“Health for all,” but for whom?

Social Performance and Health Promotion

So, why does the public health community continue to uphold the biomedical model of health? And what are the impacts for people with disabilities?

Let’s go back to the WHO’s concept of health promotion. The WHO defines it as “the process of enabling people to increase control over, and to improve, their health” (WHO, 2024). Berthelot-Raffard (2022) illustrates how conceptions of health promotion that are rooted in people taking “control” over their mental and physical well-being equate health with “normal functioning,” seen as the ability to operate at the level of social performance expected in modern society. In our world, that means the ability to live and work independently, to make a living, and to minimize vulnerabilities that may cause a “burden” on the health system. Indeed, the Ottawa Charter for Health Promotion (1986) begins its priority strategies with “Good health is a major resource for social, economic and personal development.” Health is positioned as being in service to societal advancement, rather than the other way around. What is really being safeguarded here, and what or who is at stake when health is seen as a “resource”?

Colonialism, Climate Crisis, and Justice

Jen Deerinwater (2021) provides a revealing account of the compounding health crises caused by colonial invasion, which have had devastating impacts on Indigenous people and particularly deaf, disabled, and ill Indigenous people. The global climate crisis, the poisoning of land and water, the forcible removal from land and severing of natural systems of care, the petrochemical and agricultural industries, the pillaging of resources, the imposition of European misogynist culture, and the permeation of ableist norms in Indigenous life, all have contributed to devastating health outcomes for disabled Indigenous people. These forces have eroded the critical roles disabled people have played in their communities and reinforced the idea that their lives are worthless. For Deerinwater and other disabled Indigenous people, health restoration needs to entail an end to colonial capitalism and a fight for disability and climate justice.

Reflection Moment

After you have engaged with the two media moments above, reflect on your own relationship to the land, to Indigenous peoples, and to settler colonialism. What are the costs of choice and control? What are the implications for how we understand health, if health is often framed as depending on personal choice and autonomy?

How does this content help expand your understanding of health promotion beyond a model of individual choice and control?

When health is associated with economic performance standards, the health of Indigenous populations as well as disabled populations (not to mention disabled Indigenous populations) are systematically impacted. When people experience barriers, require additional supports, or are simply not in a position to perform at the standards required by capitalism, they are more often denied the resources necessary to adequately support their health. Control over health choices, the process identified by the WHO as enabling health promotion, is significantly limited by the negative systemic effects of capitalism and colonialism on Indigenous communities, and particularly disabled Indigenous people.

Access, Urban Life, and Structural Exclusion

Another context in which disabled people face systemic barriers to health promotion is access to good and adequate food in urban settings. Naomi Schwartz, Ron Buliung, and Kathi Wilson’s (2023) Toronto-based study of people who have mobility ‘limitations’ and/or use mobility aids illuminates the compounding economic, physical, and social barriers to accessing food. For the respondents in this research, it was not mobility ‘limitations’ related to their disabilities that most restricted their ability to access suitable housing, transportation, care, and choice in how and where to access food but rather the limited economic resources available to them. The findings highlight how cities like Toronto and their associated health campaigns are designed for statistically ‘normal’ (read: ‘healthy’) people who have control over their time and consumer choices without being restricted by functional or temporal barriers. State-level initiatives such as Ontario Disability Support Program (ODSP), AODA guidelines, and paratransit services serve as technical “box-checking” while being purposely inflexible and failing to meet real needs for access and livability (Schwartz et al., 2023). In effect, a healthy middle class is leveraged at the expense of disabled people, whose exclusionary treatment by civil society further compromises their health outcomes.