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Foundations for Health Promotion
FOURTH EDITION
Jennie Naidoo
Principal Lecturer, Health Promotion and Public Health, University of the
West of England, Bristol, UK
Jane Wills
Professor of Health Promotion, London South Bank University, London, UK
Table of Contents
Cover image
Title page
Copyright
Preface
Acknowledgements
Part One. The theory of health promotion
Introduction
Chapter One. Concepts of health

Importance of the Topic
Defining health, well-being, disease, illness and ill health
Well-being
The Western scientific medical model of health
A critique of the medical model
Lay concepts of health

Cultural views of health
A unified view of health
Conclusion
Summary
Chapter Two. Influences on health

Determinants of health
Social class and health
Income and health
Housing and health
Employment and health
Gender and health
Health of ethnic minorities
Place and health
Explaining health inequalities
Tackling inequalities in health
Conclusion
Summary
Chapter Three. Measuring health

Why measure health?

Ways of measuring health
Measuring health as a negative variable (e.g. health is not being diseased

or ill)
Mortality statistics
Morbidity statistics
Measuring health and disease in populations
Measures of health as an objective attribute
Measuring deprivation
Subjective health measures
Physical well-being, functional ability and health status
Psychological well-being
Social capital and social cohesion
Quality of life
Conclusion
Summary
Chapter Four. Defining health promotion

Foundations of health promotion
Origins of health promotion in the UK
Public health
The World Health Organization and health promotion
Defining health promotion

Critiques of health promotion
The argument for health promotion
Advocacy
Enablement
Mediation
Conclusion
Summary
Chapter Five. Models and approaches to health promotion

The medical approach
Behaviour change
The educational approach
Empowerment
Social change
Models of health promotion
Theories in health promotion
Conclusion
Summary
Chapter Six. Ethical issues in health promotion

The need for a philosophy of health promotion

Duty and codes of practice
Consequentialism and utilitarianism: The individual and the common good
Ethical principles
Conclusion
Summary
Chapter Seven. The politics of health promotion

What is politics?
Political ideologies
Globalization
Health as political
The politics of health promotion structures and organization
The politics of health promotion methods
Being political
Conclusion
Summary
Part Two. Strategies and methods
Introduction
Chapter Eight. Reorienting health services

Introduction
Promoting health in and through the health sector
Primary healthcare and health promotion
Primary healthcare principles
Primary healthcare: strategies
Primary healthcare: service provision
Participation
Equity
Collaboration
Who promotes health?
Public health and health promotion workforce
Specialist community public health nurses
Mental health nurses
School nurses
Midwives
General practitioners
Practice nurses
Dentists
Pharmacists
Environmental health workers
Allied health workers
Care workers
Specialists
Conclusion
Summary
Chapter Nine. Developing personal skills

Definitions
The health belief model
Theory of reasoned action and theory of planned behaviour
The stages of change model
The prerequisites of change
Conclusion
Summary
Chapter Ten. Strengthening community action

Defining community
Why work with communities?
Approaches to strengthening community action
Defining community development
Community development and health promotion
Working with a community-centred approach
Types of activities involved in strengthening community action

Dilemmas and challenges in community-centred practice
Conclusion
Summary
Chapter Eleven. Developing healthy public policy

Defining HPP
Health in all policies (HiAP)
Health impact assessment (HIA)
The history of HPP
Key characteristics of HPP: advantages and barriers
The practitioner’s role in HPP
Evaluating an HPP approach
Conclusion
Summary
Chapter Twelve. Using media in health promotion

Introduction
The nature of media effects
The role of mass media
Planned campaigns
Unpaid media coverage

Media advocacy
Social marketing
What the mass media can and cannot do
Communication tools
Conclusion
Summary
Part Three. Settings for health promotion
Introduction
Chapter Thirteen. Health promoting schools

Why the school is a key setting for health promotion
Health promotion in schools
The health promoting school
Policies and practices
Links with the community
Effective interventions
Conclusion
Summary
Chapter Fourteen. Health promoting workplaces

Why is the workplace a key setting for health promotion?
The relationship between work and health
Responsibility for workplace health
Health promotion in the workplace
Conclusion
Summary
Chapter Fifteen. Health promoting neighbourhoods

Defining neighbourhoods
Why neighbourhoods are a key setting for health promotion
Conclusion
Summary
Chapter Sixteen. Health promoting health services

Defining a health promoting hospital
Why hospitals are a key setting for health promotion
Promoting the health of patients
Promoting the health of staff
The hospital and the community
Organizational health promotion
The HPH movement

Health promoting pharmacies
Conclusion
Summary
Chapter Seventeen. Health promoting prisons

Why prisons have been identified as a setting for health promotion
Barriers to prisons as health promoting settings
Health promoting prisons
Examples of effective interventions
Conclusion
Summary
Part Four. Implementing health promotion
Introduction
Chapter Eighteen. Assessing health needs

Defining health needs
The purpose of assessing health needs
Health needs assessment
Setting priorities
Conclusion
Summary
Chapter Nineteen. Planning health promotion interventions

Reasons for planning
Health promotion planning cycle
Strategic planning
Project planning
Planning models
Stage 1: What is the nature of the problem?
Stage 2: What needs to be done? Set aims and objectives
Stage 3: Identify appropriate methods for achieving the objectives
Stage 4: Identify resources and inputs
Stage 5: Plan evaluation methods
Stage 6: Set an action plan
Stage 7: Action, or implementation of the plan
Planning models
PRECEDE-PROCEED model
Quality and audit
Conclusion
Summary
Chapter Twenty. Evaluating health promotion interventions

Defining evaluation
Why evaluate?
What to evaluate
Process, impact and outcome evaluation
Evaluation research methodologies
How to evaluate: The process of evaluation
How to evaluate: Gathering and analysing data
Building an evidence base for health promotion
What to do with the evaluation: Putting the findings into practice
Conclusion
Summary
Glossary
Index
Copyright
© 2016, Elsevier Ltd. All rights reserved.
No part of this publication may be reproduced or transmitted in any

form or by any means, electronic or mechanical, including
photocopying, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Details on
how to seek permission, further information about the Publisher’s
permissions policies and our arrangements with organizations such as
the Copyright Clearance Center and the Copyright Licensing Agency,
can be found at our website: www.elsevier.com/permissions.
This book and the individual contributions contained in it are

protected under copyright by the Publisher (other than as may be
noted herein).
First edition 1994
Second edition 2000
Third edition 2009
ISBN 978-0-7020-5442-6
British Library Cataloguing in Publication Data

A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data

A catalog record for this book is available from the Library of
Congress
Notices
Knowledge and best practice in this field are constantly changing.
As new research and experience broaden our understanding,
changes in research methods, professional practices, or medical
treatment may become necessary.
Practitioners and researchers must always rely on their own

experience and knowledge in evaluating and using any information,
methods, compounds, or experiments described herein. In using
such information or methods they should be mindful of their own
safety and the safety of others, including parties for whom they have
a professional responsibility.
With respect to any drug or pharmaceutical products identified,
readers are advised to check the most current information provided
(i) on procedures featured or (ii) by the manufacturer of each
product to be administered, to verify the recommended dose or
formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on
their own experience and knowledge of their patients, to make
diagnoses, to determine dosages and the best treatment for each
individual patient, and to take all appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the
authors, contributors, or editors, assume any liability for any injury
and/or damage to persons or property as a matter of products
liability, negligence or otherwise, or from any use or operation of
any methods, products, instructions, or ideas contained in the
material herein.
Printed in China
Preface
Health promotion is a core aspect of the work of a wide range of

healthcare workers and those engaged in education and social
welfare. It is an emerging area of practice and study, still defining its
boundaries and building its own theoretical base and principles. This
book aims to provide a theoretical framework for health promotion, as
this is vital to clarify practitioners’ intentions and desired outcomes. It
offers a foundation for practice which encourages practitioners to see
the potential for health promotion in their work, to be aware of the
implications of choosing from a range of strategies and to be able to
evaluate their health promotion interventions in an appropriate and
useful manner.
This fourth edition of Health Promotion: Foundations for Practice has
been comprehensively updated and expanded to reflect recent
research findings and major organizational and policy changes over
the last decade. Our companion volume, Public Health and Health
Promotion: Developing Practice (Naidoo and Wills, 2010), discusses in
more detail some of the challenges and dilemmas raised in this book,
e.g. partnership working, tackling inequalities and engaging the
public.
The book is divided into four main parts. The first part provides a
theoretical background, exploring the concepts of health, health
education and health promotion. Part One concludes that health
promotion is working towards positive health and well-being of
individuals, groups and communities. Health promotion includes
health education but also acknowledges the social, economic and
environmental factors which determine health status. Ethical and
political values inform practice, and it is important for practitioners to
reflect upon these values and their implications. Part One embraces
the shift towards well-being rather than a narrow interpretation of
health, and the move away from a simple focus on lifestyle changes as
the goal of health promotion. Its aim is to enable readers to
understand and reflect upon these theoretical drivers of health
promotion practice within the context of their own work.
Part Two explores strategies to promote health, and some of the
dilemmas they pose. Using the Ottawa Charter (World Health
Organization, 1986) framework to identify the range of strategies, the
potential, benefits and challenges of adopting each strategy are
discussed. Examples of interventions using the different strategies are
presented. What is reflected here is how health services have not
moved towards prioritizing prevention, although there is much
greater acceptance and support for empowerment approaches in work
with individuals and communities. While policies that impact on
health still get developed in isolation from each other, there is a
recognition of the need for health in all policies, and for deliberative
democracy and working methods that engage with communities as
the ways forward.
Part Three focuses on the provision of supportive environments for
health, identified as a key strategy in the Ottawa Charter. Part Three
explores how a range of different settings in which health promotion
interventions take place can be oriented towards positive health and
well-being. The settings discussed in this part – schools, workplaces,
neighbourhoods, health services and prisons – have all been targeted
by national and international policies as key for health promotion.
Reaching specific target groups, such as young people, adults or older
people, within these settings is also covered in Part Three. There is
much debate about the need for systems thinking and seeing such
settings more broadly as environments where physical, social and
economic drivers come together, and not just as places in which to
carry out health education and lifestyle behaviour interventions.
Part Four focuses on the implementation of health promotion
interventions. Each chapter in this part discusses a different stage in
the implementation process, from needs assessment through planning
to the final stage of evaluation. This part is designed to help
practitioners to reflect on their practice through examining what
drives their choice of practical implementation strategies. A range of
real-life examples helps to illustrate the options available and the
criteria that inform the practitioner’s choice of approach.
This book is suitable for a wide range of professional groups, and
this is reflected in the choice of examples and illustrative case studies,
which have been completely updated for this edition. In response to
reader feedback about the ways to engage with a textbook, we have
changed the format for this edition. Each chapter has between 6 and
15 learning activities which encourage readers to engage with the text
and extend their learning. Indicative feedback about the points that a
reader or student might wish to consider is provided at the end of the
chapter. Each chapter also includes at least one case study and
research example to provide the reader with examples of application
and encourage a focus on topics. Further questions at the end of each
chapter encourage readers to reflect on their practice, values and
experience, and to debate the issues. To reflect the huge changes in
information management since this book was first published in 1994,
website addresses are given for resources and further reading where
possible.
The book is targeted at a range of students, including those in basic
and post-basic training and qualified professionals. By combining an
academic critique with a readable and accessible style, this book will
inform, stimulate and encourage readers to engage in ongoing
enquiry and reflection regarding their health promotion practice. The
intention, as always, is to encourage readers to develop their practice
through considering its foundation in theory, policy and clear
principles.
Jennie Naidoo
Jane Wills, Bristol and London
References
Naidoo J, Wills J. Public Health and Health Promotion: Developing Practice. third
ed. London: Baillière Tindall; 2010.
World Health Organization. Ottawa Charter for Health
Promotion. Geneva: WHO; 1986.
Acknowledgements
It is 21 years since the publication of the first edition of this book,

which was initially prompted by our teaching on the first
postgraduate specialist courses in health promotion. Students and
colleagues at the University of the West of England and London South
Bank University have, as always, contributed to this edition through
their ideas, debates and practice examples. We continue to be
committed to the development of health promotion as a discipline.
We dedicate this fourth edition to our children, Declan, Jessica, Kate
and Alice.
PA R T O N E
The theory of health promotion
OUTLINE
Introduction
Chapter One. Concepts of health
Chapter Two. Influences on health
Chapter Three. Measuring health
Chapter Four. Defining health promotion
Chapter Five. Models and approaches to health promotion
Chapter Six. Ethical issues in health promotion
Chapter Seven. The politics of health promotion
Introduction
Part One explores the concepts of health, health education and health
promotion. Health promotion draws upon many different disciplines,
ranging from the scientific (e.g. epidemiology) and the social sciences
(e.g. sociology and psychology) to the humanities (e.g. ethics). This
provides a wealth of theoretical underpinnings for health promotion,
ranging from the scientific to the moralistic. This in turn means that
health promotion in practice may range from a scientific medical
exercise (e.g. vaccination) or an educational exercise (e.g. sex and
relationships education in schools) to a moral query (e.g. end-of-life
options). An important first step for health promoters is to clarify for
themselves where they stand in relation to these various different
strategies and goals. Are they educators, politicians or scientists? In
part this will be determined by their background and initial
education, but health promotion is an umbrella which encompasses
all these activities and more. Working together, practitioners can bring
their varied bodies of knowledge and skills to focus on promoting the
health of the population, and achieve more significant and sustainable
results than if they were operating on their own.
This first part of the book explores different understandings of the
concept of health and well-being, and the ways in which health can be
enhanced or promoted. The effect on health of structural factors such
as income, gender, sexuality and ethnicity and the way in which social
factors are important predictors of health status are explored in
Chapter 2. The different ways in which health is measured reflect
different views on health, from the absence of disease to holistic
concepts of well-being, and these are discussed in Chapter 3. Chapters
4 and 5 debate what health promotion is, adopting an ecological
model in which change in health is said to be influenced by the
interaction of individual, social and physical environmental variables.
Chapters 6 and 7 will help those who promote health to be clear about
their intentions and how they perceive the purpose of health
promotion. Is it to encourage healthy lifestyles? Or is it to redress
health inequalities and empower people to take control over their
lives?
CHAPTER ONE
Concepts of health
LEARNING OUTCOMES
By the end of this chapter you will be able to:

• define the concepts of health, well-being, disease, illness and ill
health, and understand the differences between them
• discuss the nature of health and well-being, and how culture and
populism influence our definitions
• understand the elements of the medical model of health and how it
influences healthcare practice.
KEY CONCEPTS AND DEFINITIONS

Biomedicine Focuses on the causes of ill health and disease within
the physical body. It is associated with the practice of medicine,
and contrasts with a social model of health.
Disease Is the medical term for a disorder, illness or condition that
prevents an individual from achieving the full functioning of all
his or her bodily parts.
Health Is the state of complete mental and physical well-being of an
individual, not merely the absence of disease or illness.
Ill health Is a state of poor health when there is some disease or
impairment, but not usually serious enough to curtail all
activities.
Illness Is a disease or period of sickness that affects an individual’s
body or mind and prevents the individual achieving his or her
optimal outputs.
Well-being Is the positive feeling that accompanies a lack of ill
health and illness, and is associated with the achievement of
personal goals and a sense of being well and feeling good.
Everyone engaged in the task of promoting health starts with a view
of what health is. However, these views, or concepts, of health vary
widely. It is important at the outset to be clear about the concepts of
health to which you personally adhere, and recognize where these
differ from those of your colleagues and clients. Otherwise, you may
find yourself drawn into conflicts about appropriate strategies and
advice that are actually due to different ideas concerning the end goal
of health. This chapter introduces different concepts of health and
traces the origin of these views. The Western scientific medical model
of health is dominant, but is challenged by social and holistic models.
Working your way through this chapter will enable you to clarify
your own views on the definition of health and locate these views
within a conceptual framework.
Defining health, well-being, disease, illness and
ill health
Health
Health is a broad concept which can embody a huge range of
meanings, from the narrowly technical to the all-embracing moral or
philosophical. The word ‘health’ is derived from the Old English word
for heal (hael) which means ‘whole’, signalling that health concerns the
whole person and his or her integrity, soundness or well-being. There
are ‘common-sense’ views of health which are passed through
generations as part of a common cultural heritage. These are termed
‘lay’ concepts of health, and everyone acquires a knowledge of them
through socialization into society. Different societies and different
groups within one society have different views on what constitutes
their ‘common-sense’ notions about health.
Lear ning Activity 1.1 What does health mean

to you?
What are your answers to the following?
• I feel healthy when…
• I am healthy because…
• To stay healthy I need…
• I become unhealthy when…
• My health improves when…
• (An event) affected my health by…
• (A situation) affected my health by…
• …is responsible for my health.
Health has two common meanings in everyday use, one negative

and one positive. The negative definition is the absence of disease or
illness. This is the meaning of health within the Western scientific
medical model, which is explored in greater detail later in this
chapter. The positive definition of health is a state of well-being,
interpreted by the World Health Organization in its constitution as ‘a
state of complete physical, mental and social well-being, not merely
the absence of disease or infirmity’ (World Health Organization,
1946).
Health is holistic and includes different dimensions, each of which
needs to be considered. Holistic health means taking account of the
separate influences and interaction of these dimensions.
Figure 1.1 shows a diagrammatic representation of the dimensions
of health.
The inner circle represents individual dimensions of health.
• Physical health concerns the body, e.g. fitness, not being ill.
• Mental health refers to a positive sense of purpose and an
underlying belief in one’s own worth, e.g. feeling good, feeling able
to cope.
• Emotional health concerns the ability to feel, recognize and give a
voice to feelings, and to develop and sustain relationships, e.g.
feeling loved.
• Social health concerns the sense of having support available from
family and friends, e.g. having friends to talk to, being involved in
activities with other people.
• Spiritual health is the recognition and ability to put into practice
moral or religious principles or beliefs, and the feeling of having a
‘higher’ purpose in life.
• Sexual health is the acceptance and ability to achieve a satisfactory
expression of one’s sexuality.
FIG. 1.1 Dimensions of health.
The three outer circles are broader dimensions of health which

affect the individual. Societal health refers to the link between health
and the way a society is structured. This includes the basic
infrastructure necessary for health (such as shelter, peace, food,
income), and the degree of integration or division within society. We
shall see in Chapter 2 how the existence of patterned inequalities
between groups of people harms the health of everyone.
Environmental health refers to the physical environment in which
people live, and the importance of good-quality housing, transport,
sanitation and pure-water facilities. Global health involves caring for
the planet and ensuring its sustainability for the future.
Lear ning Activity 1.2 Holistic model of health
What are the implications of a holistic model of health for the
professional practice of health workers?
Well-being
‘Well-being’ is a term widely used to describe ‘what makes a good
life’. It is also used in healthcare discourse to broaden views on what
health means beyond the absence of illness. Feeling good and
functioning well are seen as important components of mental well-
being. This, in turn, leads to better physical health, improved
productivity, less crime and more participation in community life
(DH, 2010). The New Economics Foundation has developed the
Happy Planet Index (New Economics Foundation, 2012) as a headline
indicator of how nations compare in enabling long and happy lives for
their citizens. In 2012:
• eight of the nine countries that are achieving high and sustainable
well-being are in Latin America and the Caribbean
• the highest-ranking Western European nation is Norway in 29th
place, just behind New Zealand in 28th place.
• the USA is in 105th position out of 151 countries.
Similarly, the UNICEF index of child well-being (UNICEF, 2013)
shows that well-being is greater in more egalitarian countries, such as
Norway and other Scandinavian countries.
Evidence (Government Office for Science, 2008) suggests that there
are five methods or steps that individuals can take to enable
themselves to achieve well-being:
• connect
• be active
• take notice
• give
• keep learning.
More recently, ‘Care (about the planet)’ has been added to this list.
Lear ning Activity 1.3 Five steps to well-being

What evidence is there for each of the steps to well-being?
Disease, illness and ill health
Disease, illness and ill health are often used interchangeably, although
they have very different meanings. Disease derives from desaise,
meaning uneasiness or discomfort. Nowadays, disease implies an
objective state of ill health, which may be verified by accepted canons
of proof. In our modern society these accepted canons are couched in
the language of scientific medicine. For example, microscopic analysis
may yield evidence of changes in cell structure, which may in turn
lead to a diagnosis of cancer. Disease is the existence of some
pathology or abnormality of the body which is capable of detection.
Disease can be due to exogenous (outside the body, e.g. viral
infection) or endogenous (inside the body, e.g. inadequate thyroid
function) factors.
Illness is the subjective experience of loss of health. This is couched
in terms of symptoms, for example the reporting of aches or pains, or
loss of function. One way that illness is given meaning is through the
narratives we construct about how we fall sick. The process of making
sense of illness is a task most sick people engage in to answer the
question ‘why me?’ Illness and disease are not the same, although
there is a large degree of coexistence. For example, a person may be
diagnosed as having cancer through screening, even when there have
been no reported symptoms; thus a disease may be diagnosed in
someone who has not reported any illness. When someone reports
symptoms, and further investigations such as blood tests prove a
disease process, the two concepts of disease and illness coincide. In
these instances, the term ill health is used. Ill health is therefore an
umbrella term used to refer to the experience of disease plus illness.
Health is the normal functioning of the body as a biological entity.
Health is both not being ill and the absence of symptoms.
Social scientists view health and disease as socially constructed
entities. Health and disease are not states of objective reality waiting
to be uncovered and investigated by scientific medicine; rather, they
are actively produced and negotiated by ordinary people. Cornwell’s
(1984) study of London’s Eastenders used three categories of health
problems.
1. Normal illness, e.g. childhood infections.
2. Real illness, e.g. cancer.
3. Health problems, e.g. ageing, allergies.
Illness has often been conceptualized as deviance – as a different
state from the healthy norm and a source of stigma. Goffman (1968)
identified three sources of stigma.
1. Abominations of the body, e.g. psoriasis.
2. Blemishes of character, e.g. human immunodeficiency virus
(HIV)/acquired immunodeficiency syndrome (AIDS).
3. Tribal stigma of race, nation or religion, e.g. apartheid.
The subjective experience of feeling ill is not always corroborated by
an objective diagnosis of disease. When this lack of corroboration
happens, doctors and health workers may label sufferers
‘malingerers’, denying the validity of subjective illness. This can have
important consequences. For example, a sick certificate, and therefore
sick pay, may be withheld if a doctor is not convinced that someone’s
reported illness is genuine. The acceptance of reported symptoms as
signs of an illness leads to a debate about how to manage the illness.
Several conditions, such as chronic fatigue syndrome and repetitive
strain injury, have taken a long time to be recognized as legitimate
illnesses.
Lear ning Activity 1.4 The medicalization of

health
What examples are there of a condition or behaviour where its
medicalization has led to its acceptance or otherwise?
It is also possible for an individual to experience no symptoms or

signs of disease, but to be labelled sick as a result of medical
examination or screening. Hypertension and pre-cancerous changes to
cell structures are two examples where screening may identify a
disease even though the person concerned may feel perfectly healthy.
Figure 1.2 gives a visual representation of these discrepancies. The
central point is that subjective perceptions cannot be overruled, or
invalidated, by scientific medicine.
The Western scientific medical model of health
In modern Western societies, and in many other societies as well, the
dominant professional view of health adopted by most healthcare
workers during their training and practice is labelled Western
scientific medicine. Western scientific medicine operates within a
medical model using a narrow view of health, which is often taken to
mean the absence of disease and/or illness. In this sense, health is a
negative term, defined more by what it is not than by what it is.
FIG. 1.2 The relationship between disease and illness.
This view of health is extremely influential, as it underpins much of

the training and ethos of a wide variety of health workers. Its
definitions become powerful because they are used in a variety of
contexts, not just in professional circles. For example, the media often
present this view of health, disease and illness in dramas set in
hospitals or documentaries about health issues. By these means,
professional definitions become known and accepted in society at
large.
The scientific medical model arose in Western Europe at the time of
the Enlightenment, with the rise of rationality and science as forms of
knowledge. In earlier times, religion provided a way of knowing and
understanding the world. The Enlightenment changed the old order,
and substituted science for religion as the dominant means of
knowledge and understanding. This was accompanied by a
proliferation of equipment and techniques for studying the world. The
invention of the microscope and telescope revealed whole worlds
which had previously been invisible. Observation, calculation and
classification became the means of increasing knowledge. Such
knowledge was put to practical purposes, and applied science was
one of the forces which accompanied the Industrial Revolution. In an
atmosphere when everything was deemed knowable through the
proper application of scientific method, the human body became a key
object for the pursuit of scientific knowledge. What could be seen, and
measured and catalogued was ‘true’ in an objective and universal
sense.
This view of health is characterized as:
• biomedical – health is assumed to be a property of biological beings
• reductionist – states of being such as health and disease may be
reduced to smaller and smaller constitutive components of the
biological body
• mechanistic – this conceptualizes the body as if it were a machine, in
which all the parts are interconnected but capable of being
separated and treated separately
• allopathic – this works by a system of opposites; if something is
wrong with a body, treatment consists of applying an opposite force
to correct the sickness, e.g. pharmacological drugs which combat
the sickness
• pathogenic – this focuses on why people become ill
• dualistic – the mind and the body can be treated as separate entities.
Health is predominantly viewed as the absence of disease. This
view sees health and disease as linked, as if on a continuum, so that
the more disease a person has, the further away he or she is from
health and ‘normality’.
The pathogenic focus on finding the causes for ill health has led to
an emphasis on risk factors, whether these are health behaviours or
social circumstances. Antonovsky (1993) called for a salutogenic
approach which looks instead at why some people remain healthy. He
identifies coping mechanisms which enable some people to remain
healthy despite adverse circumstances, change and stress. An
important factor for health, which Antonovsky labels a ‘sense of
coherence’, involves the three aspects of understanding, managing
and making sense of change. These are human abilities which are in
turn nurtured or obstructed by the wider environment.
The medical model focuses on etiology, and the belief that disease
originates from specific and identifiable causes. The causes of
contemporary long-term chronic diseases in developed countries are
often ‘social’. Medicine and medical practice thus recognize that
disease and the diseased body must be placed in a social context.
Nevertheless, the professional training of many healthcare workers
provides an exaggerated view of the benefits of treatment and pays
little attention to prevention. In part this is due to the dominant
concern of the biomedical model with the organic appearance of
disease and malfunction as the causes of ill health.
Resear ch Exam ple 1.1 Carers’ health

An ageing population means that caring for the elderly will become
a more common experience for younger adults or even children.
This has significant implications for the health of the population as
a whole. Research studies have reported a clear association between
caring and care givers’ poor mental and physical health, emotional
distress and increased mortality. A more intense caring role (e.g.
having to provide 24-hour cover, or caring for someone with both
mental and physical ill health) is associated with poorer health
outcomes on the part of the carer. Yet evidence also shows that not
all carers report poor health. Indeed, caring has the opposite effect
on some carers, conferring positive benefits through feelings of
altruism, fulfilment of familial obligations and personal growth. It is
likely that the impact of caring on the health of carers will be to
some extent dependent on the existence, or lack, of a supportive
environment, including, for example, community activities and
respite opportunities. It also seems likely that the existence of
personal religious and faith beliefs is associated with improved
health and caring, as religion provides an overarching rationale for
existence, even if this is compromised by poor health. Religious
centres often provide supportive and caring activities for members
of their faith, enabling carers to cope better with their burden of
care, and providing some respite care for people with disabilities.
See for example Awad et al., 2008; Rigby et al., 2009; Vellone
et al., 2008.
Table 1.1 contrasts the traditional views of a medical model with

those of a social model of health.
A critique of the medical model
The role of medicine in determining health
The view that health is the absence of disease and illness, and that
medical treatment can restore the body to good health, has been
criticized. The distribution of health and ill health has been analysed
from a historical and social science perspective. It has been argued
that medicine is not as effective as is often claimed. The medical writer
Thomas McKeown (McKeown, 1976) showed that most of the fatal
diseases of the nineteenth century had disappeared before the arrival
of antibiotics or immunization programmes. McKeown concluded
that social advances in general living conditions, such as improved
sanitation and better nutrition made available by rising real wages,
have been responsible for most of the reduction in mortality achieved
during the last century. Although his thesis has been disputed, there is
little disagreement that the contribution of medicine to reduced
mortality has been minor when compared with the major impact of
improved environmental conditions.
Table 1.1
The medical and social model of health
Lear ning Activity 1.5 The impact of medicine

• What effects do medical advances in knowledge have on death
rates?
• What other reasons could account for declining death rates?
The rise of the evidence-based practice movement (see Chapter 20)

is attributed to Archie Cochrane (1972). His concern was that medical
interventions were not trialled to demonstrate effectiveness prior to
their widespread adoption. Instead, many procedures rest on habit,
custom and tradition rather than rationality. Cochrane advocated
greater use of the randomized controlled trial as a means to gain
scientific knowledge and the key to progress.
The role of social factors in determining health

Most countries are characterized by profound inequalities in income
and wealth, and these in turn are associated with persistent
inequalities in health (see
www.who.int/social_determinants/sdh_definition/en/). The impact of
scientific medicine on health is marginal when compared to major
structural features such as the distribution of wealth, income, housing
and employment. Tarlov (1996) claimed that medical services
contributed only 17 percent to the gain in life expectancy in the
twentieth century. As Chapter 2 shows, the distribution of health
mirrors the distribution of material resources within society. In
general, the more equal a society is in its distribution of resources, the
more equal, and better, is the health status of its citizens (Wilkinson
and Pickett, 2009).
Medicine as a means of social control

Social scientists argue that medicine is a social enterprise closely
linked with the exercise of professional power. Foucault (1977) argues
that power is embedded in social organizations, expressed through
hierarchies and determined through discourses. Medical power
derives from its role in legitimizing health and illness in society, and
the socially exclusive and autonomous nature of the profession. The
medical profession has long been regarded as an institution for
securing occupational and social authority. Access to such power is
controlled by professional associations that have their own vested
interests to protect (Freidson, 1986). The 1858 Medical Act established
the General Medical Council, which was authorized to regulate
doctors, oversee medical education and keep a register of qualified
practitioners. The Faculty of Public Health Medicine opened
membership to non-medically qualified specialists in 2003, becoming
the Faculty of Public Health.
Medicine is a powerful means of social control, whereby the
categories of disease, illness, madness and deviancy are used to
maintain a status quo in society. Doctors who make the diagnoses are
in a powerful position. The role of the patient during sickness as
conceptualized by Parsons (1951) is illustrated in Table 1.2.
Increasingly, too, doctors are involved in decisions relating to the
beginning and ending of life (terminations, assisted reproduction,
neonatal care, euthanasia). The encroachment of medical decisions
into these stages of life subverts human autonomy and, it is argued,
gives to medicine an authority beyond its legitimate area of operation
(Illich, 1975).
Table 1.2
The sick role
Medicine as surveillance
Public health medicine has been concerned with the regulation and
control of disease. Historically this included the containment of
bodies, such as those infected with the plague, tuberculosis or
venereal disease. Mass-screening programmes have given rise to what
has been called medical surveillance. The wish to identify the
‘abnormal’ few with ‘invisible’ disease justifies monitoring the entire
target population. Another critique of the pervasive power of
medicine suggests the mapping of disease and identification of risk
have subtly handed responsibility of health to individuals. This may
invite new forms of control in the name of health, e.g. random drug
testing or linking deservingness for surgery to lifestyle factors. The
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libraries of Arabic literature, to compile local histories and poems,
and, in a measure, to become centres for the propagation of
intellectual thought.
That is the condition in which Leo Africanus found them in the
sixteenth century, when he first revealed their existence to an
incredulous and largely unlettered Western world; in which the
pioneer explorers of the nineteenth century found them; in which the
political agents of Great Britain found them ten years ago when
destiny drove her to establish her supremacy in the country. That is
the condition in which they are to-day in this difficult transition stage
when the mechanical engines of modern progress, the feverish
economic activity of the Western world, the invading rattle of another
civilization made up of widely differing ideals, modes of thought, and
aims, assailed them.
Will the irresistible might wielded by the new forces be wisely
exercised in the future? Will those who, in the ultimate resort, direct
it, abide by the experience and the advice of the small but splendid
band of men whose herculean and whole-hearted labours have
inscribed on the roll of British history an achievement, not of
conquest, but of constructive statesmanship of just and sober
guidance nowhere exceeded in our management of tropical
dependencies? Will they be brought to understand all that is
excellent and of good repute in this indigenous civilization; to realize
the necessity of preserving its structural foundations, of honouring its
organic institutions, of protecting and strengthening its spiritual
agencies? Will they have the patience to move slowly; the sympathy
to appreciate the period of strain and stress which these
revolutionary influences must bring with them; the perception to
recognize what elements of greatness and of far-reaching promise
this indigenous civilization contains? Or will they, pushed by other
counsellors, incline to go too fast both politically and economically,
impatiently brushing aside immemorial ceremonies and customs, or
permitting them to be assaulted by selfish interests on the one hand
and short-sighted zeal on the other? Will they forget, amid the
clamorous calls of “progress” and “enlightenment” that their own
proclaimed high purpose (nobly accomplished by their
representatives) of staying the ravages of internal warfare and
healing open wounds will be shamed in the result if, through their
instrumentality, the seeds of deeper, deadlier ills are sown which
would eat away this fine material, destroy the lofty courtesies, the
culture and the healthy industrial life of this land, converting its
peoples into a troubled, shiftless mass, hirelings, bereft of economic
independence and having lost all sense of national vitality? Thoughts
such as these must needs crowd upon the traveller through these
vast spaces and populous centres as he watches the iron horse
pursue its irrevocable advance towards the great Hausa cities of the
plains, as he hears the increasing calls from the newly opened tin
mines for labour, from the Lancashire cotton-spinner for cotton and
markets; as he takes cognisance of the suggestions already being
made to break the spirit of the new and admirable land-law, and of
the efforts to introduce a militant Christian propaganda; as he listens
in certain quarters to the loose talk about the “shibboleths” and
“absurdities” of indigenous forms and ceremonies, the
cumbrousness of native laws and etiquette.
CHAPTER IV
THE LIFE OF THE PEOPLE—THE LONG-DISTANCE TRADER
A broad, sandy road, piercing a belt of shea trees, gnarled and

twisted, their bark figured like the markings of a crocodile’s back,
from which peculiarity you can distinguish the true shea from the so-
called “false” shea, or African oak. From the burnt grasses, golden
flowers destitute of leaf companionship peep timidly forth as though
fearful of such uncongenial surroundings. The heat rays quiver over
the thirsty soil, for it is Christmas time and no rain has fallen for nigh
upon four months. On the summit of a blackened sapling, exquisite
in its panoply of azure blue and pinkey-buff, a bird of the size of our
English jay but afflicted with a name so commonplace that to
mention it in connection with so glorious a visitant would be cruel,
perches motionless, its long graceful tail feathers waving ever so
slightly in the still air. The sun beats downward shrewdly, and
combined with the gentle amble of the patient beast beneath you,
induces drowsiness. You find yourself nodding in the saddle until the
loosening grip of thighs jerks the rider once more into sentiency. It is
hot, dreamily, lethargically hot. All the world seems comatose, the
unfolding panorama unreal as if seen through a fog of visionary
reverie. But there is nothing fanciful about the rapidly approaching
cloud of dust ahead, which emits a swelling murmur of confused
sound. It takes shape and substance, and for the next half-hour or
so, drowsiness and heat are alike forgotten in the contemplation of a
strange medley of men and animals. Droves of cattle, among them
the monstrous horned oxen from the borders of Lake Chad,
magnificent beasts, white or black for the most part. Flocks of
Roman-nosed, short-haired, vacant-eyed sheep—white with black
patches. Tiny, active, bright brown goats skipping along in joyful
ignorance of impending fate. Pack-bullocks, loaded with potash,
cloth, hides and dried tobacco leaves, culinary utensils, and all
manner of articles wrapped in skins or in octagon-shaped baskets
made of parchment, tight drawn in a wicker framework, which later—
on the return journey—will be packed with kolas carefully covered
with leaves. A few camels, skinny and patchy, and much out at
elbows so to speak, similarly burdened. The drivers move among
their beasts. Keeping in the rear, with lengthy staves outstretched
over the animal’s back, they control any tendency to straggle across
the road. Tall spare men, for the most part, these drivers, small-
boned, tough and sinewy. Hausas mainly, good-featured, not
unfrequently bearded men, often possessed of strikingly handsome
profiles, with clean-shaven heads and keen cheerful looks. But many
Tuaregs are here also from the far-distant north, even beyond the
Nigerian border; their fierce eyes gleaming above the black veil
drawn across the face, covering the head and falling upon the robe
beneath, once white, now stained and rent by many weeks of travel.
From the shoulders of these hang formidable, cross-handled swords
in red-leather tasselled scabbards. Nor are the Hausas always
innocent of arms, generally a sword. But here is a professional
hunter who has joined the party. You can tell him from his bow held
in the right hand and the quiver of reed-arrows barbed—and, maybe,
poisoned—slung across his back. The legs of the men are bare to
the knees, and much-worn sandals cover their feet. Some carry
loads of merchandise, food and water-gourds; others have their
belongings securely fastened on bullock or donkey. Women, too,
numbers of them, splendid of form and carriage, one or both arms
uplifted, balancing upon the carrying pad (gammo) a towering load of
multitudinous contents neatly held together in a string bag. Their
raiment is the raiment of antiquity, save that it has fewer folds, the
outer gown, commonly blue in colour, reaching to just below the
knees, the bosom not generally exposed, at least in youth, and
where not so intended, gravely covered as the alien rides by; neck,
wrists and ankles frequently garnished with silver ornaments. Many
women bear in addition to the load upon the head, a baby on the
back, its body hidden in the outer robe, its shiny shaven head
emerging above, sometimes resting against the soft and ample
maternal shoulders, sometimes wobbling from side to side in
slumber, at the imminent risk, but for inherited robustness in that
region, of spinal dislocation. Children of all ages, the elders doing
their share in porterage, younger ones held by the hand (nothing can
be more charming than the sight of a youthful Nigerian mother
gladsome of face and form teaching the young idea the mysteries of
head-carriage!). Two tired mites are mounted upon a patient ox, the
father walking behind. A sturdy middle-aged Hausa carries one child
on his shoulders, grasps another by the wrist, supporting his load
with his free hand. A gay, dusty crowd, weary and footsore, no
doubt, tramping twenty miles in a day carrying anything from forty to
one hundred pounds; but, with such consciousness of freedom, such
independence of gait and bearing! The mind flies back to those
staggering lines of broken humanity, flotsam and jetsam of our great
cities, products of our “superior” civilization, dragging themselves
along the Herefordshire lanes in the hop-picking season! What a
contrast! And so the trading caravan, bound for the markets of the
south, for Lokoja or Bida—it may well be, for some of its units,
Ibadan or Lagos—passes onwards, wrapped in its own dust, which,
presently, closes in and hides it from sight.
A NIGERIAN HUNTER STALKING GAME WITH THE HEAD OF THE GROUND

HORNBILL AFFIXED TO HIS FOREHEAD.
(Copyright.) (Photo by Mr. E. Firmin.)

Throughout the dry season the trade routes are covered with such
caravans and with countless pedestrians in small groups or in twos
or threes—I am told by men who have lived here for years and by
the natives themselves, that while highway robbery is not unknown,
a woman, even unattended (and I saw many such) is invariably safe
from molestation—petty traders and itinerant merchants, some
coming north loaded with kolas, salt and cloth, others going south
with butchers’ provender, potash, cloth, grass, and leather-ware,
etc., witness to the intensive internal commerce which for centuries
upon centuries has rolled up and down the highways of Nigeria.
A TRADING CARAVAN.
CHAPTER V
THE LIFE OF THE PEOPLE—THE AGRICULTURIST
Allahu Akbar! Allahu Akbar! The sonorous tones perforate the

mists of sleep, heralding the coming of the dawn. Ashadu Allah, ila-
allahu, ila-allahu! Insistent, reverberating through the still, cold air—
the night and first hours of the day in these latitudes are often very
cold. A pause. Then the unseen voice is again raised, seeming to
gather unto itself a passionate appeal as the words of the prayer flow
more rapidly. Ashadu an Muhammad rasul ilahi! Haya-al essalatu!
Haya al el falahi! Kad Kamet essalatu! Another pause. The myriad
stars still shine in the deep purple panoply of the heavens, but their
brilliancy grows dimmer. The atmosphere seems infused with a
tense expectancy. Allahu Akbar! Allahu Akbar! La illaha, ila-Allahu,
ila-Allahu. Muhammad Rasul ilahi. Salallah aleiheiu, ... Wassalama.
The tones rise triumphant and die away in grave cadence. It thrills
inexpressibly does this salute to the omnipotent Creator ringing out
over every town and village in the Moslem Hausa States. “God the
Greatest! There is no God but the God!” And that closing, “Peace!” It
has in it reality. Surely it is a good thing and not a bad thing that
African man should be reminded as he quits his couch, and as he
returns to it, of an all-presiding, all-pervading, all-comprehending
Deity? His fashion may not be our fashion. What of that? How far are
we here from the narrow cry of the “Moslem peril”! Whom does this
call to God imperil? The people who respond to it and prostrate
themselves in the dust at its appeal? Let us be quite sure that our
own salvation is secured by our own methods, that the masses of
our own people are as vividly conscious of the Omnipotent, as free
and happy in their lives, as these Nigerian folk, ere we venture to
disturb the solemn acknowledgment and petition that peal forth into
the dusk of the Nigerian morn.
FRUIT-SELLERS.
WATER-CARRIERS.
And now a faint amber flush appears in the eastern sky. It is the
signal for many sounds. A hum of many human bees, the crowing of
countless roosters, the barking of lean and yellow “pye” dogs, the
braying of the donkey and the neigh of his nobler relative, the
bleating of sheep and the lowing of cattle. The scent of burning wood
assails the nostrils with redolent perfume. The white tick-birds, which
have passed the night close-packed on the fronds of the tall fan-
palms, rustle their feathers and prepare, in company with their
scraggy-necked scavenging colleagues the vultures, for the useful if
unedifying business of the day. Nigerian life begins, and what a busy
intensive life it is! From sunrise to sunset, save for a couple of hours
in the heat of the day, every one appears to have his hands full.
Soon all will be at work. The men driving the animals to pasture, or
hoeing in the fields, or busy at the forge, or dye-pit or loom; or
making ready to sally forth to the nearest market with the products of
the local industry. The women cooking the breakfast, or picking or
spinning cotton, or attending to the younger children, or pounding
corn in large and solid wooden mortars, pulping the grain with
pestles—long staves, clubbed at either end—grasped now in one
hand, now in the other, the whole body swinging with the stroke as it
descends, and, perhaps, a baby at the back, swinging with it; or
separating on flat slabs of stone the seed from the cotton lint picked
the previous day. This is a people of agriculturists, for among them
agriculture is at once life’s necessity and its most important
occupation. The sowing and reaping, and the intermediate seasons
bring with them their several tasks. The ground must be cleared and
hoed, and the sowing of the staple crops concluded before the early
rains in May, which will cover the land with a sheet of tender green
shoots of guinea-corn, maize, and millet, and, more rarely, wheat.
When these crops have ripened, the heads of the grain will be cut
off, the bulk of them either marketed or stored—spread out upon the
thatch-roofed houses to dry, sometimes piled up in a huge circle
upon a cleared, dry space—in granaries of clay or thatch, according
to the local idea; others set aside for next year’s seeds. The stalks,
ten to fifteen feet in height, will be carefully gathered and stacked for
fencing purposes. Nothing that nature provides or man produces is
wasted in this country. Nature is, in general, kind. It has blessed man
with a generally fertile and rapidly recuperative soil, provided also
that in the more barren, mountainous regions, where ordinary
processes would be insufficient, millions of earth-worms shall
annually fling their casts of virgin sub-soil upon the sun-baked
surface. And man himself, in perennial contact with Nature, has
learned to read and retain many of her secrets which his civilized
brother has forgotten. One tree grows gourds with neck and all
complete, which need but to be plucked, emptied and dried to make
first-rate water-bottles. A vigorous ground creeper yields enormous
pumpkin-shaped fruit whose contents afford a succulent potage,
while its thick shell scraped and dried furnishes plates, bowls, pots,
and dishes of every size, and put to a hundred uses: ornaments, too,
when man has grafted his art upon its surface with dyes and carved
patterns. A bush yields a substantial pod which when ready to burst
and scatter its seeds is found to contain a fibrous substance which
resembles—and may be identical with, I am not botanist enough to
tell—the loofah of commerce, and is put to the same uses. From the
seeds of the beautiful locust-bean tree (dorowa), whose gorgeous
crimson blooms form so notable a feature of the scenery in the
flowering season, soup is made, while the casing of the bean affords
a singularly enduring varnish. The fruit of the invaluable Kadenia or
shea tree is used for food, for oil, and medicinally. The bees receive
particular attention for their honey and their wax, the latter utilized in
sundry ways from ornamenting Korans down to the manufacture of
candles. As many as a dozen oblong, mud-lined, wicker hives closed
at one end, the other having a small aperture, may sometimes be
seen in a single tree. Before harvest time has dawned and with the
harvesting, the secondary crops come in for attention. Cassava and
cotton, indigo and sugar-cane, sweet potatoes and tobacco, onions
and ground-nuts, beans and pepper, yams and rice, according to the
locality and suitability of the soil. The farmers of a moist district will
concentrate on the sugar-cane—its silvery, tufted, feathery crowns
waving in the breeze are always a delight: of a dry, on ground-nuts:
those enjoying a rich loam on cotton, and so on. While the staple
crops represent the imperious necessity of life—food, the profits from
the secondary crops are expended in the purchase of clothing, salt
and tools, the payment of taxes, the entertainment of friends and
chance acquaintances (a generous hospitality characterizes this
patriarchal society), and the purchase of luxuries, kolas, tobacco,
ornaments for wives and children. It is a revelation to see the cotton-
fields, the plants in raised rows three feet apart, the land having in
many cases been precedently enriched by a catch-crop of beans,
whose withering stems (where not removed for fodder, or hoed in as
manure) are observable between the healthy shrubs, often four or
five feet in height, thickly covered with yellow flowers or snowy bolls
of white, bursting from the split pod. The fields themselves are
protected from incursions of sheep and goats by tall neat fencing of
guinea-corn stalks, or reeds, kept in place by native rope of
uncommon strength. Many cassava fields, the root of this plant
furnishing an invaluable diet, being indeed, one of the staples of the
more southerly regions, are similarly fenced. Equally astonishing are
the irrigated farms which you meet with on the banks of the water-
courses. The plots are marked out with the mathematical precision of
squares on a chess-board, divided by ridges with frequent gaps
permitting of a free influx of water from the central channel, at the
opening of which, fixed in a raised platform, a long pole with a
calabash tied on the end of it, is lowered into the water and its
contents afterwards poured into the trench. Conditions differ of
course according to locality, and the technique and industry
displayed by the farmers of one district vary a good deal from the
next. In the northern part of Zaria and in Kano the science of
agriculture has attained remarkable development. There is little we
can teach the Kano farmer. There is much we can learn from him.
Rotation of crops and green manuring are thoroughly understood,
and I have frequently noticed in the neighbourhood of some village
small heaps of ashes and dry animal manure deposited at intervals
along the crest of cultivated ridges which the rains will presently
wash into the waiting earth. In fact, every scrap of fertilizing
substance is husbanded by this expert and industrious agricultural
people. Instead of wasting money with the deluded notion of
“teaching modern methods” to the Northern Nigerian farmer, we
should be better employed in endeavouring to find an answer to the
puzzling question of how it is that land which for centuries has been
yielding enormous crops of grain, which in the spring is one carpet of
green, and in November one huge cornfield “white unto harvest,” can
continue doing so. What is wanted is an expert agriculturist who will
start out not to teach but to learn; who will study for a period of say
five years the highly complicated and scientific methods of native
agriculture, and base possible improvements and suggestions,
maybe, for labour-saving appliances, upon real knowledge.
Kano is, of course, the most fertile province of the Protectorate,
but this general description of agricultural Nigeria does not only
apply to Kano Province. I saw nothing finer in the way of deep
cultivation (for yams and guinea-corn chiefly) than among the Bauchi
pagans. The pagan Gwarri of the Niger Province have for ages past
grown abundant crops in terraces up their mountainsides whither
they sought refuge from Hausa and Fulani raids. The soil around
Sokoto, where the advancing Sahara trenches upon the fertile belt,
may look arid and incapable of sustaining annual crops, yet every
year it blossoms like a rose. But the result means and needs
inherited lore and sustained and strenuous labour. From the early
rains until harvest time a prolific weed-growth has continuously to be
fought. Insect pests, though not conspicuously numerous in most
years, nevertheless exist, amongst them the locusts, which
sometimes cover the heavens with their flight; the caterpillar, which
eats the corn in its early youth; the blight (daraba), which attacks the
ripening ear. In some districts not so favoured, the soil being of
compact clay with a thin coating of humus, intensive cultivation has
proved exhausting, and it is a study to note how every ounce of
humus is tended with religious care. Very hard work at the right time
is the secret of success for the Nigerian agriculturist. It is little short
of marvellous that with all he has to do he somehow manages to
build our railways and our roads. Indeed, if that phenomenon has in
many respects its satisfactory, it has also its sombre, social side.
One can but hope that the former may outweigh the latter as the
country gradually settles down after the severe demands placed
upon it these last few years.
A GWARRI GIRL.
A HAUSA TRADING WOMAN.
Truly a wonderful country, and a wonderful people, a people who

with fifty years’ peace will double its numbers, a people whom it is
our paramount duty to secure for ever in the undisturbed occupation
and enjoyment of the land, precluding the up-growth of a middle-man
class of landlord from which the native system is free, and being so
free need never be saddled with.
CHAPTER VI
THE LIFE OF THE PEOPLE—THE HERDSMAN AND THE ARTISAN
The word “peasant” as applied to the Fulani is, no doubt, a

misnomer. I employ it merely to distinguish the herdsmen from the
caste of statesmen and governors, evolved in Nigeria by the genius
of Othman Fodio, but, as their recorded history throughout Western
Africa shows, inherent in this mysterious race whose moral
characteristics have persisted through all degrees of admixture with
the negro. The Fulani peasant is but rarely an agriculturist in Nigeria,
but he plays an important, if indirect, part in the agriculture of the
Hausa provinces. Over the face of the land he wanders with his
great herds—which may number upwards of several thousand head
in one herd—of beautiful hump-backed cattle, mostly white, ever
seeking “pastures new.” Speaking under correction, in Borgu only
does his settlement partake of permanency. Elsewhere he is a
wanderer. One month a given district may be full of Fulani camps,
come from where his fellow-man has but the vaguest of notions. The
next, not a single Fulani will be seen within it. But they return, as a
rule, the ensuing year to their old haunts. To the Hausa farmer the
M’Bororoji or “Cow-Fulani” are an invaluable asset, and he enters
into regular contracts with them for turning their cattle on to his fields;
and he buys milk from them. I struck several of their encampments,
at distances hundreds of miles apart. The first, at the crossing of the
Bako, between Badeggi and Bida, was in charge of a patriarch who
might have stepped out of the book of Genesis: a Semite every inch
of him: spare of form, emaciated in feature, with high cheek-bones,
hawk-like nose, flashing, crafty eyes, a long white beard and a
bronzed skin without a trace of black blood.
A FULANI GIRL.
There is no more interesting sight in Nigeria than a Fulani

encampment. It is usually pitched well away from the beaten track,
albeit within convenient distance of a village. You rub your eyes and
wonder if you can really be in the heart of the Dark Continent, as
these gracefully built, pale copper-coloured men and women—one
may say of some of the young girls with the sun shining on their
velvety skins, almost golden coloured—appear tending their herds
and flocks, or standing and sitting at the entrance to their temporary
shelters. Even the latter differ frequently from the African hut,
resembling in shape the wigwam of the North American Indian. As
for the people themselves, you are aware of an indefinable
sentiment of affinity in dealing with them. They are a white, not a
black race.
I have discussed their origin and West African history elsewhere,[8]
and will only say here that delicacy of form, refinement of contour
and simple dignity of bearing distinguish this strange people, just as
the ruling families possess the delicacy of brain and subtlety of
intellect which impress their British over-lords. A fact worth
recording, perhaps, is that while the Hausa woman spins and the
Hausa man weaves cotton, the Fulani woman does both the
spinning and the weaving.
If the agricultural life of the Northern Nigerian peoples is a full one,
the industrial life, especially in the northern provinces of the
Protectorate, is equally so. It is an extraordinarily self-sufficing
country at present, and the peasant-cultivator and artisan are
interdependent, the latter supplying the domestic wants and making
the requisite implements for the former. The variety of trades may be
estimated from the old Hausa system of taxation. This system the
Fulani adopted, modifying it slightly here and there by enforcing
closer adherence to the Koranic law, and we are modifying it still
further by a gradual process tending to merge multiple imposts under
two or three main heads, with the idea of establishing a more
equitable re-adjustment of burdens and to ensure greater simplicity
in assessment. The Hausa system provided that taxes should be
levied upon basket and mat-makers, makers of plant for cotton-
spinners, bamboo door-makers, carpenters, dyers, blacksmiths and
whitesmiths, as well as upon bee-keepers, hunters, trappers and
butchers. Exemption from taxes was granted to shoe-makers, tailors,
weavers, tanners, potters, and makers of indigo; but market taxes
were imposed upon corn measurers, brokers, sellers of salt,
tobacco, kolas, and ironstone.
The chief agricultural implement is the Hausa hoe, the galma, a
curious but efficient instrument, which simultaneously digs and
breaks up the soil and is said to be of great antiquity, but which is
easier to draw than to describe. There is also in daily use among the
Hausas a smaller, simpler hoe and a grass-cutter, while the pagan
favours a much heavier and more formidable-looking tool. This
pagan hoe somewhat resembles our English spade, but is wielded in
quite different fashion. Iron drills, rough hammers and axes, nails,
horseshoes, stirrup-irons and bits are included among the ordinary
forms of the blacksmith’s art. Iron-stone is common in many parts of
the country and is extensively worked, furnaces being met with in
every district where the use of the metal is locally in vogue. It is to be
hoped that “Civilization” will not seek to stamp out this native industry
as the tin-miners have done their best—and, unless the promise
made to the smelters of Liruei-n-Kano by Sir H. Hesketh Bell is not
speedily carried out, but too successfully—to crush the interesting
tin-smelting industry. The history of native tin smelting in Nigeria
furnishes a remarkable proof of the capacity of the Nigerian native,
but is too long to set forth here in detail. Suffice it to say that for a
hundred years, a certain ruling family with numerous branches, has
succeeded in turning out a singularly pure form of the white metal
whose sale as an article of trade brought prosperity to the
countryside. When I left the tin district, owing to unjust and stupidly
selfish interference with immemorial rights, the native furnaces had
been closed for nine months and poverty was beginning to replace
comparative affluence.
PANNING FOR IRON.

Foundations For Health Promotion 4Th Edition Jennie Naidoo Full Chapter

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Foundations for Health Promotion 4th

Edition Jennie Naidoo

Chapter One. Concepts of health

Defining health, well-being, disease, illness and ill health

The Western scientific medical model of health

A critique of the medical model

Lay concepts of health

A unified view of health

Chapter Two. Influences on health

Social class and health

Income and health

Housing and health

Employment and health

Gender and health

Health of ethnic minorities

Place and health

Explaining health inequalities

Tackling inequalities in health

Chapter Three. Measuring health

Why measure health?

Measuring health as a negative variable (e.g. health is not being diseased

Measuring health and disease in populations

Measures of health as an objective attribute

Subjective health measures

Physical well-being, functional ability and health status

Social capital and social cohesion

Chapter Four. Defining health promotion

Foundations of health promotion

Origins of health promotion in the UK

The World Health Organization and health promotion

Defining health promotion

The argument for health promotion

Chapter Five. Models and approaches to health promotion

The medical approach

The educational approach

Models of health promotion

Theories in health promotion

Chapter Six. Ethical issues in health promotion

The need for a philosophy of health promotion

Consequentialism and utilitarianism: The individual and the common good

Chapter Seven. The politics of health promotion

The politics of health promotion structures and organization

The politics of health promotion methods

Part Two. Strategies and methods

Chapter Eight. Reorienting health services

Promoting health in and through the health sector

Primary healthcare and health promotion

Primary healthcare principles

Primary healthcare: strategies

Primary healthcare: service provision

Who promotes health?

Public health and health promotion workforce

Specialist community public health nurses

Mental health nurses

Environmental health workers

Allied health workers

Chapter Nine. Developing personal skills

The health belief model

Theory of reasoned action and theory of planned behaviour

The stages of change model

The prerequisites of change

Chapter Ten. Strengthening community action

Why work with communities?