Medical Edirtafiori 1988, 22, 67-77

REPORT

UNIVERSITY O F EDINBURGH CONFERENCE, 23 MAY 1987

The University and the wider concept of health

K. M. PARRY

Scottish Couricil for Postgraduate Medical Educatiori

Opening the Conference Principal SivJobti Burnett referred to its origin in the technical discussion that had taken place at the World Health Assem- bly (WHA) in 1984. Universities had been invited in the Assembly’s Resolution 37/31 to develop increasing involvement and to respond to the growing social challenge of providing ser- vices in their own countries; they should devote at least some of their considerable resources to the furtherance of health. The Conference had been convened as a pilot study initiated by the Committee of Vice-Chancellors and Principals (CVCP) to explore ways and means of respond- ing to the Resolution in the United Kingdom. Health in its broadest sense was not an easy con- cept to grasp, and he hoped that the Conference would continue to attempt to define it, as well as developing some indicators on how the univer- sities should respond to the WHA initiative.

Proferror Henry Wulton, Chairman of the Organizing Group and Professor of International Medical Education, outlined the Resolution, which was in three parts. Its preamble noted that univcrsities throughout the world had a growing involvement with social challenges and increasingly sought to provide services to their local communities. They should be recognized as resources for promoting the health of their com- munities although, as Professor Walton showed, not all the 174 countries of the world had univer- sities of their own. The majority of universities were in Europe, North America, South America, India and other parts of Asia; other

Correspondence: Dr K. M. Parry, Scottish Council for Postgraduate Medical Education, 8 Queen Street, Edinburgh EHz IJE, UK.

countries, such as some of those on the continent of Africa, had no more than one, but the number was increasing rapidly throughout the world. The WHA resolution. referred not only to the university faculties committed to the health pro- fessions but to all faculties that might contribute to the promotion of health in the widest context. Professor Walton welcomed the decision of the Committee of Vice-Chancellors and Principals to invite Edinburgh University to hold the pilot conference to consider both the provision of health care and the promotion of health; he saw the universities addressing the central problem of how to combine commitment with objectivity and scientific independence of thought with involvement in social participation.

Professor George McNico/, Principal of Aber- deen University, representing the CVCP, con- gratulated Edinburgh University on its initi- ative, which he regarded as timely, relevant and imaginative. He felt that the UK’s longstanding record of involvement in health issues world- wide had been impressive, and had continued under the auspices of the British Council and the overseas development programme in which Bri- tish universities were deeply involved. He listed a variety of university commitments to matters of health, particularly in Third World countries, which were not confined to faculties of medicine. Health economics, for instance, was an increasingly important way of ensuring that the best use was made of constrained resources. Universities were themselves conscious of the need to recognize their organizational respon- sibilities individually and collectively, and to establish closer links with industry. Mechanisms

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for ensuring academic standards were under scrutiny, and this could extend into areas o f academic content.

T h e Lord Provost o f Edinburgh, Dv Johri iVfacKay, discussed the city’s expectations from the University in the wider context of health; these were inevitably influenced by the tradi- tional involvement oflocal government in public health and by the contribution o f the University to that activity as an institution for teaching and research. Local government had a longstanding commitment to the creation o fa healthy environ- nient by the control o f pollution and the provi- sion and control of housing. These were essentially defensive functions concerned with the protection o f citizens from the ill effects of their o w n and other people’s activities. This was becoming increasingly important as the popula- tion increased; the ways in which homes were heated, food prepared, goods manufactured and transport used could have seriously damaging effects on health directly and environmentally. Ikterni ining acceptable levels o f pollution was an essentially political decision, but niust be based on the best possible advice. From their earliest involvement in public health, local authorities had had the benefit of the advice of medical officers trained in universities. T h e basis of local government intervention and its direc- tion were likewise influenced by research under- taken in universities into the causes of disease. I n an increasingly complex world the city must expect from its University a continuation o f con- cern for public health which should not be coii- fined to its excellent comniunity and occupational medicine activities: this should be based on research activities in many other University departments, arid include work on dangers to health which should be identified before new manufacturing processes were adopted. I n addition to traditional public health activities, local authorities were concerned with problenis o f modern society, for example the stresses and strains o f family life in highrisc buildings, the effects of unemployment in a n affluent society, and the sensitive issues o f government intervention. T h e involvement o f the city in the actual promotion of health by providing a variety of recreational facilities might need to be extended and there might be ways in which the University could assist in

devising methods o f persuading individuals o f the impoctance of their personal health.

Summarizing, the Lord Provost listed four expectations of the University held by the city:

( I ) a continuation o f the University’s established interest in community and occupa- tional medicine;

( 2 ) an extcnsiori o f this as new industries developed and new problems arose within established industries;

( 3 ) assistance with the identification o f the health consequences of social problems and the preparation of countermeasures; (4) help with the identification o f the role o f the

city in its active promotion of individuals’ health consciousness.

Pvqfessov Air hre y Mmi t i i i ip, Ilepar tment o f Zoology, welcomed the emphasis given to the involvement in health o f faculties other than medicine. A healthy population could be achieved only if there was a better understanding of h o w society worked, and there must be a proper balance between seeking ways of improv- ing health and recognizing a new threat to humanity; ‘sustainability’ within the planet in which w e lived was a key issue in the definition o f health. Solving medical problems was c o n - paratively straightforward coniparcd with those o f human bchaviour. Conventions had to be challenged, and conflict was inevitable, for example within the food industry. H e suggested two ways in which the university could help to improve understanding about how the world worked-recognizing among today’s ‘cranks’ tomorrow’s visionaries-for instance, keeping an open niirid on aspects o f ‘fringe’ medicine which might be the basis ofriew holistic practice, and mobilizing the health of the planet, since the health o f people was inseparable f rom the health o f the land. H e recognized that it was hard for universities to break d o w n departmental barriers but this was essential ifstudents at undergraduate level were to benefit f rom a broad university education. Courses were too specialized, and it should be recognized that specialist training should bc undertaken in the postgraduate rather than the undergraduate stage of training.

DvJohn Banrrqft, M R C Reproductive Biology Unit , drew attention to the very rapid rate at which medical science was developing, for example in molecular biology. Increasing

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specialization created barriers to communication between specialties, yet if proper use was to be made ofnew information it should be integrated into a more holistic concept of the body, illness and health. He was anxious therefore that there should be an attempt to bridge the gap between disciplines and to remove or reduce barriers to communication. The Centre for Social Epi- stemics was an example ofhow disciplines might work better together and suggested that cogni- tive science was another example of inter- disciplinary collaboration among centres throughout the world. In his own professional experience the field ofhuman sexuality, although specialized, required a grasp of a variety of dis- ciplines, for example biochemistry, endocrino- logy, neurophysiology , pharmacology, psycho- logy, sociology and psychotherapy. This posed an academic task in its own right-the ability to integrate knowledge from different disciplines and to synthesize a broader understanding of the subject. He suggested that two types ofacademic might be required-the specialist focusing on very special areas, and the integrator, who had the ability to bring together information from different disciplines. Although the first type was well catered for in the current university system the second was not, and there was little formal recognition of the need for career opportunities and encouragement for the development of this particular type of scholastic ability.

Professional education in the University

Dr A. L . Muir, Department of Medicine, Chair- man of the Undergraduate Curriculum Com- mittee, described the training of doctors in the Faculty of Medicine. The present 5-year course had been introduced in 1976 and subsequently modified in the light of the Kecomniendations of the General Medical Council in 1980. The course did not aim to produce a competent practising doctor but one who was broadly educated in human biology and who became competent to practise through subsequent postgraduate train- ing. The course was in three phases-a ground- ing in the sciences on which medicine was based and their application to medical practice, an introduction to the main disciplines of clinical medicine, and a period of apprenticeship where the student acquired a concept of patient care in

various disciplines. The aim was to help students to develop professional skills such as the ability to elicit, record and interpret a medical history and the symptoms ofphysical and mental illness, and to identify problems and how they might be managed. They learnt how to carry out simple clinical procedures, deal with common medical emergencies and communicate effectively with both patients and professional colleagues. They should also develop the skills necessary to use laboratory and other diagnostic and therapeutic services effectively and economically and in the best interests of patients. It was important too to help students to develop appropriate attitudes to the practice of medicine, which included the recognition of the need for a blend of scientific and humanitarian approaches and concern for the interests and dignity of the patient. Students had to learn the limitations of their own knowledge and develop willingness not only to seek further help where necessary but to cultivate a capacity for self-education and recognize an obligation to contribute to the progress of medicine, evaluat- ing critically new knowledge arid methods of medical practice. With an ever more complex health service it was increasingly important to foster good working relationships with members of other health care professions.

The General Medical Council regarded the acquisition of defined knowledge, skills and atti- tudes as essential, but this was not an exclusive catalogue of the qualities and capacities required in basic medical education. Medicine was con- stantly changing and hence education must adapt as new sciences such as molecular biology evolved. Change within the medical faculty was impeded, however, because of current budgetary arrangements by which departments were funded according to the number of hours they taught; no department was willingly going to reduce its hours of teaching, and ‘full-time equivalence’ was a powerful disincentive to change. Dr Muir also suggested that there was a need for change in matters of assessment, which were currently by way of qualifying examina- tions under the general supervision of the General Medical Council. H e suggested that con- sumer interests should be reflected in the knowledge, skills and attitudes taught to medical students, and he thought the views of health boards and patients should be considered.

Dr A m Fuulkrrer, speaking for Professor Petmy Prophit, Department of Nursing Studies, described health as an essential value in nursing. By tradition, nursing as a discrete health dis- cipline had been defined as health oriented, Florence Nightingale’s Notes oti Nurririf ( I 859) emphasizing that nursing the person was the pro- per concern ofnursing, not the disease. A century later Virginia Henderson described the unique function of the nurse as t o assist the person, sick o r well, in the performance o f those activities contributing t o health or its recovery (or to a peaceful death) that he would perform unaided if he had the necessary strength, will o r knowledge, and to assist in such a way as to help him gain independence as quickly as possible.

Preparation for competent and compassionate practice in riursing involved the development and growth o f whole people to care for whole people. T h e curriculum in nursing therefore focused not only on the hands/skills/doing o f nursing, and the head/cognitive/knowing o f nursing, but also the heart/affective/being o f nursing. The process of values clarification was one of the major ways in which this last and essential aspect of nursing education was being taught and experienced. Health as a concept and basic value in nursing was explored conceptually as well as the implications o f a rehabilitative focus and an advocacy role orientation. T h e artistry o f nursing practice was studied in terms of the heal- ing, therapeutic agent of care, and involved the skills of communication and intuition.

T h e complementary and interdependent nature of medicine arid nursing were emphasized, recognizing that each had a deci- sion-making function and each needed the other. There were a number of areas in which doctors and nurses had equivalent competences and others in which both doctor and nurse had unique competence. Through the introduction of individualized, patient-centred care in nurs- ing, with the valuing o f the whole and unique person w h o was patient o r client, nursing was moving into a new era. Perhaps one could say that nursing was now able to appreciate the central values and role that health played in nurs- ing tradition and was rediscovering the wisdom of Nightingale in her description o f the nature o f nursing.

Prqfessor. Johrr Howie, Lkpartment of General

Practice, said that the W H A Resolution had listed nine recommendations for W H O which were mainly administrative, I I for governments that would require political will to implement, and I 3 for universities. These were all attractive and possible but would need major personal cornmit- nient f rom individuals as well as f rom institu- tions to make their achievement possible. To convert rhetoric to reality, he wished to make three suggestions, but before doing so he drew attention to common confusion between ‘health’ and ‘illness’, and between ‘primary care’ and ‘general practice’, terms which were not syn- onymous. H e spoke as one interested in ‘health and primary care’, having been trained in ‘illness and general practice’: the latter was the stand- point f rom which his faculty o f medicine assumed he would teach arid research. That introduced his first point-it was easier to build ‘health for all’ into a programme in a developing country o r a new medical school than it was to change priorities and emphases in ‘I developed country and in an old established, prestigious research-led medical school; in short it was easier to till a void than a vacuum.

His second point was that reality told him that investment was nowadays largely dependent on achievement. Within the University, the Medical Faculty and the Scottish H o m e and Health Department he had been encouraged t o ~ i i o v e his interests from the ‘medical’ to the ‘behavioural’ model, but he had been handicapped by tradi- tional funding constraints which had left him without infrastructure resources for ‘risk’ academic development. It had taken him 7 years to achieve the platform he felt he necdcd to start researching ‘health for all’ within the context in which he worked.

Thirdly, in universities in the past decade coii- cepts of daniagc limitation and development had been in sharp and uncomfortable juxtaposition with each other; everyone in charge o f a dcpart- ment saw their primary priority as defending staff Icvcls, curriculum time arid ‘full-time equivalent’ costs. T h e limiting ‘departmental’ model in the Faculty of Medicine was slowly beginning to change but the difficulties thcse evolutionary processes involved deterred him from tackling seriously thc wider challenge of cross-faculty developments. Rhetoric said ‘times change and w e change with them’; reality said

The wider concept of health 71

‘the more things change, the more they remain the same’. He would like to think the opposite- that the commitment to change had to be from ‘people’ as well as from ‘the institutions’ they worked in.

Proferror Barvie Wilson, Department of Architecture, Director of the Centre for Social Epistemics, said that despite the large number of regulations and codes buildings had to satisfy which had their origins in a concern for health, the word was rarely used in architectural educa- tion or criticism. He raised two points: that in at least one profession in which health was a basic aim the word was hardly mentioned; and that the aim of health was present-albeit by inference- only in terms of the avoidance of ill health, with ill health defined in terms of medically recogniz- able symptoms. There were currently quite a number of what had become known as ‘sick buildings’, the product of the energy crisis- well-sealed buildings whose design or operation cut ventilation in an effort to save energy to the point a t which the air in them became of poor quality, resulting in high rates of absenteeism among the people using them. No doubt techni- cal solutions would be found to these problems but what kind of concept of health did they embody? They might instruct designers on what they must do to avoid conditions that would otherwise lead to non-health-a double negative, treating health only as something assumed to exist if bad practices did not disturb it. In architecture a need for knowledge about health was felt only when health was absent-as with the ‘sick buildings’-and as soon as the problem was solved the need disappeared.

The consequences of adopting this narrow concept of health could be generalized. By ‘nar- row concept’ he meant health defined as the absence of illness-something which sent one to a doctor. Existentially, normal life and work and the need for knowledge about health defined this way were mutually exclusive. Except for the health and health-related professions, health was an issue only when it was absent; and when it was absent, the normal work and aims of the profes- sion were impaired or impossible. Once the problem had been cured the absence of ill health carried with it the absence of the need for knowledge about health-only for practices that avoided ill health. The fact that some professions

were regarded as being health-related-thereby implying that others were not-was the nub of the issue. If the other professions were to incor- porate a concern for health as such in their prac- tices a wider and deeper concept of health was needed.

T w o kinds of distinction appeared to be generally useful: one was between positive approaches to health and negative or ‘elimina- tive’ definitions of it; the other involved existen- tial and objective concepts. The narrow view was both eliminative and objective-it treated health as the negative of ill health, and focused attention on objective, scientific knowledge about ill health and its removal. This approach had cer- tainly been necessary for the development of modern medicine and had produced, and would continue to produce, uncountable benefits. It was not an eitherlor question, but a bothland one-a need to embed a narrow concept in a wider one. Without non-health-without ill- ness-there could be no concept of health; but that did not mean that health had to be treated as a flat, featureless tableland on which everything else was built, with only its outer edges and beyond mapped out. Health as well as illness had its geography and its topography, although a somewhat different language was needed to describe them.

The knowledge-base of architecture was dominated by two rather different interests: one had everything to do with functional utility, with roots in applied science, economics, etc; the other was about the visual appearance and special char- acter of buildings treated as three-dimensional objects; building construction linked the two. What kind of modern man was implied by an architecture that leant heavily upon these two sources of knowledge? If one assumed that build- ings were for people and were strongly condi- tioned by the knowledge used in their design, then the model of man implied by contemporary architecture was of a mobile machine with an educated eye. But a different model of man would produce a different framework for profes- sional thought and action. It would lead to shifts of emphasis and require different forms of knowledge. For instance a model derived from a phenomenological approach to all the meanings of being in and among buildings would de-emphasize the objective and quantitative pro-

72 K . M . Pavvy

perties of buildings-whether visual or utilitarian-and concentrate upon giving these their proper place in a hierarchy of values derived from the whole gamut of experience and response. In the action-oriented worlds of the professions, knowledge was a means to an end, not an end in itself. The true end was the total condition and state ofbeing-soundness in body, mind and spirit-of the ultimate recipients of the use of the knowledge-in the case of architec- ture, the users of buildings; in the case of health, all people. It was a false and mischievous use of technical knowledge if it was allowed to define and delimit that state. The professions needed to be continually on guard against forgetting that their specialized models of their clients were simply abstractions with a technical purpose, and not realities.

Concluding, Professor Wilson said it was easier to talk about health than to do anything about it. I t would be different if a concept of health were to be generally adopted which was not only wide enough to include both illness and well-being, but which was open at the ‘well’ end. This would imply a different and much more comprehensive model of man than appeared to underline many mainstream considerations of health at the moment. He had suggested that architecture had an analogous need, and this might also be true ofother professions, including education generally. With such an open model there would be no difficulty in spreading health concerns into many if not all aspects of the universities’ work. The model would be on the way to becoming a common property, and the specialized models of each profession could then be embedded within it.

Dv Helen Zea l l ey , representing Lothian Health Board, drew attention to the WHO challenge of ‘Health for All by the Year zooo’. The main themes were greater equity in health: the addition of years to life-by preventing premature deaths; the addition of health to life-by preventing unnecessary ill health; and the addition of life to years-by ensuring respect and the opportunity to develop self-respect despite illness and/or dis- ability. To achieve these aims it would be necess- ary to seek active inter-sector cooperation and greater participation by the public at all levels of decision-making about health. So far most of the bodies who were taking active steps to move

towards the ‘health for all’ goal in the UK were, with the exception of general practitioners and community physicians, outwith the universities, outwith health professional groups and, sadly, outwith Scotland. She asked how well the goals of the medical curriculum were being attained, and whether in the interaction between the doc- tor/nursing roles and responsibilities the patient was being lost sight of as an equal partner in the arrangement. Referring to adverse comments on the present curriculum she drew attention to cur- rent perceptions ofmedical training and the auto- cratic behaviour of some health care staff, which were consistent with Pendleton’s (1984) reminder that society still criticized the medical profession not for lack of skill in combating dis- ease but for ignorance and insensitivity in coping with the patients’ ideas, concerns and expecta- tions, i.e. their ‘well-being’. A much earlier report (Eron 1955) had drawn attention to the main changes in student attitude during medical education, which were loss of idealism, growth of cynicism, and detachment from the patient. Although this was not universally true sufficient concern was being expressed to draw attention to the challenge of packing in all the necessary knowledge and skill while at the same tinie encouraging an appropriate degree of detach- ment and maintaining an idealistic commitment to improving health and well-being. This could only come about if the teachers believed all three to be important.

Dvjark Pottev, Executive Dean ofthe Faculty of Medicine, said that ‘health’ defied precise defini- tion but it had been said that the primary goal of medicine was to enable everyone to die healthy. Lewis Thomas had remarked on the inherent robustness and self-repairing capacity of the human frame when it was not poisoned, starved, infected, infested, or-at the outset-genetically impaired. He underlined the importance of biomedical research for the future well-being- and even survival-of mankind, including for example basic behavioural studies as a key to understanding and humanizing the political mind. Behavioural and other types of research might ultimately get to the root of major disease problems, but meantime what appeared to be 3

fundamental human need for mood-altering chemicals and experiences deserved a more prag- matic approach. Referring to D r Muir’s and Pro-

73 T h e wider concept of health

fessor Howie’s comments on the medical curriculum, he thought the importance of ensur- ing competence in its graduates must be the first concern of any medical school. In the UK com- petence in the medical graduate implied the ability to undertake pre-registration training safely, productively and rewardingly. There were undoubtedly many additional worthwhile exposures which might serve to enrich the undergraduate medical experience and aware- ness, but only those that contributed to compe- tence were truly essential. Today the body of knowledge was so immense that it was essential to evolve efficient methods of learning; these were not the same as efficient methods of teach- ing although the present financial circumstances of the universities put a premium on efficient teaching at the expense ofeffective learning. For- tunately, the quality of students entering medicine remained high in terms of intellectual capacity, motivation and aptitude, and the majority retained much of their initial idealism although they grew more reticent about it.

In discussion the ‘high-tech’ and ‘low-tech’ con- cept as applied in the architectural and medical professions was regarded as highly relevant to the conference; ‘high tech’ was in many respects incompatible with the aim of ‘health for all’, yet was far more interventionalist. The needs of different societies varied enormously, and both ‘high’ and ‘low’ technical developments were necessary to reflect those varying needs; they should not be seen as mutually exclusive-it was as important for people in Scotland to learn how to avoid a heart attack as to be able to have specialized treatment for it. Responsibility for these complementary aspects of care should be shared: the university should not confine its interest to ‘high-tech’ development, and the con- tribution of departments which specialized in ‘low-tech’ changes should be regarded as ofequal merit. A positive approach to health was needed, rather than a negative response to social problems.

The University and society Dv A l e x Robertson, Department of Social Policy and Social Work, discussed the significance of change in the pattern of disease, and its effect on the planning of health services. There had been a shift from acute diseases with well-defined

aetiology, to chronic and degenerative condi- tions that were far less well defined and which required complex management. He suggested there was a need to move towards more com- prehensive services and closer integration with social services to enable people to adapt to the limitations of medical treatment. He raised three issues-policy emphases, policy-making struc- tures, and the content of policy.

New emphases in policies were a product of greater cost control, calling for better manage- ment and more efficient, although not neces- sarily more effective, services. There was a move away from dependence on services and towards self-help and prevention. Strategies for the latter were not well developed in the UK in relation to human behaviour, health care organization, lifestyle or environment; these four concepts should be used as means of identifying an approach to health. I11 health could be quantified, for example by epidemiological studies; degenerative conditions, such as arthritis, were less easily described. Although complex, the problem was not insoluble. Crude distinctions between lifestyle and environment could be drawn and preventive policies described, with greater emphasis on the responsibilities of the individual and those of industry, for example in relation to sugar and tobacco. Other countries had been more willing to enter the sensitive area of defining nutritional and food policies-creat- ing an environment where individuals could make more sensitive choices and discouraging health-threatening activities, for example by subsidies on health foods. In this potential area for the development of health policy universities should be able to identify the applications in their own countries and consider problems of imple- mentation, devising systems which dealt with uncertainty and a search for consensus to enable a flexible policy to evolve, able to adapt to chang- ing knowledge and understanding.

Health service structures needed to come to terms with a shift in emphasis from acute to chronic conditions, taking account ofthe concept of adaptation rather than cure. Consumer par- ticipation had been negelected in the UK both at the level of the delivery of health services and at the level of the receipt of services. Consumers needed to be involved in the allocation of resources because of the increasing expense of

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health care. Consumer input in Britain was reac- tive and was dominated at the political level by professional advisers. In other countries more harmonized structures had been developed, with elected members working with professionals in determining local needs.

Profesror Frank Bechhofer, Research Centre for Social Sciences, said the age-old dilemma for universities was whether they should be dispas- sionate and detached-as seekers after truth-or passionately and indissolubly involved with the societies in which they were embedded. Speak- ing as a sociologist who had studied inequality, class, status and power, he referred to a variety of reports and studies concerned with health and its close association with social factors and especially social inequality; he mentioned in par- ticular the work of Thomas McKeown, the Lalonde Report, the Black Report, the ‘Health Divide’ (from the Health Education Council) and the ‘Health and Lifestyle Survey’ recently published by the Health Promotion Research Trust. These, and other overwhelming evidence, had shown that health and illness were clearly patterned by social rather than individual factors which were not simply scattered randomly around the population; they were highly struc- tured, particularly by occupation and class, by region and, in very complex ways, by gender. The recognition of structured inequality was at the heart of the welfare state. Want, ignorance, idleness, squalor and disease were the great evils identified by Beveridge in 1942 which had to be tackled in order to improve ‘welfare’, and these were almost identical with the problems ofhealth in the sense it was being used today. The solu- tions were to have been through social security, education, full employment, building and environmental programmes and the National Health Service, but since 1942 all the data sug- gested that inequality had not been reduced and might indeed have increased. There were still many unemployed and low-income families, income was unevenly distributed and wealth even more so, vast tracts of housing were effec- tively uninhabitable, and homelessness was anything but uncommon-all structural factors closely related to health and illness. Circum- stances for the median person and family had improved, but the range of inequality had not been reduced; ‘health for all’ could not be

achieved by the year 2000 by raising median stan- dards-there would need to be a sizeable measure of redistribution. Whatever explanations were given, social class and regional variations in health and health provision were undeniable, and redistribution would be necessary unless vast additional resources were available. These issues were highly politicized, and there was obvious incompatibility between some political stances and the goal of ‘health for all’. Moreover, the structural processes involved in perpetuating a situation in which a large minority of British citizens were denied ‘health’ paled into insignifi- cance beside those affecting the Fate of the Third World.

Universities naturally tended to see concepts in straight educational or research ternis; the research potential of ‘health for all’ was undenia- ble, but that was not the essence of the matter. If the universities were to be involved as institu- tions they should understand precisely what was implied; the W H O demand of ‘health for all’ was not a simple prescription to be approved on the nod-it raised fundamental questions about, among other things, the role of universities in the modern world.

MY Graham Robertson, Lothian Health Board, put forward some practical proposals for ways in which the universities might work to promote health. He was assuming that health would be seen in its widest sense, as being concerned as much with well being and the quality of life as with the absence of disease, that is, as a resource for living; and secondly that health promotion, which sought to create an environment in which people participated in aspects of their health care and which was conducive to the maintenance of health and the encouragement of well bcing, would be regarded as desirable. These assump- tions underlined the need for a multidisciplinary approach to health promotion, which in turn depended upon the contributiou of mauy dis- ciplines and departments. Promotion of health demanded the further development of multi- disciplinary teaching but this must entail real joint activity and not token gestures. Students in many disciplines should learn to recognize the health dimension in whatever field they would be working, and this would require considerable interfaculty and interdepartmental cooperation, involving for example economists, social scien-

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tists and technologists. Cooperation between the university and other organizations was also desirable, particularly in the research field. He cited an example in Germany where a university associated with its local community on an ecological project gave assistance to the coni- munity, including the university campus itself, to improve the environmcntal conditions under which people were living. The work involved the community itselfand sought to recreate areas of ground which were practical, stimulating and pleasing to live in. The project was appealing, because it demonstrated a number of issues at the core of the Conference’s theme, namely that health was about the quality oflife; that teaching and research could involve communities in a mutually beneficial and practical way; that other views of what health was about were welcomed and respected; and that there were communal as well as individual responsibilities for health.

Edinburgh University and the community

D r Una Maclean, Department of Community Medicine, reminded the Conference that Edin- burgh University had been founded as ‘the Toune’s College’ and its medical graduates had earned a reputation for their ‘civic character’, being concerned with society as well as with sickness. Public health had been formally taught for over a hundred years, and she asked whether, with such a legacy, the University could feel satisfied with its achievements. At first sight it seemed as if the ancient college offered a wealth of educational and cultural opportunities to citizens who wished to enlarge their experience and quality of life, and the presence of a medical centre of excellence was an undoubted benefit to the local populace, as was the professional train- ing provided for dentists, veterinary surgeons, ministers of religion and lawyers. The Depart- ment of Extra-Mural Studies and public lectures served a range of interests, and a variety of centres provided for the occasional participation of selected outsiders. Cultural tastes were enhanced by concerts, opera, amateur theatri- cals, art shows and physical culture. But she felt the University was ministering to a highly selected population and there were undoubted class distinctions to be discerned among the reci- pients of its largess. Education was still not

available to all who could benefit from it and the broad extra-mural offerings attracted university graduates who had already benefited from higher or superior education.

Her own discipline of public hcalth had uncovered grave differences in the life chances of separate sections of British society. Those who had the misfortune to be poor, especially those that had been born and reared in deprived cir- cumstances, had a markedly reduced life expec- tancy when compared with the better-off. They would not live so long after retirement, they suffered more chronic illness, and their chance of dying from practically every classified cause was greater. The premature death of adults was all too common in Scotland, and Edinburgh was no exception; sheer physical disease limited the sur- vival of a disturbing proportion of the popula- tion. Education, like public health, was a political issue and the University should boldly proclaim the association between ignorance, poverty and ill-health-until these were remedied the broader concepts of health would remain insubstantial and self-indulgent. Du David McQueen, Research Unit in Health

and Behavioural Change, described the princi- ples of health promotion, which involved the population as a whole in the context of their everyday life rather than focusing on people at risk from specific diseases. It was directed towards action on the determinants of causes of health, and combined diverse but comple- mentary methods or approaches. Health promo- tion aimed particularly at active and effective public participation and although it was basically an activity in the health and social fields and not a medical service, health professionals-par- ticularly in primary health care-had an impor- tant role in nurturing and enabling it. Health promotion best enhanced health through integ- rated action at different levels on factors influenc- ing health-economic, environmental, social and personal. The general objectives of health promotion included a focus on access to health, the development of an environment conducive to health, the strengthening of social networks and social supports, increasing knowledge by dis- seminating information relating to health, and promoting positive health behaviour and appropriate coping strategies-a key aim in health promotion. The goal was towards balanc-

76 K . M . Pnrvy

ing resources and individual control; Dr McQueen described two practical problems- developing and using the right methods, and getting them accepted. Researchers were drawn from a variety of disciplines and centres, and the research involved cooperation between research units, departments, local authorities and com- munities. They addressed issues which were con- cerned with a variety of problems. The applied research was interventionist, cross-national and evaluative. The commitment of the University’s behavioural research unit was towards long-term data collection-i.e. tracking behaviour rather than undertaking a series of one-off surveys, and including a mechanism for linking this tracking with indicators of the health status of the popula- tion. Community studies focused on enabling people to develop healthier lifestyles and a healthier context to live in. The greatest challenge was to determine how social processes could induce behavioural change and bring about improved health outcomes.

The traditional university response to research was to derive models on the basis of academic thinking, but he questioned whether this was appropriate to the wider concepts of health. His research unit was taking university-based research into the community, and he questioned whether the university was the proper setting for research into the wider concept of health and relevant to applied community research in this wider concept. He drew attention to the spectre ofcontract research and asked who should set the agenda for health.

Mvs L i n d a H e a d l a n d , President of the Associa- tion of Scottish Health Councils, said it would be a pity if the answers to Dr McQueen’s questions turned out to be negative. The University should work on behalf of the community. It was an invaluable resource for helping to answer ques- tions, although it was not just for the university to set the agenda-it should be a matter of shar- ing power ‘with the people’. She wondered whether priorities in the provision of medical services were sufficiently sensitive to community needs; ‘high-tech’ developments were important but they should not be at the expense of smaller- scale services, and there was insufficient com- munity involvement in hospital building policies. This stricture included the circums- tances in which medical students were taught-it

seemed wholly inappropriate that they should learn to care for people at a time when they, the patients, were largely outside their natural environment. The Faculty ofMedicine should be more responsive to the views of others on both the content of the medical curriculum and the context within which students were taught.

Dv Zan Thompson, of the Scottish Health Education Group, described how SHEG looked to universities for support, for example in the use of mass media, in education and training, and in research. From personal experience he was aware of the difficulty of interfaculty cooperation, and he felt it was important for the concept of health to be given greater credibility as a valued term, and for every department to explore its individual potential contributions to the health not only of the community but of its own stu- dents. Complaints about lack of time and resources should be seen in the context of the teaching and research facilities available in less developed countries.

Opening the discussion, the Principal invited participants to express views on what steps should be taken within his own University and between the University and the city of Edin- burgh. Among other suggestions the formation of a group to give further thought to the WHA theme was proposed, with the remit of seeking practical ways for university departments to become more fully involved. It was thought that in general, the area of communication had been neglected: on the one side the notion of ‘health’ might be explored by social anthropologists, and on the other how people in the community per- ceived relative lack of resources and how their views could be communicated to medical experts.

Summarizing, the Principal said that despite the debate, health still seemed to be thought ofas absence of disease, which was perhaps the prag- matic approach to the problem; progress was often made in small practical ways rather than by tackling major issues, and the variety of sugges- tions made a t the Conference might be taken up by individual departments. However, telling people what to do could be counterproductive, and he favoured a small group within Edinburgh University thinking about one practical change, for example a closer association between social science and medicine. Another step could be to

The wider concept qfhealrh 77

involve the University in a community issue, possibly by way ofstudents, w h o were very city conscious. H e was still unsure what ‘health for all by the year 2000’ really meant, and although it was often helpful to think in broad and simple terms, it seemed an impractical objective.

Professor Henry Walton felt that the Conference had been an achievement in its o w n right. We lived in one world, and problems such as the population explosion, acid rain, and the relation- ship between industry and food policy were of universal concern and a challenge to the univer- sities. Health was a political issue but also an academic one, and involved other disciplines than medicine. H e strongly supported a multi-

disciplinary approach and a search for ways in which universities in the developed world could help those in less fortunate circumstances. Despite past failures in collaboration further efforts should be made to overcome departmen- tal barriers and to promote interdisciplinary cooperation, particularly in collaborative teach- ing and in a reappraisal o f the settings in which students were taught. T h e social accountability of the university should be reflected in the sup- port provided by the state, although there was a need for balance between academic freedom and the universities’ commitment to the problems of society, for which there was a proud university tradition.