This Conference continued a sequence of events which began with the WHO commitment to Health Targets for All (1977), followed by the International Conference on Primary Care in Alma-Ata (1978), promoted by UNICEF/WHO, and then the 1st International Conference on Health Promotion in Industrialised Countries (Ottawa 1986).
The subsequent meetings on Healthy Public Policies (Adelaide 1988) and the Call to Action: Health Promotion in Developing Countries, (Geneva 1989), deepened and clarified the importance and meaning of health promotion.
In parallel with these health developments, public concerns about global threats that may affect the environment have grown dramatically. This has been clearly expressed by the World Commission on Environment and Development in its report Our Common Future, which has provided a new understanding of the imperatives of sustainable development.
This call to action is addressed to politicians and decision-makers in all relevant sectors and at all levels. Health, environment and social justice advocates and activists should form a broad alliance, aiming at the common goal of Health for All. We, the participants in the Conference, are committed to taking this message to our communities, countries and governments for action. We also call on the organisations linked to the United Nations to strengthen their cooperation and challenge each other to make a real commitment to sustainable and just development.
A favourable environment is of paramount importance for health. The two are interdependent and inseparable. We urge that their achievement be a central objective in planning development priorities. In the day-to-day management of government policies, whenever situations of conflict of interest arise, environment and health must take priority.
Inequalities are reflected in a growing health gap both within our nations and between rich and poor countries. This situation is unacceptable. Action to achieve social justice in health is urgently needed. Millions of people live in extreme poverty and suffer great deprivation in environments that are progressively deteriorating both in rural and urban areas. An alarming and unpredictable number of people are suffering the tragic consequences of armed conflicts for their health and well-being. Rapid population growth is a major threat to sustainable development. Many people have to survive without proper drinking water, adequate food, shelter or sanitation.
Poverty frustrates people's expectations and their dreams of building a better world, while limited access to political structures undermines the foundations of self-determination. For many, education is inaccessible or insufficient or, in its present form, fails in its mission to enable and empower. Millions of children lack access to basic education and have little hope for a better future. Women, who make up the majority of the world's population, continue to be oppressed, either sexually or through discrimination on the labour market and in many other areas, which prevents them from playing a real role in building favourable environments.
More than a billion people around the world do not have access to essential health care. Health care systems certainly need to be strengthened. The solution to these vast problems lies in the social action, resources and creativity of individuals and communities for health. Unlocking this potential requires a fundamental change in the way we look at our health and our environment and a clear and strong political commitment to sustainable health and environmental policies. Solutions are beyond traditional health systems.
Initiatives must come from all sectors that can contribute to the creation of health-friendly environments and be developed by people, in their local communities, at the national level by governments and non-governmental organisations and at the global level by international organisations. Action will predominantly involve sectors such as education, transport, housing, urban development, industrial production and agriculture.
In the context of health, the term health-friendly environments refers to the physical and social aspects that surround us. That is, the places where people live, work and spend their free time. This also involves the structural issues that determine access to vital resources and empowerment opportunities. Thus, action to create enabling environments has several dimensions - physical, social, spiritual, economic and political - inextricably linked, in dynamic interaction. To achieve solutions that are truly sustainable, action must be coordinated at local, regional, national and global levels.
The Conference highlighted four strands of Favourable Environments:
- The social dimension, which includes how standards, customs and social processes affect health. In many societies traditional social relations are changing in such a way that they tend to become a threat to health, as they lead, for example, to increased social isolation, to meaningless, inconsistent and aimless daily life or to sudden changes in traditional values and cultural heritage.
- The political dimension, which requires governments to ensure democratic participation in decision-making and to decentralise responsibilities and resources. It also requires a commitment to the defence of human rights and peace and the redirection of resources used in the arms race.
- The economic dimension, which requires a re-channelling of resources towards the goals of Health for All and sustainable development, including the transfer of reliable and secure technology.
- The need for recognition and use of women's skills and knowledge, in all sectors - including those of political responsibility and those related to the economy - in order to develop a more positive infrastructure to support favourable environments. The workload of women should be recognised and shared between men and women. Community women's organisations should have a strong voice in the development of Health Promotion policies and strategies.
The Sundsvall conference believes that proposals to implement Health for All strategies should reflect two basic principles:
1- Equity should be a key priority in creating health-friendly environments, freeing energy and creative power, including all human beings in this unique effort. All policies that aim for sustainable development must be subject to new forms of accountability in order to achieve a fair distribution of responsibilities and resources.
All action and resource allocation must be based on a clear priority and commitment to the poorest populations, alleviating the extreme poverty of marginalised people, minorities and people with disabilities. The industrialised world needs to repay the environmental and human debt it has accumulated through the exploitation of the developing world.
2 - Public action to create health-friendly environments needs to recognise the interdependence of all living beings and manage all natural resources, taking into account the needs of future generations. Indigenous peoples have unique cultural and spiritual relationships with the physical environment, which can be valuable examples to the rest of the world. It is therefore essential that they are involved in activities for sustainable development and in negotiations on their rights to property and cultural heritage.
A call for the creation of health-friendly environments is a practical proposal for action in Public Health at the local level, focusing on the role of environments in building health, enabling wider community involvement and control.
Examples from all parts of the world were presented at the Conference, concerning education, food, housing, social support and care, work and transport. These examples clearly show that health-friendly environments enable people to expand their capacities and develop their self-confidence. More information on these practical proposals is available in the Conference report, which is published in book form.
Based on the examples presented at the Conference, it was possible to identify four strategic public health actions, which are fundamental to promoting the creation of health friendly environments at Community level:
1 - Strengthening advocacy through community action, in particular using women's groups.
2 - Empower communities and individuals to control their health and environment through education and empowerment.
3 - To build alliances for health and for the creation of support environments, in order to strengthen the cooperation between strategies and actions promoted by health and environment.
4 - Mediate conflicting interests in society in order to ensure equitable access to health-friendly environments.
In short, the empowerment of people and community participation are seen as essential factors in a democratic Health Promotion strategy and as a driving force for self-confidence and development.
In particular, participants in the Conference recognise that education is a basic human right and the key element for political, economic and social change, so necessary to make health a possibility for all. Education must be accessible throughout life and be based on principles of equity, especially with regard to culture, social class and gender.
People are an integral part of the global ecosystem. Their health is fundamentally intertwined with the global environment. All the information available tells us that it is not possible to sustain the quality of life, of human beings and of all living species, without drastic changes in attitudes and behaviour at all levels, with regard to the management and preservation of the environment.
Concerted action to achieve a favourable and health-supporting environment is the challenge of our times.
At international level, there are major differences in per capita income, leading to inequalities both in access to health and in societies' ability to improve their situation and maintain an acceptable quality of life for future generations. Emigration from rural to urban areas has increased dramatically and, as a result, people living in very deprived and peripheral neighbourhoods with poor sanitation and drinking water supplies.
Political decisions and industrial development are very often based on short-term planning and economic gains that do not take into account the true costs of people's health and the environment. International debt absorbs much of the scarce resources of poor countries. Military spending is increasing and war, in addition to causing death and disability, is now introducing new forms of ecological vandalism. The exploitation of the labour force, the export and deposit of dangerous substances, particularly in the poorest and most disadvantaged countries, as well as the wasteful consumption of the world's resources show that the current development strategy is in crisis.
Urgent progress is needed towards a new ethics and a global agreement, based on peaceful coexistence, allowing for a more equitable distribution and use of the world's limited resources.
The Sundsvall Conference calls on the international community to establish new accountability mechanisms for health and ecology based on principles of sustainable health development. Achieving this requires unambiguous statements with an impact on programmes and policy initiatives relating to health and the environment. WHO and the United Nations Environment Programme (UNEP) should urgently step up their efforts to develop codes of conduct in the market and marketing of substances and products harmful to health and the environment.
WHO and UNEP should, as a matter of urgency, develop guidelines based on sustainable development principles for use by their member states. All bilateral and multilateral donor agencies, such as the World Bank and the International Monetary Fund, should use these guidelines in planning, implementing and evaluating development projects. Urgent action is needed to support developing countries in identifying and implementing their own solutions. Close collaboration with NGOs must be ensured throughout the process.
The Sundsvall Conference demonstrated once again that health, environment and development issues cannot be separated. Development must involve improving the quality of life and health as a guarantee of sustainable environmental preservation.
Only global action, based on global partnerships, can ensure the future of our planet.