Last year's March/April edition of Global Perspectives focused on the issue of workplace health promotion and introduced several innovative initiatives in various countries. Two articles featured the global approaches of large corporations: Nortel Networks and Coca Cola. The trend emerging last year is now increasing: multi-national corporations are putting increasing resources into getting and keeping their global workforces healthy. Soaring health care costs, nationalization and privatization of health insurance plans, an aging workforce, and fierce competition in the global marketplace, are forcing the corporate world to invest more capital in their employees. Though companies have pursued a workplace health policy as long as companies have existed, with some major changes taking place, such as changes in the demography of the labor market, changes in the nature of economic activity, and changes in the nature of work, this area of human resource management has gained a new significance. Strategies and programs that call for building, recruiting and maintaining healthy and vital employees, are undoubtedly linked to high performance. Corporate activities have shifted from production to complex work operations requiring highly-qualified employees. In most large companies, the ratio of blue- and white-collar workers reversed over the last 20 years. A growing number of high-tech companies are in need of "intellectual capital," i.e., qualified, innovative, flexible, and motivated employees. To find these employees, employers must provide more than material benefits, such as personal freedom of action, possibilities of further development, respect and recognition by superiors, and healthy working conditions. This is where health promotion becomes an important business factor in a comprehensive human resource strategy.

Cost Savings or Fringe Benefit?

Corporations have different reasons for implementing health promotion programs depending on the corporate culture, regulatory environment, business cycle, industry sector, employee profile, etc. Many companies, especially in the United States, set clearly defined goals to decrease health care costs and absenteeism through effective health promotion programs. The incentive is great, as in most cases the employer carries the burden of the health care costs. On the other hand, other companies, most often in environments where the pressure to reduce health care costs is not as imminent (e.g., Europe), primarily look at health promotion as an added fringe benefit for the employees in order to create a more attractive working environment. Guenther Goth, co-head of Human Resources at Siemens, Germany, follows this line of thinking: "Trying to draw up a proper balance sheet would mean only analyzing the tip of the iceberg in the cost benefit sector. It would mean undoing the progress we have made with the introduction of the health management system and reducing the employee to a robot. How can you measure motivation and performance in units of currency?" (May, 1999). All companies strive to increase productivity and reduce absenteeism, but health promotion program managers in different companies are subject to varying levels of accountability.

Multi-National Corporations with Different Strategies

This issue of Global Perspectives will highlight five multi-national corporations and the different approaches they have taken to creating a healthy global workforce. All of these corporations, of which four have headquarters in the US and one in Germany, are making major efforts in developing global strategies which can serve as a framework for sites in any country. Dow Chemical is looking at ways to leverage the knowledge and experience that has accumulated over years of successful programming in the United States. Caterpillar is in the process of coordinating and expanding the many piecemeal measures at their international sites to make a visible impact on productivity. Decentralized programming is the motto for Santa Clara based Applied Materials as regionally specific programs are encouraged, as is an integrated approach. AIG has developed the Global Wellness Initiative, which is tasked with incorporating wellness components into their clients' international benefits packages. Finally, Siemens, a major global electrical engineering and electronics company based in Germany, is following a holistic approach in order to stay competitive in the global economy.

This edition's country spotlight is on Ireland, a fascinating and economically booming country in the European Union, and with a growing health promotion movement. The last two pages provide a brief overview of a very significant event with regards to international health promotion: The 5th Global Conference on Health Promotion, hosted by the World Health Organization (WHO) in Mexico City, from June 5-9. Selected case studies are introduced, as well as an overall summary from the perspective of various IIHP members. Especially noteworthy, is the signing of a Statement for the Promotion of Health by over 100 Ministers of Health.

The Dow Chemical Company is a global science and technology based company that develops and manufactures a portfolio of chemical, plastic, and agricultural products and services for customers in 168 countries around the world. With annual sales of more than $18 billion, Dow conducts its operations through 14 global businesses, employing 39,000 people. The company has 123 manufacturing sites in 32 countries and supplies more than 3,500 products. Dow’s vision is to "provide superior solutions for our customers and society through science and good thinking."

Health promotion has a strong tradition at Dow Chemical. The Occupational Health Services Function has been serving the employees for more than seven decades with health education and preventive health activities. A formal distinct health promotion program was started at the corporate headquarters in 1985. In 1988, this effort evolved to include the creation of a corporate expertise/resource center for health promotion to serve the global operations of Dow. The program received the C. Everett Koop Award for Health Promotion in 1994, and international recognition in 1996 when the Brazilian Association of Life Quality (ABQV) presented Dow with the award for outstanding performance in health promotion. Dow Chemical administers health promotion as part of the Health Services Expertise Center within the Environment, Health, and Safety function. It is a shared service, which is leveraged across the entire corporation and individual business units.

Dow’s Aims and Strategies

Dow’s Health Promotion Management Standard is a key factor for global standardization, effective focus and future success. Health promotion at Dow has three objectives: to improve the health status of Dow people, to positively affect the health related costs of Dow people, and to be perceived as a valued service by Dow people. Health Promotion at Dow is part of a larger Integrated Health Management effort designed to capitalize on Dow’s human investment.

Dow’s Global Health Promotion Resource Center coordinates services to international locations, develops and/or identifies core products and services, provides subject matter expertise, maintains best practice technology, ensures standardization, eliminates redundancy, evaluates effectiveness, and monitors quality. The mission is to drive and leverage the most cost-efficient and effective health promotion programs, services, and resources across global sites for optimal Health Promotion delivery.

Dow has a truly global approach to its health services, including health promotion. For example, a global stress assessment tool exists to promote stress management, and monthly health awareness fliers are translated and distributed internationally. The programmatic issues for 2000 are life management and physical preparedness, i.e. being healthy to perform the job successfully. A more holistic approach to health promotion is envisioned for the future. A worldwide health campaign addressing total health (mind, body, and spirit) is planned, including issues such as depression, nutrition, stress, substance abuse and workload. Improved integration with other health-related services, e.g., health benefits, training and development, employee assistance programs (EAP), and occupational health services, is also a priority.

Health Promotion Site Expertise Leaders are accountable for site health promotion planning, delivery, administration, and evaluation within North America. Outside of North America, health promotion is implemented primarily by Occupational Health physicians, nurses, and/or contractors. Health promotion professionals, with the proper credentials, are recruited from a variety of health-related sources, primarily from either the health education or physical education field.

Integration and Participation

Comprehensive information systems are being looked at to integrate group health, worker’s compensation, participation, and absenteeism data at Dow. Global participation data is not available, however, the global injury and illness rates have steadily dropped over the last decade. 1999 was the best year so far in Dow’s history with an all-time low of 0.98 per 200,000 work hours. The health promotion programs are believed to be a major factor in this trend. Dow will continue to recognize the value of health promotion in improving health and employee productivity, and therefore continuing to link health strategies with business strategies.

Nancy Lamb is the Global Resource Center Manager for Health Promotion and can be reached at NELAMB@dow.com (e-mail) or 517-638-7251 (fax).

Caterpillar: Investing in a Lifetime of Well-Being by Bev Gilmore

Caterpillar began operations in 1925 with three facilities in the United States and has grown to more than 200 facilities and more than 66,000 employees worldwide, of which 28,500 are outside the United States. Headquartered in Peoria, Illinois, Caterpillar Inc. is the world’s largest manufacturer of construction and mining equipment, diesel and natural gas engines, and industrial gas turbines. Caterpillar is one of only a handful of US companies that leads its industry whilst competing globally from a primarily domestic manufacturing base. More than half of Caterpillar’s sales are to overseas customers. Caterpillar is committed to servicing a product throughout its life, monitoring product health, scheduling maintenance and repairs, and minimizing their customers’ cost of doing work. This same philosophy is extended to the way Caterpillar’s employees are treated, with the company investing in the health and well-being of employees throughout their work life.

A Central Focus

Caterpillar has encouraged its facilities throughout the world to implement health promotion programs that fit the culture of their population. Until 1997, programming had no central focus, but met the needs of each geographic location. In 1997, the Corporate Medical Department developed a core program to provide consistency, direction and measurements to evaluate the effectiveness of interventions offered. The program was designed to improve the health of employees, reduce health care costs, and urge employees and their families to assume responsibility for their health. As a self-insured employer, health care has a direct impact on the profitability of the company. Caterpillar spent over a million dollars a day in 1999 to pay for medical benefits for US-based employees, retirees, and their dependents.

Healthy Balance^SM

Caterpillar’s Healthy BalanceSM program is central to the company’s health management agenda; it gets its direction from the corporate medical director located at corporate headquarters, and is supported by a health promotion manager and a small staff. All facilities are encouraged to enhance the core program with exercise programs, weight loss campaigns, smoking cessation techniques and other health initiatives provided in the community. Most larger facilities have medical departments staffed with physicians and registered nurses who provide screening exams and other occupational health initiatives. Other sites have coordinators whose job responsibilities are outside of health promotion, but volunteer to administer health promotion programs. "Healthy BalanceSM News," a health newsletter developed internally, is distributed to most English-speaking employees in the US and abroad. The newsletter is also translated into French and Portuguese where appropriate. Ninety-five percent of US-based employees, and ninety-six percent of spouses, participate in the Healthy BalanceSM program.

Caterpillar Brasil S.A, .in Piracicaba, Brazil, also runs a comprehensive Quality of Life program, directed by a Caterpillar physician. The Brazilian program includes a medical clinic for employees and their families where health needs as well as lifestyle behaviors are addressed. Physicians may prescribe any number of behavioral classes at the Quality of Life Center, exercise regimes, etc. In addition, the Employee Center offers recreational facilities for the entire family. This focus on quality and employee initiatives resulted in the receipt of the Brazilian National Quality Award in 1999.

Global Programming

Caterpillar uses live satellite broadcasts to feature health initiatives at facilities around the world. Recently, a group of employees from Skinningrove, England, were shown walking along the coast at lunch and challenging other global facilities to do the same. Testimonials from employees are also featured, e.g., an employee in Russia was encouraged and supported by his coworkers to quit smoking and he succeeded. One Japanese employee and his wife have begun to walk five miles a day around the Imperial Palace in Tokyo, Japan, after being encouraged by Healthy BalanceSM News. The facility in Australia offers blood pressure and other screenings, along with health newsletters, to support healthy lifestyle changes.

Caterpillar anticipates that with the ability to measure the impact on productivity, the Healthy BalanceSM program will be expanded throughout Europe and many other parts of the world. Caterpillar’s health promotion programs will also be expanded to retirees in the U.S. and Europe as appropriate. Some disease management modules, which show lots of promise in the area of diabetes and heart diseases as secondary prevention are also being piloted.

Bev Gilmore is Health Promotion Manager and can be contacted at Gilmore_Beverlee_L@Cat.com (e-mail), or 309-675-1076 (fax).

Decentralized Programming: The Case of Applied Materials by Judy Webster

Applied Materials is the leading supplier of semiconductor wafer processing systems and services worldwide. Established in 1967, it now has approximately 15,000 employees in over 80 locations worldwide and revenues of over US$ 4 billion per year. Applied Materials employees have an average age of early thirties. The company mission is to be the leading supplier of semiconductor fabrication solutions worldwide through innovation and enhancement of customer productivity with systems, process modules and service solutions. The wellness program was initiated in 1989 at the request of Chairman of the Board, Jim Morgan, to help employees improve basic health and thereby increase productivity. Applied Materials strives to provide a variety of tools and resources to employees throughout the world to enable them to develop their own personal wellness program, a key to success at Applied Materials.

The Wellness Programs

All full-time employees worldwide are eligible to participate in the wellness programs. Applied Materials follows a decentralized approach with regionally specific programs. Multiple departments work together to create an integrated approach: Benefits; Safety; Occupational Health; Risk Management; Human Resources; Food Service; and Corporate Affairs. In addition, individual product divisions administer joint programs to maximize resources. The programs focus on lifestyles and self-care to maintain and improve basic health and maximize productivity. Depending on the location, the following areas are targeted: health appraisals; nutrition/weight control; physical activity/fitness; stress management/work life balance, which include an employee assistance program and community events; special population programs; and online services. Specific risk factors targeted are stress, lack of physical activity, obesity, high blood pressure and nutrition. While participation varies from program to program, an overall rate of 39% has been documented. Every two years a global employee survey is conducted, which includes questions on wellness and work life programs. The US operations also administer an employee satisfaction survey. Some international offices have their own employee wellness satisfaction surveys. A formal evaluation including the tracking of health care costs, worker’s compensation, absenteeism, turnover rates, and disability data is performed in the United States. The annual report compares health claim costs and absenteeism rates between participants and non-participants.

Regional Variations

Applied Materials wellness programs have corporate health promotion staff in Santa Clara, California, Austin, Texas, and Taiwan. All other sites often rely on individuals from nursing and human performance related fields, who volunteer to organize employee wellness activities. But in all cases, the programs have a different focus according to country and culture:

• People’s Republic of China: The government sponsors group exercises in the office during work time. Other activities include sports competitions such as table tennis, jump rope, volleyball, and walking.

• Japan: Offices are smoke-free, health club memberships are subsidized in some locations, and other discounted sports and social activities are offered. The Korean program is closely tied to occupational health services, and features smoking cessation, fatigue management, and stress reduction.

• Taiwan: The office has an on-site fitness center with full-time staff which offers massage, hair salon, facials, relaxation lounge, and evening educational sessions.

• Singapore: The site offers employee sports days, family days, bowling, sports leagues, and lunch and learn sessions on basic health, fatigue management, travel health, and shift-work health.

• Israel: Various on-site fitness centers exist. Other programs offer employee fitness events, healthy foods in cafeterias, recreation days, and stress management.

• Ireland: Offerings include educational sessions, stress management weekends, and reimbursement for health and fitness activities.

• United Kingdom: Health and fitness club memberships are subsidized, cafeterias serve healthy foods, smoking cessation and exercise classes are offered on-site.

• Continental Europe: Various sites focus on family recreation activities as well as provide subsidized health club memberships, and offer stress management activities.

Concerns

Challenges for the future include reaching remote employee groups and securing participation in fast-paced work environments, which allow little time for personal activities. Other critical issues Applied Materials face abroad are finding qualified staff, complying with local and employee welfare legislation, and making programs culturally appropriate. A continuing need exists to convince the management of the value of health promotion for the employees and company.

Judy Webster is the Director of Corporate Wellness and can be reached at Judy_Webster@amat.com (e-mail).

Ensuring Wellness: American International Group by Mary Schmitz

American International Group, Inc. (AIG) is a multi-national insurance company which focuses on the health of the workforces of its US-based multinational clients through the Global Wellness Initiative. AIG is US-based and is the largest underwriter of commercial and industrial insurance coverage in the United States. Headquartered in New York, AIG employs 40,000 people through a network of worldwide offices. AIG's Group Management Division has operations in 85 countries and provides group life, medical, and disability products to more than 22,000 firms and 3.5 million lives.

The Global Wellness Initiative

AIG’s Group Management Division developed the Global Wellness Initiative in 1996 in response to the overwhelming support for health promotion programs indicated in the Louis-Harris survey of 400 US-based and 20 Europe-based multinational companies. More than 90 percent of respondents believed that employee wellness programs would become a key component of international benefit packages within the next five years. However, the primary concern of benefit managers was how to implement this type of program in a variety of countries. The Global Wellness Initiative works with the clients interested in wellness activities to identify specific goals that vary from country to country. These goals can be tied to corporate priorities, health or business needs recognized by local management, statistics on the country's morbidity and mortality, medical claims data, or in-country health initiatives. An in-country needs assessment is completed to determine such items as the site's existing communication resources; past experiences with site-wide programs; and particular cultural concerns and supportive program activities and policies at the site that affect implementation decisions. This could include information on the percentage of office vs. field workers; current demographics; involvement of the unions; availability of eligibility list; reliability of addresses; preferred delivery sites; on-site health care providers; company smoking policy; and fitness and nutrition resources available at the facility. The programmatic features offered include a country-specific health assessment, feedback to participants on their priority health areas to address, and a group report; adapted and translated brochures on topics such as walking, stress, smoking cessation, and weight management as well as customized newsletters, both licensed from the HOPE Heart Institute.

International Wellness

The first health assessment for employees of the Otis Elevator Company in Spain, reached participation rates of more than 40 percent. Other wellness activities, such as brochures and health fairs, have been offered in Peru, Mexico, and Panama. Evaluation measures are based on the health assessment’s documentation of risk areas, readiness to change, physician visits, hospital stays, and absenteeism.

The Global Wellness Initiative is becoming more and more aware of the differences in motivation, environment, and values with regard to health promotion in the international market compared to the US. For example, decreasing health care costs may not always be the prime reason for implementing programs, but rather employee retention and recruitment. In addition, organizational health often plays a bigger role in other countries, e.g., in Europe, than in the US where individual health is the priority. Cultural norms have varying influences on the programs, e.g., the high status of the physician in many countries, or the significance of confidentiality, play an essential role. Lack of access to modern technology (e.g. computers, internet) is also an important factor when designing a program.

Mary Schmitz is a consultant to AIG's Global Wellness Initiative and can be reached at HTMaryS@aol.com (e-mail).

Siemens: A Holistic Approach by Nancy Lamb

Siemens is a global electrical engineering and electronics company based in Germany with 436,000 employees across 190 countries. This multi-national corporation has adopted a holistic approach to health management. It has been calculated that Siemens spends roughly 100 million Deutsche Marks, which amounts to approximately US$ 200 million, on employee health care every year. This includes 80 occupational physicians and their first-aid stations, occupational medical check-ups, spa facilities used by 2,100 employees every year, sports amenities, rehabilitation measures after serious illnesses, social consultants, and other health-promotion activities. In order to stay competitive in the global marketplace, especially in the high-tech industry, Siemens has made it a priority to address the demands of the modern-day employee by creating a favorable working environment, motivation incentives, and a corporate culture with which everyone identifies.

Human Resources at the Core

Human resources policy is an integral element of Siemens’ business strategy. The policy is based on the following factors: leadership and cooperation, staff development, recruitment, pay systems, and workplace health management. Under health management, the company strives to create general conditions in which the employees enjoy working by advocating proactive health promotion. In 1996, the project, "Top in Form," was initiated. This project started with a detailed analysis of absenteeism causes and obstacles to better performance. Crucial factors affecting health and performance were leadership style, work stress and personal behavior, poor working climate, information and communication, working conditions, job security, individual constitution, private life, corporate culture, self-motivation, and "unjust" pay. This analysis had far-reaching consequences for the managerial staff. Managers are now assessed on their efforts to promote cooperation within their team as well as the extent to which they support the personal development of their staff. The managers are also accountable for what they do to maintain their own personal, physical and mental capacity. The system is aimed at establishing a culture of dialogue and trust. This culture is enhanced through interviews regarding development, promotion, and recognition of staff, "manager discussions" during which employees get the chance to evaluate their direct superior, and staff surveys, in which employees can provide comments anonymously on a variety of issues (e.g., customer benefit of their work).

Through the "Top in Form" program, Siemens was able to produce financial savings by reducing absenteeism rates from 4.4% to 3.3% in two years. However, Siemens’ philosophy with regard to workplace health promotion may be best described by Guenther Goth’s (co-head of human resource management at Siemens) statement that "it is totally non-sensible to compare the income and expense of a health management system in purely economic terms." Dr. Goth views the measurement of motivation, commitment and performance in units of currency as impossible, and underlines that investments in employees always pay dividends.

From "The Importance of a Modern Workplace Health Policy as a Competitive factor. Strategies and experience of Siemens AG" by Guenther Goth, co-head of Human Resources at Siemens, at the Conference of the European Network for Workplace Health Promotion, May, 1999.

"Health promotion is the science and art of helping people change their lifestyle to move toward a state of optimal health. Optimal health is defined as a balance of physical, emotional, social, spiritual and intellectual health. Lifestyle change can be facilitated through a combination of efforts to enhance awareness, change behavior and create environments that support good health practices. Of the three, supportive environments will probably have the greatest impact in producing lasting change." (American Journal of Health Promotion, 1989, 3, 3, 5.)

Country Profile Health and Health Promotion in 21st Century Ireland by Sharon Friel, Department of Health Promotion, National University of Ireland, Galway

There are currently over 3.6 million people living in the twenty-six counties of the Republic of Ireland. Although traditionally a country of agriculture, unemployment and emigration, on entering the 21st century, Ireland finds itself as one of the most economically vibrant countries in Europe. Major demographic and economic changes took place in the latter half of the twentieth century, one result being net immigration in the Republic for the first time since the seventies. With 41% under the age of 25 years, Ireland has the highest proportion of young people in Europe. We have not yet experienced the boom in elderly population as in other countries worldwide, but with increasing life expectancy, and continuing decline in birth rate, the proportion of citizens over the age of 65 years is steadily growing.

Although longevity has increased for both males and females, Ireland continues to experience one of the worst mortality rates in Europe for the two major chronic diseases, cardiovascular disease and cancer. Recent figures from the national statistical office show age standardized mortality rates of 212.2 for ischaemic heart disease, and 213.3 per 100,000 for malignant neoplasms.

Social and cultural change

In parallel with the demographic and economic changes has been major social and cultural reform. The reduction in family size has implications for care of older people, urbanization continues to escalate nationwide and the arts movement has gained in stature. Peace on the island of Ireland is now a very real possibility with the political troubles of Northern Ireland coming to an end, thanks to the collaborative efforts of UK and Irish governments and with the help of the US.

Changes in society are echoed in our attitudes towards and behaviors in health and lifestyle practices. The first ever national health and lifestyle surveys of adults and young people were carried out in 1998. The Survey on Lifestyle, Attitudes and Nutrition, SLÁN, comprised 6,539 participants, representative of Irish adults over 18 years of age. Information on a range of topics such as general health and well-being, lifestyle behaviors including tobacco and alcohol use, and diet and exercise habits was collected. The Health Behavior in School-going Children, HBSC, followed an international protocol and collected data from 8,497 participants in 187 nationally representative schools. Interesting findings arose, particularly in relation to smoking and alcohol. Only those people aged 55 years and over are close to the Department of Health’s target of 20% smoking prevalence. Alarmingly high levels of smoking were observed amongst women in their teens and early adulthood years, particularly in lower social groupings. Where once the paradox of high alcohol consumption and high rates of teetotalers existed, most Irish adults now drink alcohol on a regular basis. This type of behavior is also being observed in the young people, many of whom experiment with alcohol and report high levels of misuse.

Health promotion

Although health education has been prominent in Ireland since the mid-1970s with the establishment of the Health Education Bureau, formal recognition of the discipline and role of health promotion in Ireland did not begin until the early nineties. One of the four professorial chairs in Health Promotion in Europe was established in the National University of Ireland, Galway, under the auspices of the Department of Health and Children. Further acknowledgement followed in the 1994 national health strategy and continual establishment of health promotion’s role in pursuing health and social gain was made in the first national health promotion strategy published in 1995 "…making the healthier choice the easier choice…."

Over the last decade, there has been major organizational change. A National Consultative Committee on Health Promotion was established in 1995. Chaired by the Minister for Health, it comprises representatives from statutory and voluntary organizations who have an impact on health in the community. Reorientation of our health services was initiated through the establishment of Public Health and Health Promotion Departments in each of the eight regional health boards, led by senior management and with dedicated budgets.

The type of approaches taken in health promotion have also seen change. A range of health education and promotion initiatives have concentrated around the four key settings community, school, workplace and hospital. We have come a long way in Ireland in terms of developing healthy public policies, health promoting infrastructure, population monitoring, and research programmes. There is now a wealth of information and research in Ireland which did not previously exist. Policies have been formulated, drawing on the data acquired, which aim to sustain and develop positively evaluated health promoting initiatives in a range of settings and population groups. The health promoting schools initiative has been supported at policy level, the recently launched workplace health promotion policy recognizes the changing employment environment in Ireland, and the recent national cardiovascular strategy, Building Healthier Hearts, encompasses health promotion, primary and secondary care in all population groups and encourages both community and hospital based heart health initiatives.

The recently established National Unit for Health Status and Health Gain in the National University of Ireland, Galway, grew from the need to research and address the patterns of inequity which seem to be arising perhaps inevitably in parallel with rapid economic and urban development. Evidence of sociodemographic and economic variations in health outcomes have been observed in most evaluation work over the past decade and was confirmed by the SLÁN and HBSC data where clear social gradients were observed in high-risk lifestyle behavior and self-reported health and quality of life.

The current updating of the national health promotion strategy identifies strategic aims and objectives which will guide health promotion research and practice in the 21st century. It expresses further the need for inter-sectoral and multi-disciplinary partnerships in influencing policy formulation, re-orientation of health services and programme development and implementation. Making the healthier choice, the truly easier choice for Irish people, requires political support, transparent partnerships, adequate resources and committed research and evaluation.

Sharon Friel B.Sc., M.Sc. is Assistant Academic Director of the Department of Health Promotion, National University of Ireland. She has responsibility for the Nutrition and Lifestyle section of the department which includes the National Nutrition Surveillance Centre. Areas of research interest are nutrition and lifestyle surveillance, health inequalities, nutritional epidemiology and research methodology. Her current doctoral thesis is on food and health inequalities and Irish policies. Her e-mail address is, Sharon.Friel@nuigalway.ie.

Several recent initiatives in health promotion from around the world were presented at the conference hosted by the World Health Organization in Mexico City from June 5-9.

Calcutta

Professor Indira Chakravorty discussed street food stalls in Calcutta, India. Describing the city’s street food vendors as "the nutritionists of the poor," Chakravorty underlined the importance of these businesses in India’s urban economy, but she also noted that street stalls may pose a substantial health risk to consumers. An FAO supported study in Calcutta by the All-India Institute of Hygiene and Public Health (AIIHPH), revealed that both food and water from the stalls were likely to be contaminated by various microbiological forms.

The AIIHPH adopted an holistic approach, beginning with extensive consultations and discussions with city government, food vendor unions, the vendors themselves, the local police, and Calcutta consumers. From these discussions, several strategies were conceived and implemented to promote health in street vendor food sales. A vendor licensing system was devised, along with a funding system for improvement and maintenance of food stalls. Plans were made to limit food vending to certain streets in the city so that potable water supply could be ensured. The municipal government provided trash services, while other authorities carry out regular inspections of food and water to ensure microbiological and chemical quality. Innovative training courses were delivered to food inspectors and to street vendors, while consumer awareness of the necessity for hygienic delivery of food services was raised. A local concern produced a prototype ideal food cart using local materials at a reasonable cost.

Though there has not been a second food and water assessment program since the implementation of these new policies and procedures, Professor Chakravorty noted that other assessments of the industry have observed a significant improvement in environmental and hawking conditions. Similar programs have been adopted in other parts of India, and in other parts of Asia, where street food vending is an important industry.

Gaza, Palestine

Liesbeth Zonneveld outlined waste disposal problems which confronted the Palestinian municipality of Gaza in 1993. She discussed and assessed the strategies used to tackle significant hazards to health and the environment. With funding from the European Union, Gaza established the Gaza City Solid Waste Management Project, which aimed not only to achieve regular and economical waste collection and disposal, but to also improve overall living conditions in Gaza and to make the city a healthy one. Ms. Zonneveld, who works as a consultant to the Gaza project, noted that the endeavor was divided into two parts: purchase of "hardware," such as refuse collection vehicles, waste containers, and landfill equipment; and implementation of "software": environmental health promotion, training, and bureaucratic restructuring.

After three years, the improvements in Gaza were significant, notes Ms. Zonneveld. Streets are clean and the air quality has improved. Complaints about waste disposal dropped from 33 a month per 100,000 to 1.6 a month per 100,000 in the years since the waste management project began. Additionally, the partnerships and participation processes developed to further the goals of the waste management project, have become a permanent feature of the ways in which the municipality and its citizens seek to promote the health of their community and improve the quality of life in Gaza.

Lower Saxony, Germany

Drs. Michael Drupp and Rudiger Krech presented the details of a pilot initiative aimed at the promotion of worker health in the Lower Saxony region of Germany. WHO partnered with the regional association of Local Sickness Funds to create an incentive for private enterprises to invest in health.

Thirty-seven leading companies were involved. Local Sickness Fund managers, combined with ongoing support and external perspectives in assessment, along with planning assistance were used to assist each company to set its own health priorities. For example, one company opted to allow workers to select their own shifts, organized work schedules to accommodate both family patterns and social interaction between employees.

As a result, the participating companies have noted increased productivity, fewer absences, and decreased expenditure on health care. However, Drs. Drupp and Krech noted that the project raised some questions yet to be answered, such as, how to turn the immediate findings into long-term benefits; how can workplace health measures become standard business practice; can lower health-related costs in the workplace be translated into tax reductions or lower insurance premiums?

Fifth Global Conference on Health Promotion in Mexico City, June 5-9

Close to a thousand technical experts, health secretaries, and other officials gathered in Mexico City from June 5-9 for the 5th Global Conference on Health Promotion hosted by the World Health Organization (WHO). The five-day conference was titled "Bridging the Equity Gap" and for the first time included participation of Ministers of Health from numerous countries. Over 100 ministers signed the Ministerial Statement for the Promotion of Health, which calls for actions to promote health through regional, national, and international policies and intersectoral collaboration. Each country will follow a countrywide plan of action for health promotion. The WHO will provide technical assistance and monitor progress towards the listed goals.

Framework for Countrywide Plan of Action for Health Promotion

A framework for this plan of action was discussed and agreed upon during the conference. The following objectives were identified:

1. To position health as a main goal of social and economic development.

2. To mobilize financial and operational resources to build human, institutional and civic capacity for the development, implementation, monitoring and evaluation of countrywide plans of action.

3. To support research, which advances knowledge on how to develop and realize human, institutional and civic capacity and potential.

4. To identify health priorities and establish healthy public policies and appropriate programs to address these priorities.

5. To establish or strengthen national and international networks which promote health and mutual support among countries and communities.

In preparing plans of action it will be necessary to keep in mind the following key questions:

- Where is health created?

- Which investments produce the largest health gain?

- Which investment reduces inequities and ensures human rights?

The planning process should include a number of common steps: needs assessment and identification of priorities; definition of goals, objectives, and outcomes; choice of strategies; drafting; implementation of the plan; and evaluation. The Ministry of Health will take the lead, coordinate collaboration with other ministries (e.g., finance, transport, environment), the cabinet, and receive technical assistance from international agencies (e.g., WHO), professional bodies, and academic institutions. The plan of action for effective health promotion involves various types of activity:

- Raising public and political awareness

- Communicating health promotion message

- Proposing healthy public policy

- Strengthening community action for health; and

- Creating supportive environments and encouraging healthy lifestyles.

An Interdisciplinary Approach to Health

The conference heavily emphasized the perception that health goes well beyond the health sector. The presented case studies ranged from a democracy and governance program in Nigeria, to social activism for housing in the United Kingdom. Dr. Gro Brundtland, Director General of the World Health Organization, pointed out in her opening speech that "promoting health means transcending the narrow slot traditionally labeled ‘health promotion’. That is why, when I am asked who is in charge of health promotion at WHO, I answer: ‘I am’. All departmental staff, be they in Geneva, the regional or the country, have explicit health promotion responsibilities."

Renewed Reorganization at WHO

The WHO has undergone renewed restructuring. Health promotion is not a separate department anymore, and Pamela Hartigan, previously interviewed by Global Perspectives (Vol. 2, No. 3), moved from Director of Health Promotion to another position within WHO. Health promotion has now been placed together with non-communicable disease prevention in one department, and will be led by Alex Kalache, formerly in charge of the Active Aging initiative. This department falls under the "Non-Communicable Diseases and Mental Health" cluster.

Technical Papers at Conference

Accomplished experts presented technical papers in six topical areas:

1. Strengthening the Evidence Base for Health Promotion

2. Investment for Health

3. Social Responsibility

4. Increasing Community Capacity and Empowering Communities for Promoting Health

5. Infrastructures to Promote Health: the Art of the Possible

6. Reorienting Health Systems and Services with Health Promotion Criteria: a Critical Component of Health Sector Reforms

These papers were further discussed in breakout sessions throughout the week. Case study presentations (please see the "Global Initiatives" page) and networking sessions rounded out the program.

Observations of IIHP Members

Numerous IIHP Members attended the conference, some of them provided Global Perspectives with a critical view:

Julita Maradzika of the University of Zimbabwe in Harare: "Although the presented case studies were very good, they did not clearly outline the concepts from the technical papers and did not provide lessons learned in terms of a systematic process for the planning of health promotion programs. The Ministerial Statement was non-committal but the framework for a countrywide action plan will be helpful for countries. The structure of the WHO is confusing and seems disappointing with regard to health promotion as it is confined to one department. Participants from Africa felt that more case studies from Africa could have been included and that communicable diseases should also have been addressed".

Peter Paulus of the University of Lüneburg, Germany: "The Ministerial Statement was disappointing in terms of innovation. The main accomplishment is that over 100 Ministers of Health signed the statement. It was not clear how all the sessions tied into the conference theme "Bridging the Gap", and it was difficult to appropriately prepare as the technical reports were not available before registration. Furthermore, the future for health promotion globally is up in the air because no upcoming conferences or events were announced".

Ricardo De Marchi of CPH Técnologia em Sáude, São Paulo, Brazil: "In spite of the presented challenges for health promotion professionals, the participants showed a high level of commitment. I left the meeting motivated and felt that the professional integration was a strong point of the conference. I now have more arguments to use here in Brazil regarding the significance of health promotion and the need to change strategies in the health services".

More information on the conference can be found at www.who.int/hpr/ conference. In addition, the "World Health Report 2000 – Health Systems: Improving Performance" just came out and can be viewed on the internet at www.who.int/whr.

The International Institute for Health Promotion (IIHP) is a global center for the development and advancement of health promotion policies, programs, services, and research that maximizes multiple efforts across the globe.  It was established in 1994 as an addition to the National Center for Health Fitness at American University in Washington, DC, to assist in leading, facilitating, and coordinating the efforts of many international individuals and organizations.  More than 50 cooperating members from 25 nations form an extensive interdisciplinary health promotion network that includes ongoing dialogue, information exchange and project participation.  Email the IIHP at iihpaa@american.edu.  The IIHP website is http://www.healthy.american.edu/iihp.html. 

Conference Dates

The 2000 Pre-Olympic Congress hosted by the International Council of Sports Science and Physical Education (ICSSPE), Sports Medicine Australia, and the Australian Council of Health, Physical Education and Recreation. Brisbane, Australia, September 7-13, 2000 .

"The Role of Physical Activity in the Prevention and Treatment of Cardiovascular Diseases: Biological Mechanisms and Policies at Regional, National and European Level". Hosted by the US Libertas Castagnaro in collaboration with the Castagnaro Municipality, Verona, Italy, October 14, 2000.

Fifth Annual Meeting of the International Institute for Health Promotion (IIHP), American University, Washington, DC, USA, October 18-21, 2000.

European Conference: "Health-Enhancing Physical Activity and Active Living for You and Your Community". Belfast, Northern Ireland, October 22-24, 2000.

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