process In adopting health for all , the countries committed themselves to a process in which equity , solidarity and justice dominate. This is the very backbone of a healthy society , one in which the possibilities are opened up for people to involve themselves in their own health. As primary health care in many quar- ters became misunderstood as either primary medical care or in any case the business only of doctors and nurses, so it became necessary to move forward to a broader and more neutral concept and terminology that would embrace individuals yearning for participation as well as societal sectors, organizations and 8 institutions that are concerned about people's health but do not identify with the medical or health systems. Health promotion was then intro- duced , not to compete with primary health care but as a broadly encom- passing concept that is also neutral enough to be accepted by people with different interests and involve- ments. It is an example of the need to follow the evolution of our un- derstanding of health and disease and then to express this process, both conceptually and in terms of concrete action and interventions. Health promotion covers activ- ities that form concentric rings with- in rings . These rings also represent the different areas of emphasis that have come forward during the 40 Left: Young health workers in training in China-one of the first countries to apply political will to the concept of primary health care. Elsewhere those responsible for training programmes were-at first-all too reluctant to accept change. Right: Once the workers in a commu- nity have had training, their task is to pass on their learning to everyone con- cerned. A lesson in basic anatomy and family planning for a class of mothers in the Philippines. Photos W HO and W HO/Zafar W ORLD HEALTH, Jan ./Feb. 1988 years of WHO's existence. They can be compared to the cooking rings on an old wood-burning stove. In- nermost is the ring that represents individual capability and the capa- city to work for one's health and to handle one's disease or infirmity. This is surrounded by the next ring, representing the family and the local community with its health- related action. An important pre- requisite is the power to act politi- cally at the local level, in the area of local government. At local, re- gional and national level the medi- cal and rehabilitative services need to be reoriented so that they are able to support individuals and WoRLD HEALTH, Jan ./Feb. 1988 their commumtles in coping with both health and disease. As the community ring supports the individual inside it so the cre- ation of a healthy environment sup- ports the community, and this is the third ring. Already the number of actors involved is increasing and the complexity of the operations becomes more challenging. But as Dr Halfdan Mahler, WHO's Director- General, likes to say: "I am suspi- cious of simplifiers, give me com- plexifiers any time." To support decisions and actions in favour of a healthy environment calls for health policies that are backed by political commitment at An evolving process the highest level. This is the widest, national ring but it has to be sup- ported by international rings of solidarity and a sharing of every- thing that we know and all the resources that we have. No one is fully healthy as long as some of us are sick, suffering and dying from causes that could have been prevented. This has been one of the central forces that have prompted the evolution from dis- ease repair to health promotion. We need both. We need all the "rings" in order to form a platform that is capable of carrying the burden of ill-health, and the possibilities and hope for health . • 9
An evolving process No one is fully healthy as long as some of us are sick, suffering and dying from causes that could have been prevented. This is one of the forces that have prompted the evolution from disease repair to health promotion by Hakan Hellberg A fter the Second World War a dominating aspect of many human endeavours was the feeling of interdependence , of social relations. This led to the development of social medicine and community health efforts. But the starting point remained the disease- oriented hospital and its profess- ional staff. The emphasis , during these early years of WHO , was on getting the cu- rative services out to the periphery, closer to people in their commu- nities. This was mainly done by professional staff, but in some in- stances it was realised that auxiliary workers with less training , or very little training, had to be used in or- der to ensure a greater spread of the services. It could be described as a centrifugal distribution of hos- pital medicine simplified. The new drugs that gradually became avail- W ORLD HEALTH, Jan ./Feb. 1988 able formed important tools in this development. As this process of decentralising the curative services continued , in many places they were combined Dr Hakan Hellberg, formerly Director of WHO's Division of Public Information and Educa- tion for Health, is now Chief Editor of the newspaper Hufvudstadsbladetin Helsinki, Finland. with preventive measures such as immunization and some degree of health education. Only rarely were these measures aimed at total cov- erage but they did reach those people who lived near the curative satellites. The concept of basic health ser- vices is a good description of this process. Those responsible for it tried to broaden the ·base so that the system of care could reach as many people as possible, but the whole system was determined from the centre and was carried out fun- damentally in terms of the hospital. Little by little some people became dissatisfied with this ap- proach , as they recognised that the reasons that underlay good health and disease in the community were not being given enough emphasis. For instance , it was quite common for the same children to come back again and again for the same treat- ment for the same diseases . Two village communities-one in India, one in Guatemala-build their own water facilities. Photos WHO/P. Larsen and WHO/UN The key role that the environ- ment plays in matters of health was now recognised. This in turn meant the involvement of specialists other than the traditional healing profes- sions ; water, food , housing, sanita- tion and education are all impor- tant prerequisites for health. If they are neglected, curative repair is only partly successful and may even be impossible. It was a short step from this to the concept of intersec- toral and multisectoral action. But the more clearly we recognised the need for such action and cooper- ation , the more the system to be managed became complicated; this is why such coordination and coop- eration, involving different sectors of interest and action, is so difficult. The kind of development that has been sketched here took place in several of the Member States of WHO , including some of the colonies 5 of Member States. The lessons learned were slowly spreading, but the rapid and unprecedented devel- opment of curative capabilities tended to overshadow the overall efforts of intersectoral health development. As usual , the ideology and the concepts developed more rapidly than the practical implementation. One of the reasons for this delay was the slowness and reluctance with which many of the training programmes for health workers ac- cepted change. One might say that all over the world we continued to train "tennis players" when "cross- country runners" or burly " football players " were needed. To perform in neat white clothing within a lim- ited area and according to set rules is all very well , but it can hardly 6 claim to have an effect on the total health situation of people and their communities. The political realities that under- line the prerequisites for health are integral aspects of the "world out there ," where readiness to take part in the rough-and-tumble processes of decision-making and power-sharing is required. The need to get involved in political re- alities was strengthened in WHO and its member countries when the new nations formed from former colo- nies and other parts of the develop- ing world in turn became WHO members. The participation of so- cialist countries and of industrialised countries experiencing rapid social and political change, such as the United Kingdom and the Nordic countries , also helped to change the An evolving process. Left: During the early years of WHO, the em- phasis was on the disease-oriented hos- pital and itsprofessional staff. Tubercu- losis patients in an old-style sanatorium in Europe. Right: In the early 1970s primary health care was born, and with it the concept of bringing health to all people. A commu- nity health worker on his house rounds in Nepal. Photos WHO and WHOff. Farkas international health scene , and the very issue of participation itself began to be felt in the field of health systems and health policy. Since the health needs in many countries were far greater than the resources available, particularly where people were living in a state of chronic crisis, it became neces- sary to consider carefully how exist- ing resources were to be spent. A number of different technical and systemic solutions for improving health and various models of plan- ning and decision-making made their appearance. They were devel- oped as appropriate solutions for different situations rather than just being copied without regard for their relevance. In WHO terminol- ogy, the slogan was " adapt don't adopt. " W ORLD HEALTH. Jan./Feb. 1988 Under the influence of all these factors, it was obvious that a new concept was emerging, and in the early 1970s primary health care was born. The Alma-Ata Declaration of 1978 incorporated all the ele- ments mentioned above. The con- ference on primary health care and the Declaration brought together the developments of several de- cades, and can be seen today as an important milestone for inter- national health. The business of putting into effect the noble ideas and practical concepts enshrined in the Declaration was and still is hampered by the fact that coun- tries move forward at a different pace and under the influence of various "cocktails" of forces all trying to influence the develop- ment process. WoRLD HEALTH, Jan./Feb. 1988 Even before the Alma-Ata Con- ference, the Member States of WHO had adopted the concept of Health for all by the year 2000. Specifically, this means the attainment by all cit- izens of the world by the year 2000 of a level of health that will permit them to lead a socially and econom- ically productive life. This there- fore goes further than the follow-up of Alma-Ata itself. In the Alma- Ata documents all the ingredients for a total new health understand- ing are there but, both at the con- ference and later during the imple- mentation, the focus was and still is too much on the medical and health care systems themselves. Certainly this is an important aspect but it also limits the perspective on health and the development of people's health in its totality. The Alma-Ata Declaration en- dorses and emphasises people's right to participation in matters concerning their own health. But it is not possible to introduce a special health democracy separate from the overall democratic processes in any given country, province or state. The overall process of pri- mary health care is slowed down as long as feudal or authoritarian models prevail. This is not only true in respect of the political systems but also within the hierarchies of the medical and health professions. To be willing to take each other se- riously, and to consider every per- son as a resource for his/her health as well as that of the community, requires a commitment to demo- cratic processes that is only gradu- ally taking root. 7 An evolving process In adopting health for all , the countries committed themselves to a process in which equity , solidarity and justice dominate. This is the very backbone of a healthy society , one in which the possibilities are opened up for people to involve themselves in their own health. As primary health care in many quar- ters became misunderstood as either primary medical care or in any case the business only of doctors and nurses, so it became necessary to move forward to a broader and more neutral concept and terminology that would embrace individuals yearning for participation as well as societal sectors, organizations and 8 institutions that are concerned about people's health but do not identify with the medical or health systems. Health promotion was then intro- duced , not to compete with primary health care but as a broadly encom- passing concept that is also neutral enough to be accepted by people with different interests and involve- ments. It is an example of the need to follow the evolution of our un- derstanding of health and disease and then to express this process, both conceptually and in terms of concrete action and interventions. Health promotion covers activ- ities that form concentric rings with- in rings . These rings also represent the different areas of emphasis that have come forward during the 40 Left: Young health workers in training in China-one of the first countries to apply political will to the concept of primary health care. Elsewhere those responsible for training programmes were-at first-all too reluctant to accept change. Right: Once the workers in a commu- nity have had training, their task is to pass on their learning to everyone con- cerned. A lesson in basic anatomy and family planning for a class of mothers in the Philippines. Photos W HO and W HO/Zafar W ORLD HEALTH, Jan ./Feb. 1988 years of WHO's existence. They can be compared to the cooking rings on an old wood-burning stove. In- nermost is the ring that represents individual capability and the capa- city to work for one's health and to handle one's disease or infirmity. This is surrounded by the next ring, representing the family and the local community with its health- related action. An important pre- requisite is the power to act politi- cally at the local level, in the area of local government. At local, re- gional and national level the medi- cal and rehabilitative services need to be reoriented so that they are able to support individuals and WoRLD HEALTH, Jan ./Feb. 1988 their commumtles in coping with both health and disease. As the community ring supports the individual inside it so the cre- ation of a healthy environment sup- ports the community, and this is the third ring. Already the number of actors involved is increasing and the complexity of the operations becomes more challenging. But as Dr Halfdan Mahler, WHO's Director- General, likes to say: "I am suspi- cious of simplifiers, give me com- plexifiers any time." To support decisions and actions in favour of a healthy environment calls for health policies that are backed by political commitment at An evolving process the highest level. This is the widest, national ring but it has to be sup- ported by international rings of solidarity and a sharing of every- thing that we know and all the resources that we have. No one is fully healthy as long as some of us are sick, suffering and dying from causes that could have been prevented. This has been one of the central forces that have prompted the evolution from dis- ease repair to health promotion. We need both. We need all the "rings" in order to form a platform that is capable of carrying the burden of ill-health, and the possibilities and hope for health . • 9
An evolving process No one is fully healthy as long as some of us are sick, suffering and dying from causes that could have been prevented. This is one of the forces that have prompted the evolution from disease repair to health promotion by Hakan Hellberg A fter the Second World War a dominating aspect of many human endeavours was the feeling of interdependence , of social relations. This led to the development of social medicine and community health efforts. But the starting point remained the disease- oriented hospital and its profess- ional staff. The emphasis , during these early years of WHO , was on getting the cu- rative services out to the periphery, closer to people in their commu- nities. This was mainly done by professional staff, but in some in- stances it was realised that auxiliary workers with less training , or very little training, had to be used in or- der to ensure a greater spread of the services. It could be described as a centrifugal distribution of hos- pital medicine simplified. The new drugs that gradually became avail- W ORLD HEALTH, Jan ./Feb. 1988 able formed important tools in this development. As this process of decentralising the curative services continued , in many places they were combined Dr Hakan Hellberg, formerly Director of WHO's Division of Public Information and Educa- tion for Health, is now Chief Editor of the newspaper Hufvudstadsbladetin Helsinki, Finland. with preventive measures such as immunization and some degree of health education. Only rarely were these measures aimed at total cov- erage but they did reach those people who lived near the curative satellites. The concept of basic health ser- vices is a good description of this process. Those responsible for it tried to broaden the ·base so that the system of care could reach as many people as possible, but the whole system was determined from the centre and was carried out fun- damentally in terms of the hospital. Little by little some people became dissatisfied with this ap- proach , as they recognised that the reasons that underlay good health and disease in the community were not being given enough emphasis. For instance , it was quite common for the same children to come back again and again for the same treat- ment for the same diseases . Two village communities-one in India, one in Guatemala-build their own water facilities. Photos WHO/P. Larsen and WHO/UN The key role that the environ- ment plays in matters of health was now recognised. This in turn meant the involvement of specialists other than the traditional healing profes- sions ; water, food , housing, sanita- tion and education are all impor- tant prerequisites for health. If they are neglected, curative repair is only partly successful and may even be impossible. It was a short step from this to the concept of intersec- toral and multisectoral action. But the more clearly we recognised the need for such action and cooper- ation , the more the system to be managed became complicated; this is why such coordination and coop- eration, involving different sectors of interest and action, is so difficult. The kind of development that has been sketched here took place in several of the Member States of WHO , including some of the colonies 5 of Member States. The lessons learned were slowly spreading, but the rapid and unprecedented devel- opment of curative capabilities tended to overshadow the overall efforts of intersectoral health development. As usual , the ideology and the concepts developed more rapidly than the practical implementation. One of the reasons for this delay was the slowness and reluctance with which many of the training programmes for health workers ac- cepted change. One might say that all over the world we continued to train "tennis players" when "cross- country runners" or burly " football players " were needed. To perform in neat white clothing within a lim- ited area and according to set rules is all very well , but it can hardly 6 claim to have an effect on the total health situation of people and their communities. The political realities that under- line the prerequisites for health are integral aspects of the "world out there ," where readiness to take part in the rough-and-tumble processes of decision-making and power-sharing is required. The need to get involved in political re- alities was strengthened in WHO and its member countries when the new nations formed from former colo- nies and other parts of the develop- ing world in turn became WHO members. The participation of so- cialist countries and of industrialised countries experiencing rapid social and political change, such as the United Kingdom and the Nordic countries , also helped to change the An evolving process. Left: During the early years of WHO, the em- phasis was on the disease-oriented hos- pital and itsprofessional staff. Tubercu- losis patients in an old-style sanatorium in Europe. Right: In the early 1970s primary health care was born, and with it the concept of bringing health to all people. A commu- nity health worker on his house rounds in Nepal. Photos WHO and WHOff. Farkas international health scene , and the very issue of participation itself began to be felt in the field of health systems and health policy. Since the health needs in many countries were far greater than the resources available, particularly where people were living in a state of chronic crisis, it became neces- sary to consider carefully how exist- ing resources were to be spent. A number of different technical and systemic solutions for improving health and various models of plan- ning and decision-making made their appearance. They were devel- oped as appropriate solutions for different situations rather than just being copied without regard for their relevance. In WHO terminol- ogy, the slogan was " adapt don't adopt. " W ORLD HEALTH. Jan./Feb. 1988 Under the influence of all these factors, it was obvious that a new concept was emerging, and in the early 1970s primary health care was born. The Alma-Ata Declaration of 1978 incorporated all the ele- ments mentioned above. The con- ference on primary health care and the Declaration brought together the developments of several de- cades, and can be seen today as an important milestone for inter- national health. The business of putting into effect the noble ideas and practical concepts enshrined in the Declaration was and still is hampered by the fact that coun- tries move forward at a different pace and under the influence of various "cocktails" of forces all trying to influence the develop- ment process. WoRLD HEALTH, Jan./Feb. 1988 Even before the Alma-Ata Con- ference, the Member States of WHO had adopted the concept of Health for all by the year 2000. Specifically, this means the attainment by all cit- izens of the world by the year 2000 of a level of health that will permit them to lead a socially and econom- ically productive life. This there- fore goes further than the follow-up of Alma-Ata itself. In the Alma- Ata documents all the ingredients for a total new health understand- ing are there but, both at the con- ference and later during the imple- mentation, the focus was and still is too much on the medical and health care systems themselves. Certainly this is an important aspect but it also limits the perspective on health and the development of people's health in its totality. The Alma-Ata Declaration en- dorses and emphasises people's right to participation in matters concerning their own health. But it is not possible to introduce a special health democracy separate from the overall democratic processes in any given country, province or state. The overall process of pri- mary health care is slowed down as long as feudal or authoritarian models prevail. This is not only true in respect of the political systems but also within the hierarchies of the medical and health professions. To be willing to take each other se- riously, and to consider every per- son as a resource for his/her health as well as that of the community, requires a commitment to demo- cratic processes that is only gradu- ally taking root. 7 An evolving process In adopting health for all , the countries committed themselves to a process in which equity , solidarity and justice dominate. This is the very backbone of a healthy society , one in which the possibilities are opened up for people to involve themselves in their own health. As primary health care in many quar- ters became misunderstood as either primary medical care or in any case the business only of doctors and nurses, so it became necessary to move forward to a broader and more neutral concept and terminology that would embrace individuals yearning for participation as well as societal sectors, organizations and 8 institutions that are concerned about people's health but do not identify with the medical or health systems. Health promotion was then intro- duced , not to compete with primary health care but as a broadly encom- passing concept that is also neutral enough to be accepted by people with different interests and involve- ments. It is an example of the need to follow the evolution of our un- derstanding of health and disease and then to express this process, both conceptually and in terms of concrete action and interventions. Health promotion covers activ- ities that form concentric rings with- in rings . These rings also represent the different areas of emphasis that have come forward during the 40 Left: Young health workers in training in China-one of the first countries to apply political will to the concept of primary health care. Elsewhere those responsible for training programmes were-at first-all too reluctant to accept change. Right: Once the workers in a commu- nity have had training, their task is to pass on their learning to everyone con- cerned. A lesson in basic anatomy and family planning for a class of mothers in the Philippines. Photos W HO and W HO/Zafar W ORLD HEALTH, Jan ./Feb. 1988 years of WHO's existence. They can be compared to the cooking rings on an old wood-burning stove. In- nermost is the ring that represents individual capability and the capa- city to work for one's health and to handle one's disease or infirmity. This is surrounded by the next ring, representing the family and the local community with its health- related action. An important pre- requisite is the power to act politi- cally at the local level, in the area of local government. At local, re- gional and national level the medi- cal and rehabilitative services need to be reoriented so that they are able to support individuals and WoRLD HEALTH, Jan ./Feb. 1988 their commumtles in coping with both health and disease. As the community ring supports the individual inside it so the cre- ation of a healthy environment sup- ports the community, and this is the third ring. Already the number of actors involved is increasing and the complexity of the operations becomes more challenging. But as Dr Halfdan Mahler, WHO's Director- General, likes to say: "I am suspi- cious of simplifiers, give me com- plexifiers any time." To support decisions and actions in favour of a healthy environment calls for health policies that are backed by political commitment at An evolving process the highest level. This is the widest, national ring but it has to be sup- ported by international rings of solidarity and a sharing of every- thing that we know and all the resources that we have. No one is fully healthy as long as some of us are sick, suffering and dying from causes that could have been prevented. This has been one of the central forces that have prompted the evolution from dis- ease repair to health promotion. We need both. We need all the "rings" in order to form a platform that is capable of carrying the burden of ill-health, and the possibilities and hope for health . • 9