What I'm thinking about most currently is how health is almost always viewed in an industrial, commodity or mechanical sense, with healthcare systems as the primary actors, rather than as an emergent property of communities, with citizens as primary actors:

(Thread) (1/n)

The traditional narrative is that prior to healthcare (C-20th), people just got sick & died (mostly young) all the time. Basically, "health" was very low. This is viewed as the "natural" state of health if there is no healthcare industry (2/n)

Then healthcare came along, as well as enlightened public services, who, with knowledge & technology, incrementally dragged health up from it's "natural" low state up to its modern level. This is a very self-affirming & congratulatory narrative for H/C Industry. (3/n)

In this paradigm, health, therefore, is a product created by H/C industry in the same industrial, reductionist, mechanical model as making cars i.e. health needs only be reduced to simple cause/effects & those causes manipulated through technology & knowledge by specialists (4/n)

The expansion of health to include the social determinants of health (SDH) is only an expansion of this model to identify further causes of ill health to be manipulated. It does not provide an alternative view of health, nor re-centre community or the citizen in health. (5/n)

The first weakness is idea that people had little health pre-healthcare. Once pointed out, its absurdity is obvious (I hope). It is true that once people got sick, there was a much higher chance of mortality/morbidity & that H/C has made huge gains in reversing pathology...(6/n)

...however, many people of this time also had long & healthy lives. Health, viewed as a certain robustness to stressors rather than just absence of disease, must have existed for humanity to survive this long & therefore its origins must long pre-date modern healthcare. (7/n)

The second weakness is that we know that, in all fields, reductionist paradigms are being recognised as being inadequate to describe the world as we can now observe it. They were an improvement on previous & a necessary step, but complexity is the new progressive paradigm. (8/n)

So, in turn, health cannot be manufactured & is not the result of industry. It is not the healthcare system heroically damming the River Stix, with marginal gains in Technik improving damming efficiency & conferring the property of health on the general population. (9/n)

The SDH help us understand that health, or at least a certain component of it, lies in the social. Influenced by the salutogenic orientation, I believe this can be viewed as resources located socially that help us overcome stressors & crises, not as absence of risk factors (10/n)

Once we reject idea that health is made mechanically by health factories, we can see that the components of health are actually the result of millions of unconscious (salutary & pathogenic) actions by huge numbers of individual actors, adapting to each other & environment: (11/n)

Making a garden look nice
Employing someone
Starting a book club
Driving within the speed limit
Helping someone with their homework
Giving some surplus courgettes to neighbours
Choosing to catch the bus instead of drive

All create health without explicitly meaning to (12/n)

These are the ways in which social health component is created - diverse, unconscious & decentralised - not by professionals - uniform, conscious & centralised. This means health is an emergent property of complex community systems, not a commodity made by health factories (13/n)

This has huge implications for health promotion practice. 1. Citizens are best placed to understand what their system's (their community or life) limiting factor is, not outside specialists. Citizens are the *primary* health-creating agents. (14/n)

2. There is no one route to health. There is no prescription to health. Institutions should support people to define the problem & help solve it (only) if they, or their communities, cannot (in that order!) (15/n)

3. Any health-promoting intervention from outside must be seen through a complex-systems lens. i.e. what are the unintended 2nd/3rd-degree effects on the whole system? Must acknowledge how the system adapts (harmfully) to outside intervention (16/n)

4. Degree of community connection becomes a critical variable for health. However, in saying this, we must warn against making this a moral obligation (healthism, medical imperialism). (17/n)

5. The chances are similar things can be said about other vague properties of communities that we are interested in:
- Security
- Democracy
- Care
- Ecological Sustainability

If these are emergent properties, then the implications for how these are approached is a 180 shift.