Social inequality and healthy public policy.

For decades, health education programmes have been based on the assumption that individual behaviours (for example smoking, drug use, eating patterns) are the major risk-factors in contemporary illness. This assumption often led to interventions that subtly "blamed the victim" for his or her ill-health. In recent years the broader social conceptualization of health and illness has directed many health educators' attention towards socio-economic and environmental factors which condition and constrain lifestyle choices, and which may be directly associated with increased disease risks. While it is becoming common for government health departments and agencies to acknowledge poverty, unemployment and other forms of social inequality as potent health hazards, programmes to ameliorate such conditions are rare. Since 1983, the Toronto health department has developed programmes based upon a socio-environmental model of disease which specifically targets social systems rather than individual behaviour for change. Elements of this approach include extensive media reports on the health implications of such issues as welfare benefits, poverty, unemployment and housing; health education programmes to stimulate a critical understanding of the causes and structure of social inequality; health advocacy initiatives to influence political and legislative reforms; and a community development orientation which involves the department in broad-based coalitions working towards healthy social change. Most recently, the department has become a resource to groups attempting to create employment and service community needs through cooperative forms of economic development. Several examples of the department's programmes in each of these areas are provided. To meet the challenge of the World Health Organization's Alma Ata Declaration, health educators must examine their own potential to act as social-change agents, and must become more sophisticated in the political analysis of their practice.