Vienna 2016 declaration

Preamble

The European Public Health Association and the Austrian Public Health Association, meeting at the European Public Health Conference, in Vienna in November 2016, reiterate their commitment to the principles of the Ottawa Charter, 1 herewith renewed in this Vienna Declaration to take account of new and emerging threats to public health that have arisen in the three decades since it was adopted, as well as the renewed global commitment to health set out in the Sustainable Development Goals and reiterated in the Global Charter on the Public’s Health2 and the draft Shanghai Declaration on Health Promotion. 3 The Vienna Declaration calls on all parts of the public health community, in Europe and beyond, working at all levels, local, national, regional and global, to recognise the multi-tiered determinants of health and opportunities for action.

The pre-requisites for health

The ideas set out in the Ottawa Charter have stood the test of time. They have provided the basis for the many achievements of those engaged in health promotion, remaining as relevant now as they were in 1986. As the draft Shanghai Declaration has shown, 3 public health and health promotion work and, where they have been implemented, they have delivered impressive results. Yet where they have not, there have been major setbacks.
The Ottawa Charter set out a series of pre-requisites for health. Here we extend and update them to take account of changing circumstances and ideas:

• Peace and freedom from fear of violence, including that within communities and families;
• Shelter that provides protection from the elements, a safe indoor environment, and access to basic utilities;
• Education for all, regardless of gender, sexuality and sexual identity, race, ethnicity, religion, and citizenship;
• Affordable, accessible, nutritious and healthy food;
• A living income, coupled with protection from fear of catastrophic expenditure and unaffordable debt;
• A stable, sustainable, and healthy eco-system, as free as possible from pollutants;
• Access to sustainable resources, especially energy sources and clean water;
• Social justice, equity, and empowerment for all, regardless of gender, sexuality and sexual identity, race, ethnicity, religion, and citizenship;
• Systems of local, national, regional, and global governance that are open and transparent, democratically accountable, and represent the interests of all members of their populations;
• Systems that provide high levels of social protection for all [2]
• Good quality work, with fair employment policies and safe, health-promoting working conditions;
• Optimal early childhood conditions, offering loving, supportive, responsive, nurturing and stimulating environments.

The Ottawa Charter: 30 years on

The Ottawa Charter identified five areas for health promotion action. As with so much of the Charter, these remain relevant today. However, as the world has changed, so should the responses to this changing environment adapt.

Build Healthy Public Policy

As was stated in the Ottawa Charter, health policy “requires the identification of obstacles to the adoption of healthy public policies in non-health sectors and the ways of removing them”. This has led, in the past three decades, to a much greater focus on the upstream, or social determinants of health and, more recently, to the commercial and political determinants of health, employing a range of methods drawn from disciplines such as political science, including those that have been used to map what are often hidden influences on policy, coupled with attention to policies in areas as diverse as welfare reform and international trade.

Create supportive environments

In many countries, the environments in which people live and work have deteriorated since the Ottawa Charter. Deindustrialisation has devastated many communities, the power of organised labour has markedly diminished, and for many, what employment exists has become increasingly precarious. These developments have consequences for the physical and social environments in which people live. Chaotic development and property speculation denies communities green spaces, safe neighbourhoods and healthy environments. New models of employment increase fear and insecurity, undermining social networks and the ability of individuals and families to invest in their future health and wellbeing. The public health community must engage actively with those responsible for economic and employment policies and officials responsible for urban planning, in fulfilment of the Ottawa Charter’s aspiration to “living and working conditions that are safe, stimulating, satisfying and enjoyable”. In doing so, it can draw on a remarkable expansion of knowledge on how physical and social environments influence health, driven in large part by the wealth of new sources of data now available.

Strengthen community actions

Despite great progress, there have been too many reversals since the Ottawa Charter. In many countries, citizens have lost trust in their governments and have disengaged from the political process, as is apparent from declining voter turnout as well as declining participation in voluntary organisations. In some countries, austerity policies have undermined community engagement, for example by closures of libraries and community centres. Yet, ironically, this has happened at a time when there is much greater understanding of the importance of what has been termed social capital for health. The public health community must now advocate for a process of civic renewal, which supports the empowerment of communities rather than undermining it.

Developing personal skills

The Ottawa Charter placed a high priority on information, education for health, and enhancing life skills. Those drafting it could not have envisaged the explosion of information provided by the Internet. For many, the challenge is now information overload, coupled with access to [3] misinformation. This poses new challenges for the public health community which have not, so far, be addressed adequately. However, there is also a need to promote health literacy, particularly for young persons and for those not in employment, education or training, as part of an overall approach to developing health-related life skills.

Reorient health services

Those providing personal health services increasingly recognise the importance of prevention and health promotion, while the rise in multi-morbidity has made a more holistic approach to the patient essential. [11] The delivery of healthcare is now informed by evidence of effectiveness to a much greater degree than in the past. However, the many new opportunities offered by technological advances now pose challenges to the sustainability of health services. Health services are as much a determinant of health as are the traditional risk factors such as clean water and road safety. The public health community must engage with those delivering healthcare, not only in respect of collective action such as screening, but also in assessing the effectiveness of interventions, the equity with which they are provided, and the trade-offs that must be made in health systems with limited resources. Crucially, they must also engage with practising clinicians in the shared struggle against the emergence of antimicrobial resistance. [12] In the competition for funding of innovative medicines and technologies, it is important to ensure that preventive measures including medicines or vaccines that are shown to avert, delay disease or complications are given priority.

Public health functions

The Ottawa Charter identified a set of core health promotion functions, advocacy, enablement, and mediation, updated, expanded and recast in the Global Charter on the Public’s Health as information, advocacy, governance and capacity. In the following sections we develop these in more detail and apply them to the wider public health agenda.

Information, or Using Data to Give Voice to the Weak

Effective public health action depends on understanding the scale and nature of threats to health.
The first step is to document and explain avoidable threats to ill health and identify their root causes. The past three decades have seen enormous progress to redress the “scandal of ignorance” where, in many countries, people are born, live and die without any record being kept. [4] Although technological advances have made surveillance of populations and disease easier than ever, there is still much to be done, and there have also been threats to the progress that has been made and, in some cases, setbacks. The establishment and continued public funding of authoritative and independent health information systems, with full involvement of skilled public health professionals is a necessary pre requisite to attain the objective of describing, explaining, and improving health.
The public health community has a duty to make the invisible visible. It does so by measuring and publicising the level and distribution of the burden of disease in populations. This must be assessed in terms not only of diseases and health status but also proximal risk factors, such as diet, smoking and alcohol, and distal factors, such as poverty, precariousness, stigma, and exclusion, as well as factors that offer protection, such as social security, social capital, and resilience, developing and deploying innovative research methods as required. The public health community must lead the development of a research agenda that can make best use of the many new sources of data to promote health. It is important that it takes this initiative to avoid the risk that the use of these data sources is dominated by narrow commercial interests, including those promoting health damaging products. [4]
The public health community must ensure that advances in the use of data do not further exclude the most vulnerable in society, including those lacking citizenship or who are incarcerated, who are often invisible in official data.
The public health community must also argue for safeguards in the use of such data, and especially that for which it is responsible, whether for commercial purposes or for threats to human rights.
The public health community must safeguard existing progress, challenging those governments that, ostensibly on economic grounds, seek to scale back existing data collection and surveillance systems, while advocating for sustained investment in techniques of data linkage that offer great potential for understanding health and its determinants.
The public health community must base its actions on information about what works, and in what circumstances. Thus, wherever possible, public health interventions should be evaluated, using rigorous research methods, and the results disseminated. This is especially true for upstream, population-level interventions that have tended to be neglected by researchers and research funders, with their focus on downstream, individual-level measures, even though the former often hold the greatest potential for overall health gain.
The public health community must ensure that evidence is used to give voice to those who would otherwise be unheard. This means that it must be disseminated effectively. There are many audiences, including policy-makers, researchers, and the public. There are also many new opportunities, including social media. It also faces many challenges. These include communicating complex information in ways that are comprehensible, disseminating evidence in a timely manner to ensure relevance and exploit windows of opportunity, and challenging those who dismiss or distort established facts and denigrate expertise in pursuit of ideologies and vested interests that undermine health. [5, 6]

Advocacy, for change

The public health community has a duty to advocate for healthy public policies, recognising that this often requires engagement with other sectors, consistent with the concept of Health in All Policies. [7] As already noted, its advocacy must be based on evidence, including not only knowledge of the disease burden and effectiveness of policies and interventions, but also an understanding of those with an interest in the policy concerned.
The public health community must recognise that advocacy requires specific skills, in framing the narrative and communicating it effectively, and a commitment to act rapidly, seizing windows of opportunity, and avoiding bureaucratic processes that render this impossible.
The public health community must engage appropriately with many different stakeholders, some of whom will be supportive, some indifferent, and some opposed. Its engagement should focus on those with most influence on policies. It should build trusted relationships with those supportive of health policies, providing them with timely, understandable, accurate, and contextually appropriate evidence, promoting a shared narrative, and supporting them in other ways. It should challenge those opposed to such policies, seeking, where possible, to persuade them to offer support. In some cases, the problem will be a lack of knowledge or an ideological difference, for example in the relationship between the individual and the state. However, in other cases, opposition will reflect the influence of powerful, and often concealed vested interests which must be identified, exposed, and challenged.
It is essential to recognize the growing role of diverse non-state actors, and especially the importance of distinguishing those that pursue public interest objectives from those that pursue [5]
commercial interests, paying particular attention to the difficulties that can arise with activities promoted as corporate social responsibility. Responses should be based on a commitment to transparency and activities that promote health gain, informed by the recent World Health Organization Framework of Engagement with Non-State Actors (FENSA) [8] and the debates around it.

Good Governance, for the Protection of Health

The public health community must promote the concept of Health in all Policies, [7] at all levels of government. While public policy involves trade-offs between many competing objectives, the public health community must demand that, where a policy has a health impact, directly or indirectly, this is assessed and considered and, if the consequences pose a risk to health, this must be made explicit. The first step is to conduct Health Impact Assessments to understand the consequences for health, positive or negative, of all policies.
Public health action can take a number of forms, from persuasion through force of argument to legislation. The form that is chosen should be appropriate to the circumstances. Specifically, when dealing with those, such as commercial interests, whose activities pose a threat to health, it is essential to retain the possibility of legislation, recognising accumulating evidence of the failure of voluntary agreements. [9]
The public health community has a key role to play in holding governments, at all levels, to account for their actions. As this can be difficult for those occupying official positions, a particular responsibility lies upon those of the public health community working in universities and non-governmental organisations, where possible working in close collaboration. This can take many forms, including research, collaboration with media outlets, and especially, investigative journalists, and the publication of shadow reports that assess the extent to which governments have complied with their international commitments.

Capacity, to bring about change

The public health community can only play an effective part in improving health if it has sufficient numbers of people, with the requisite skills, and with access to the relevant data. Unfortunately, in many countries, this is far from the reality.
The public health community must call for a sustained investment in public health training, ensuring not only the creation and expansion of educational infrastructure but also attractive, adequately rewarded career pathways for those it trains, ensuring that they have the competencies necessary to deliver essential public health operations. [10] There is a particular need to invest in development of the next generation of public health professionals and in the leaders of tomorrow.
The public health community must ensure, through programmes of lifelong learning, that its workforce remains up to date with advances in knowledge, methods, and skills.
The public health community must advocate for sustained investment in research, especially on the effectiveness of interventions and on the upstream determinants of health. Public health research is intrinsically multi-disciplinary and there is a need to reach beyond traditional collaborations to include disciplines such as political science, macroeconomics, and media studies, among many others.

Commitment to public health

The participants in this conference reiterated the principles set out in the Ottawa Charter, including the need to create supportive environments, to strengthen community actions, to develop personal skills, and to reorientate health services, in each case taking account of the changing circumstances facing public health in the early 21st-century. [6]
They pledge to:

• Develop, use, and improve inclusive, high-quality, transparent and innovative information systems that can inform public health policies;
• advocate for health, working with those whose goals we share, even though they may not yet be engaged in the quest for better health, but challenging those whose words and activities threaten health;
• make visible the health effects of policies in all sectors, holding those in power accountable for their actions in the quest for better health;
• create a motivated, highly qualified workforce who, in their many different roles and sectors, can contribute to improved health for the entire population.

References

1. World Health Organization. Ottawa charter for health promotion. Ottawa: WHO, 1986.
2. Lomazzi M. A Global Charter for the Public’s Health-the public health system: role, functions, competencies and education requirements. European journal of public health 2016;26(2):210-2.
3. World Health Organization. Draft Shanghai Declaration on Health Promotion in the 2030 Agenda for Sustainable Development: Ensuring sustainable health and well-being for all. 2016:http://www.who.int/healthpromotion/conferences/9gchp/shanghai-declaration-zero-draft.pdf.
4. Rajaratnam JK, Marcus JR, Levin-Rector A, et al. Worldwide mortality in men and women aged 15-59 years from 1970 to 2010: a systematic analysis. Lancet (London, England) 2010;375(9727):1704-20.
5. Keyes R. The post-truth era: Dishonesty and deception in contemporary life. New York: St Martin’s Press, 2004.
6. Diethelm P, McKee M. Denialism: what is it and how should scientists respond? European journal of public health 2009;19(1):2-4.
7. Ståhl T, Wismar M, Ollila E, et al. Health in all policies. Prospects and potentials Helsinki: Finnish Ministry of Social Affairs and Health 2006.
8. World Health Organization. Framework of engagement with non-State actors. 2016:http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_R10-en.pdf?ua=1.
9. Knai C, Petticrew M, Durand MA, et al. The Public Health Responsibility deal: has a public-private partnership brought about action on alcohol reduction? Addiction (Abingdon, England) 2015;110(8):1217-25.
10. Rechel B, McKee M. Facets of public health in Europe. Buckingham: McGraw-Hill Education (UK), 2014.
11. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet (London, England) 2012;380(9836):37-43.
12. Howard SJ, Hopwood S, Davies SC. Antimicrobial resistance: a global challenge. Science translational medicine 2014;6(236):236ed10.

The Vienna Declaration was prepared by:

• Martin McKee, president of EUPHA
• David Stuckler, EUPHA Policy Pillar Lead
• Thomas Dorner, president of ÖGPH and chair of Vienna 2016
• Dineke Zeegers Paget, executive director of EUPHA

The aim of the Vienna Declaration is to reiterate support for the Ottawa Charter. It is aimed at public health professionals, public health associations and other organisations working in health