w w w . e l s e v i e r . p t / r p s p
Original
article
On
becoming
healthier
communities:
Poverty,
territorial
development
and
planning
José
Manuel
Henriques
HigherInstituteofBusinessandLabourSciences,UniversityInstituteofLisbon(ISCTE-IUL),Lisbon,Portugal
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received30October2012 Accepted30May2013 Availableonline10July2013
Keywords:
Healthycommunities Socialdeterminantsofhealth Healthinequities
Anti-povertyaction Territorialdevelopment Learningfrompractice
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b
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Healthycommunitiesseektoimprovethehealthoftheircitizensasacentralaimof devel-opmentpoliciesanddeveloppossibilitiesforhealthrelated‘economicintegration’.They dependstronglyonMunicipalinitiativeinanimatingcross-sectoralpolicyintegrationand empoweringcivilsociety.Contemporaryconditionsrequire‘socialinnovation’depending oncentralparadigmshiftsinscience,inmovingbeyond‘deprivation-oriented’anti-poverty action,inlinkinghealthtoterritorialdevelopmentandindevelopingadequateplanning approaches.Thispaperdiscussestheabovementionedparadigmshifts,illustrates possibil-itiesofactionandsuggeststhepossibilityof‘learningfrompractice’basedontheexperience oftheWHOHealthyCitiesMovement.
©2012EscolaNacionaldeSaúdePública.PublishedbyElsevierEspaña,S.L.Allrights reserved.
Como
tornar
as
comunidades
mais
saudáveis:
pobreza,
desenvolvimento
do
território
e
planeamento
Palavras-chave:
Comunidadessaudáveis Determinantessociaisdasaúde Desigualdadesemsaúde Ac¸õesanti-pobreza
Devenvolvimentodoterritório Aprendizagempelaprática
r
e
s
u
m
o
Comunidadessaudáveispromovemasaúdedoscidadãoscomoobjetivocentraldassuas políticasdedesenvolvimentoedesenvolvemformassaudáveisde‘integrac¸ãoeconómica’. Dependemfortementedainiciativamunicipalnacriac¸ãodecondic¸õesparaaintegrac¸ão ter-ritorialdepolíticaspúblicasepromovendooempowermentdasociedadecivil.Ascondic¸ões contemporâneasrequereminovac¸ãosocialdependentedemudanc¸asparadigmáticas cen-traisnasciências,naperspetivac¸ãodocombateàpobrezaparaalémdarespostaàprivac¸ão, narelac¸ãoentresaúdeedesenvolvimentoterritorialenaadopc¸ãodeabordagensadequadas deplaneamento.Esteartigodiscuteasmudanc¸asparadigmáticasatrásenunciadas,ilustra possibilidadesdeac¸ãonapromoc¸ãodasaúdeesugereapossibilidadede‘aprendercoma prática’combasenaexperiênciaedosresultadosdaRededasCidadesSaudáveispromovida pelaOMS.
©2012EscolaNacionaldeSaúdePública.PublicadoporElsevierEspaña,S.L.Todosos direitosreservados.
E-mailaddress:jose.henriques@iscte.pt
0870-9025/$–seefrontmatter©2012EscolaNacionaldeSaúdePública.PublishedbyElsevierEspaña,S.L.Allrightsreserved. http://dx.doi.org/10.1016/j.rpsp.2013.05.006
Context
Communitiesbecomehealthierwhenlocalgovernance institu-tionsareabletocombinelocalinitiativeandorganizational capacitywithcross-sectoralactionandcommunity involve-ment tackling local conditions and structural causes of ‘socialdeterminants’.Communitiesbecomehealthieraspeople are empowered to develop critical awareness concern-ing the avoidable causes of ill-health and are prepared to change attitudes and behaviour concerning their own lifestyles. Communities become healthier when their mem-bers increase the control over the factors that relate local conditions to the ‘social determinants’ of their own health.
TheHealth2020policyframeworkproposes,asoneofits fourpriorityareas,thecreationofsupportiveenvironments andresilientcommunities.Thisisbasedontheassumption thatpeople’sopportunitiesforahealthylifearecloselylinked tothe conditions in which theyare born,grow, work and age:“Resilientandempoweredcommunitiesrespondproactivelyto neworadversesituations,prepareforeconomic,socialand environ-mentalchangeandcopebetterwithcrisisandhardship”.1‘Social
inequities’inhealtharerelatedwithunfairandavoidable differ-encesinhealthstatusacrossgroupsinsocietystressingthose thatresultfromthe unevendistributionof‘social determi-nants’.‘Socialdeterminants’ofhealthand‘healthinequities’ areamenabletochangethroughpolicyandgovernance inter-ventions.
Ontheotherhand,WHOrecognizespovertyasakeyfactor inexplainingpoorerlevelsofhealth:“Povertyisakeyfactorin explainingpoorerlevelsofhealthbetweenthemostandleast well-off countries and population groups within the same country.Yetdifferencesinhealthalsofollowastrongsocial gradient. This reflects an individual or population group’s positioninsociety,whichtranslatesindifferentialaccessto, andsecurityof,resources,suchaseducation,employment, housing,aswellasdifferentiallevelsofparticipationincivic societyandcontroloverlife”.2
Povertyrelated‘healthinequities’arebecomingmore diffi-culttotackle.PovertyisanexpandingphenomenoninEurope andcontemporarycrisisconditionsarecontributingtoreveal howpovertyisbecomingmorecomplex.Povertyiscurrently exhibiting increasingly diversified concrete manifestations. Aspovertyislivedinparticularplacesanditsmanifestations becomeconcreteinspatiallydiversifiedandlocalspecific con-texts,anti-povertyactionhasanunavoidablelocaldimension butcannotremainalocalissue.Actually,lastingchangesat locallevelrequirespecificanti-povertyactionhavingbotha
localandanon-local dimension.Povertyeradicationrequires societalchangegivenitsstructuralnature.
Contemporarycrisisconditionsarecontributingto clari-fyingthe limitsofcurrent understandingsinpublicpolicies and how adequate action is depending on ‘social innova-tion’andcentralparadigmshifts.Aswasalreadypolitically recognized,reformulation ofconventional economic, social andspatialpoliciesisrequiredifsignificantchangesshould beachievedinthe Europeancontext ofpoverty.Therefore, povertyisbestunderstoodasadevelopmentproblem requir-ingpolicyintegrationatdifferentterritoriallevelsandthesearch
fornewinstitutionalandorganizationalmodelsforspecific anti-povertyaction.
Municipalities canplayakeyrole inmakingthis under-standing concrete and in tackling poverty related ‘health inequities’ in improving healthy communities. This paper aimsatclarifyingsomecritical epistemological,conceptual and theoreticalaspectsinvolvingthepotentialcontribution ofMunicipalitiesinincorporatingthesekindsofchallenges incurrentterritorialplanning.Territorialplanningisafuture orientedactivitywhosetheoreticalobjectremainsonlinking
scientificknowledgetoactioninthepublicdomainaimingat socialtransformation.3
Thus,thecentralproblemguidingthispapercanbestated asfollows:howcanMunicipalitiesimprovehealthy communi-tiesfocusingonpovertyrelated‘healthinequities’interritorial planningforlocaldevelopment?
Thispaperwilldevelopacontributiontothischallengeby discussingfivecentraldomainsofparadigmshiftswithdirect implicationindesigning,implementingandmanagingaction. First, the relation between poverty-related health inequities and social determinants of health in improving healthycommunitieswillbeintroduced.Second,ascientific paradigm shift enabling the production of knowledge on
non-observable‘conditionsofpossibility’foremancipationand social transformation willbe presented.Third, a paradigm shift from ‘deprivation-oriented’ income support of poor households to the creation of health-related ‘economic integration’inmeetinghumanneedsbeyondconsumption, market-dependency andthe roleofthehealthcaresystem willbeproposed.
Fourth, a paradigm shift in linking health to territorial development beyond consumption-oriented approaches to meeting humanneedswillbediscussed. Fifth,aparadigm shiftinplanning willbepresentedand the implicationfor plannersinchoosingmethodsandtoolswillbeintroduced. Sixth,someexampleswillbepresentedasacontributionto illustratepossibilitiesofwideningMunicipalactionin improv-ing ‘healthy communities’. The examples are taken from actionstemmingfromdifferentcontextsinordertoovercome theabsence,insufficiencyorunsuitabilityofcurrentresponsesin dealingwithcontemporarychallenges.Finally, some condi-tionsfor‘socialinnovation’arediscussedandtheopportunity tolearnfrompracticedevelopedintheframeworkoftheWHO HealthyCitiesMovementisproposed.
Healthy
communities:
focusing
on
poverty-related
‘health
inequities’
The‘healthycommunities’ approachissupposed toplaya centralroleinachievinghumandevelopmentinthe twenty-firstcentury.Theliteratureinthefieldemphasizes‘healthy communities’asaprocess,notastatus.Ahealthycommunity isonethatseekstoimprovethehealthofitscitizensbyputting healthhighonthesocialandpoliticalagenda.Healthy com-munitiesareabouttheprocessthatenablespeopletoimprove theirhealththroughapplyingtheconceptsandprinciplesof healthpromotion atthelocallevel. TheWHOCommission onSocialDeterminantsofHealthrecognizesitspotentialasa newapproachtodevelopment.Healthandhealthequitymay
notbetheaimofallpublicpoliciesbuttheywilldefinitively beafundamentalresult.AsrecognizedbytheCommission, withoutappropriatepublicpoliciestoensurefairnessinthe waybenefitsaredistributed,growthcanbringlittlebenefitto healthequity.4
Asstated bythe WHO, traditionally, societies looked to thehealthsectortodealwithitsconcernsabouthealthand disease.And, certainly, misdistribution of health care, not deliveringcaretothosewhomostneedit,isoneofthesocial determinantsofhealth.Goodmedicalcareplaysacentralrole inthewell-beingofpopulations.Butimprovedclinical medi-calcareisnotenoughtomeetthechallengesoftodayandto overcomehealthinequities.5
Withoutactionon‘socialdeterminants’itwillnotbe possi-bletomeetthechallengeofreducingchronicdiseasessuchas cardiovasculardiseases,cancerordiabetes.Chronicdiseases are growingincountries thatalsofaceunsolved infectious epidemics.Themajorillnessproblemsaswellasill-health responsibleforavoidableprematurelossoflifeare strongly relatedwiththeconditionsinwhichpeopleareborn,grow, live,work,andage.Thus,healthinequitiescanbeovercome. Furthermore,giventheinterdependencybetween biolog-ical, psychological and socio-economic dimensions of life, health is not independent from mental health. As health canbe definedasthe possibility todevelopa positiveand autonomous attitude towards life, illness associates some formofsufferingwithasocialbehaviourrelatingtothesocial construction ofthe conceptofillness.6 On theother hand, becomingillisacontext-dependentprocessasonlyconcrete persons getill.Illness onlybecomesreal inthe context of structural,materialandsocialconstraintsthathumanbeings andcommunitiesface.Thesocio-psychosomaticdimensions ofill-healtharereal.7,8Thepotentialfailureofimmune
sys-tems cannotbeoverlooked.Anxiety, stress and depression caninterferewiththeirperformance(lossofhope,job insta-bilityandinsecurity,absenceofappropriatesocialwelfarein responsetolong-termunemployment,etc.).9–11
Healthycommunitiesarebasedonaholistic understand-ing of health and on an agencyperspective ofcommunity action. Municipalities are supposed to play a central role buildinglocalgovernance(cross-sectoralhealth-related pol-icyintegration),communityinvolvementandempowerment ofcivilsociety.12Peoplearesupposedtobecomeincreasingly
enabledtotakecontrolofthefactors(‘socialdeterminants’of health)thatdeterminetheirwell-beingandtheirhealth.
‘Socialdeterminants’ofhealtharetheconditionsinwhich peopleareborn,growup,live,workandage.2Theseconditions
influenceaperson’sopportunitytobehealthy,hisorherriskof illnessandlifeexpectancy.Andactiononthe‘social determi-nants’ofhealthmustinvolvethestate,civilsocietyandlocal communities.Policiesandprogrammesmustinvolveallthe keysectorsofsociety,notjustthehealthsector.Health sec-torauthoritiescanpromotea‘socialdeterminants’ofhealth approachatthehighestlevelpolicy decision-making.They candisseminateinformationabout‘goodpractice’ illustrat-ing‘howitcanbedone’andtheycontributetodeveloppublic policiesthatpromotehealthequity.
Actionon the‘social determinants’ focuseson the pro-cessesthatenablepeopletoincreasecontrolovertheirhealth followingtheconceptsandprinciplesofhealthpromotionat
thelocallevel.13Modifiableriskfactorsforchronicillnesssuch
aspoordiets,alcoholabuseorsmokingcannotbereducedto individualchoicesalone.Institutionsaswellaspoverty inter-ferewiththeindividualandcollectivesubjectiveperceptions thatmayfavour,ornot,‘healthylifestyles’.Actionon‘social determinants’hastotackletheunderlyingsocialconditions thatmakepeopleinpovertymorevulnerableinlinewiththe perspectiveoftheWHOCommissiononSocialDeterminants ofHealth):“Thecausesoftheselifestylecausesofpoorhealthreside inthesocial,legalandpoliticalcontextbroadlyconceived”.14
Asintroducedabove,povertyrelated‘healthinequities’are becomingmoredifficulttotackle.Inacontextofhigh unem-ployment and cut-backs in public expenses, anti-poverty actioninvolvesparticularchallenges.Itisstillimpossibleto accuratelypredictalltherepercussionsthatthepresentcrisis intheinternationalfinancialsystemandtheglobaleconomy combinedwithnationalausteritypolicieswillhaveonpoverty, employmentandstatebasedsocialprotection.Increasing dif-ficultiesfacingbusinesses,droppinglocaldemandasresultof recessionandstifferinternationalcompetitionaregivingrise toconcernsaboutincreasingandlastinghighunemployment eventuallyreinforcedbyausteritypoliciesstrictlyorientedto shorttermstructuraladjustment.Manyexamplesofcommon insecureconditionscanbehighlighted:insecureemployment, precariousnessresultingfromlabourmarketderegulationand liberalization,frequentperiodsofshort-termunemployment orlong-termunemployment,irregularmigration,exposition tonegativeorstigmatizingattitudes,rapidlychangingwelfare provision,etc.
Inthiscontext,giventheinterdependencybetweenhealth and mental health, poverty related ‘health inequities’ are becomingincreasinglycomplex.Forexample,insecurityand powerlessness combined withbad qualityfood and spatial concentration indeprivedneighbourhoodsincrease vulner-abilitytodisease.Decreasingaccesstohealthservices and adequatemedicalcarecannotcompensatethiskindof vul-nerability. Childrenmissroutinevaccinationsand illiteracy blockades access to information about health risks. Con-cerning chronic diseases, poverty creates ill-health as, for example,experiences inuteroand intheearly years asso-ciated withlowfamily socioeconomic positionatbirth are linked toincreasedriskofobesityand cardio-vascular dis-easeinadultlife.15Evidenceshowsthatpoorpeoplearemore
likelytoreportdepression,asthma,diabetes,highblood pres-sure andheartattacksrelatedwithhigherlevelsofobesity andalsocancerorhighcholesterol(poorpeoplearelesslikely tohaveregularpreventivecare,screeningtests,bloodtests, etc.).16
Healthy communities are very much context and time dependent.17 Improving healthy communitiesin the years
tocomewillbeverydifferentfromhowitwasdoneinthe industrializingcitiesofthenineteenthcentury.Asthemajor determinantsofhealtharetobefoundbeyondthehealth sec-tor,issuessuchasinter-sectorialpartnerships,cross-sectoral policyintegration,healthy communitycoalitions,local gov-ernment’sinvolvementorparadigmshiftsinthedebateabout the relationsbetweenhealthanddevelopment willsee their relevanceincrease.
Therefore,Municipalitiesimprovinghealthycommunities requirethecapacityofproducingknowledgeabouttheroot
causesofhealthinequities anddesigningthepossibility of tacklingthematlocallevel. Theyrequirethe improvement ofthe healthoftheir citizens as the centralaimof devel-opment policies. They focus on the processes that enable people to increase control over their health following the concepts and principles of health promotion at the local level.17
A
paradigm
shift
in
science:
‘reality’
and
‘conditions
of
possibility’
for
social
change
The debate on an eventual paradigm shift in science has acentral relevance forhealthy communities.9,18–26 Healthy
communitiesaimatincreasingcontrolover‘social determi-nants’ofhealthandthisrequiresthecapacityofproducing knowledgeaboutthe rootcauses of‘health inequities’and designingthepossibilityoftacklingthematlocallevel. Search-ingforpossibilitiesmaywellrequiretheobservationofexisting realitiesactivelymadeinvisiblebyhegemonicepistemological, conceptualandtheoreticalassumptions.Ontheotherhand, searchingforpossibilitiesmaystillnothaveempiricevidence.
Searchingforpossibilitiesrequiresthatknowledgehastobe pro-ducedon the basisof the identification of‘causal powers’ thatmayleadtopossibleempiricalmanifestationsandofthe conditionsthatmayfacilitatetheactivationofthese‘causal powers’.
Actionon‘socialdeterminants’aswellasactionon‘health inequities’ may have to be based on adequate knowledge about the causes of their underlying context-dependency. Actionmayalsohavetoincludethelinkingofthisknowledge tothebuildingofcriticalawarenessandcollectiveactionin changinglivingconditions.
Thecrisisofthehegemonicparadigmcannotbeignored. Evenifit isstillnotpossibletoidentifyanalternative and coherentemergingparadigmitispossibletoidentifycrucial issuesand show the directionof recent developments. This contributedelsewheretothe attempttomakeexplicithow apossibleresponsecouldbefoundwithintheframeworkofa ‘critical’realistepistemology.27–31
Povertyrelatedhealthinequitiesandhealthrelated anti-poverty action is a domain of research where a number of critical issues are directly linked to the crisis of the hegemonicparadigm. Actioninthisfieldtouchesthe inter-dependence between the natural and the social sciences. Povertyisabouthumansufferingandunmethumanneeds areatthebasisofexperiencedill-healthandlackof auton-omy. Overcoming poverty and meeting needs have both biologicalandsocialdimensions(health,foodandnutrition, shelterand housing, etc.). Asovercomingpoverty leads us to the analysis of human needs, even if we may concen-trateonthesocialandeconomicaspectsofthischange,we mustnotforgetthisunderlyingcriticaldimensionofhuman specificity.32,33
In tackling poverty related health inequities, action-orientedknowledgeisspecificastheconcretenessofpoverty related‘socialdeterminants’ofhealtharecontext-dependent. The complexity, spatial diversity and local uniqueness of poverty related health inequities call for the context-dependentconcretenessofaction.Knowledgebasedonlaws,
formalcausalityandgeneralizationofobservedregularitiesis oflittlehelpindesigningunique‘projectsofhope’for particu-larindividuals,householdsorgroupsorindesigning‘strategic
visions’ for communities in localities or regions. The mul-tidimensionalityofpovertyrelated healthinequitieshasto beunderstood inits wholeness. Toknow about therelation betweenpovertyandill-healthistoknowabouthowpoor peo-pleliveandexperiencethoseproblemsthenon-pooridentify
aspoverty problems.A ‘divisionofreality’basedon scien-tificdisciplinesdoesnothelptoreconstitutethecomplexity ofexperiencedlife.
Thesubstantivecontentofanti-povertyactionisnot inde-pendent from the waythe ‘object’ ofactionis approached. If anti-poverty action is conceivedas dealing with experi-encedproblemsofrealpeople,facingunmetbasic-needsin realplaces,towhichtheyarehistoricallytiedbycognitiveand affectivebonds,ortowhichtheyaredeterminedtobelong,the ‘subject-object’relationbecomesarelationbetweensubjects.In anti-povertyaction,theroleofplannerscannotbedissociated fromarelationbetweensubjectsaimingatemancipationand empowerment.
Health related anti-poverty actionisalsoabout interac-tionbetweenplanningagentsandothersocialagentseither for thepurpose ofcontrollingsome undesirablechange or for the purpose of enabling action aiming at some desir-able change. In anti-poverty action, planning agents call for scientific support searching for practical adequateness (eradicating or mitigating poverty, tackling social determi-nants of healthand healthinequities, etc.).But, the other socialagentsdeveloptheirstrategiesonthebasisofcommon senseknowledge.Scientificknowledgemayfacesterilityin anti-poverty actionifnot‘(re)translated’into commonsense knowledge inorder tomake interaction and dialogue pos-sible. ‘Reformulation’ in non-directive psychotherapy can be seen as an interestingexample34 in meeting this
chal-lenge.
A
paradigm
shift
in
anti-poverty
action:
‘economic
integration’
of
poor
households
beyond
employment
and
‘deprivation-oriented’
welfare
policies
Thecomplexityofpovertyandanti-povertyactionhastobe explicitlyaddressed.Povertyisnotonlyamajor‘social deter-minant’ of health. Poverty isinitself the very difficulty of meeting the existentialconditions forthe avoidance of ill-health.
Incontemporarycrisisconditions, risingunemployment combined with shortcomings in welfare policies are con-tributing to emphasize the limits of reducing anti-poverty actiontodeprivationorientedincomesupport.Thisis partic-ularlythecasewhenactionfocusesonpovertyrelated‘health inequities’andonhealthrelated‘economicintegration’.This involvesactionbeyondtheroleofhealthcaresystemsand rep-resentsamajorchallengeinpractice.Dealingwith‘economic integration’,understoodasthe‘economic’dimensionof anti-poverty action,involvesaparadigmshiftinaction.Explicit reformulationisneededinvolvingvalues,conceptsand theo-riesinformingaction.
Deprivation,povertyandunmetneeds
InEuropeancontemporaryconditions,theunderstandingof poverty cannotberestricted tolow incomealone. This has beenanalyzedelsewherewithdetail.30Povertywas
conceptu-alizedasasituationofunmetbasic-needs(illhealthandlackof autonomy)35–37whichemergesastheoutcomeofaprocessby
meansofwhichunmetintermediateneeds(food,housing, medi-calcare,etc.)arerelatedwithinsufficiencyofresources(material ornonmaterial)inagivendiscursive-organizationalcontext.
Understoodasabsolutepoverty,povertywasdefinedasthe inabilitytomobilizematerialandnon-materialmeanstocreate
synergicsatisfierstomeetintermediateneedsandavoidill-health andlackofautonomy.Thisinabilityistheresultofthefailure
ofconstitutingpurposefulagencyinarelationalcontextdefined byadiscursivefieldmarkedbyhegemonyandanorganizational fieldcharacterizedbyorganizationaloutflanking38ofthepoor.
Thisleadstoaclearerunderstandingwhypovertycannot
resultfromlowincomealone.Povertymayberelatedtoa com-plexinterdependencybetweendetachmentfromproduction(lack ofmoney,lackofproductivetoolsforself-consumption,etc.), lackofcognitiveskills(relevantknowledge,strategic informa-tion,etc.),weakenedaffectiveconditions(isolationandrupture ofinterpersonalrelations,lackofcollectiveorganization,etc.) andblockingemotionalconditions(anxiety,depression,lossof identity,etc.).Thisweakenstheverypossibilityofhopeandthe constitutionofanemancipatoryprojectwhichcouldarticulate individualandcollectiveinterests.
The expansion of poverty due to increasingly difficult accesstomoneyresourcesshouldnotcauseotherdimensions underlyingunmetbasicneedstobeoverlooked.Precarious interpersonalrelationsorsocialisolationmaymakematerial resourcesuselessinthepreventionofseriousharm(lackof hope,senseofpowerlessness,psychologicaldisorder,etc.).
Specifically forthe purpose ofthis paper, other dimen-sionsofintermediateneedscanbeabstractedandattention maybefocusedontheroleofunemployment,precariousnessand cut-backsindeprivation-orientedstateresponseintheway thesubstantiverelations(whethernecessaryorcontingent) betweenhealthandintermediateneedssuchashousing,medical care,professionalskills,criticalunderstandingandsocialrelations
areconstitutedandcanberelatedwith‘socialdeterminants’ ofhealthandterritorialdevelopment.Themarket-dependency
of meeting ‘intermediate needs’ due to society’s commod-ification, and consumption-oriented subjective interpretation of need and action, are historical constructs, thus liable to change.
Therefore,the differencebetweenthe conceptof ‘depri-vation’andtheconceptof‘poverty’playsacriticalrelevance for anti-poverty action.39–42 Poverty was understood
else-where defined as a state of deprivation that results from
scarcityorinsufficiencyofresourcesinadiscursive-organizational context.30,43 Asresourcesarefunctionaltoagents’purposes,
andpower wasdefinedbothasagent’saccesstoresources andasitscapacitytorealizespecificpurposesinaspecific organizational-discursiverelational context,agents’purposes
becomeconstitutiveofthe role played bythe entitiesthat
becomeresources.
Thatisthereasonwhytheexerciseofpowerisnot inde-pendentfrom theprocessbymeansofwhichresourcesare
‘constituted’. Thus, as both agents’ purposes and human actionareconcept-dependent,conceptsplayaroleinthe consti-tutionofthepossibilitytoexercisepower.Powerisexercised overresourcesonthebasisofadiscursive-organizationalsocially created context. The very relevance, sense and meaning of resources become bothcontext-dependent and concept-dependent.Therefore,thematerialityofresourcescannotbe assessedindependentlyofthepurposesthatcreateresourcesas themeansrequiredfortheirfulfilment.
Thatiswhytheinstitutionaldiscoursesonpovertyplaya centralrole.Theyestablishtheconceptualboundariesforthe actual perception ofthe problems felt by those in poverty aswellasitscauses.Thepoorfindthemselvescaughtina webofrelationswhichtheydonotcontrol.Othersproduce dis-coursesonpovertythatdefinetheveryconceptualboundaries inthecontextofwhichtheirproblemsarerecognized,accepted
orunderstoodas‘poverty’.
Havinginmindtherichdebateabouttherelationbetween ‘relative’and‘absolute’poverty,povertywasintroducedabove asabsolutepoverty.44–47Giventheanti-povertyorientationof
thispaper,theexistentialdimensionofpovertyhastobethe focusoftheconceptualandtheoreticaldebate.Anti-poverty actionisaboutchangingpoorpeople’slives.
Concerningthe‘absolutistcore’ofthenotionofpoverty,a conceptofpovertycanbebuiltonapreciseconceptof basic-needwithuniversalvalidity.Itwasshownthatanobjective conceptofbasic-needwaspossiblewithoutremaininga nor-mativeconcept.Humanneedshavenotbeenlatelytheobject ofmuchattentioninthesocialsciences.Nevertheless,there isaveryrichdebateinthefieldwhichisveryusefulin con-ceptualizingpovertyandanti-povertyaction.48–56
Anti-povertyactionandthe‘economicintegration’ofpoor households
Accordingly, ‘economic integration’ was defined as action
aimedatprocessesoflinkingthe knowledgeaboutmaterial conditions of unmetbasic needs withthe kind ofmaterial
transformationwhichmaycontributetoanti-povertyeffects, namely, through wideningpossibilities fordecreasing market-dependency in meeting intermediate needs and broadening possibilitiesforincomeearningactivitiestodecreasedependency on working for a wage in the formal employment sys-tem(producingforself-consumptionandsmall-scalemarket production, centrality ofhumanrelationsin building solu-tions,creatingassociationsandcooperatives,team-startersin ‘inclusiveentrepreneurship’initiatives,etc.30).
Itwasconceptualizedasaprocess ofmeeting intermedi-ate needs bymeans ofcreating synergic satisfiers enabling theleastpossiblemarket-dependencyandthehighestpossible
autonomyconcerningincome-earningactivitiesnotrestrictedto workingforawageintheformalemploymentsystem.This processassumesconditionsforwealthcreationwhichinvolve bothusevalueandexchangevalue.Thiswayof understand-ingthesubstanceofthe‘economic’dimensionofanti-poverty actionrecoverslongdebatesstemmingfromheterodox con-tributionsinEconomics57–70 aswellasthediscussionabout
thepotentialpathogeniceffectoftheassumptionsofthe hege-monicparadigminEconomics.71
Given the relational understanding of human beings, the household was seen as central in the ‘whole econ-omymodel’72,73 and its context-dependency and territorial embeddedness in each locality was kept. The kind of last-ing contextual change enabling the ‘economic integration’ ofpoorhouseholdswasconceptualizedaslocaldevelopment.
Thehouseholdoffersthefundamental relationalsetting of poorhouseholdsasthebasisofsurvivalstrategies.Itoffers anopportunity forre-thinking economic relations relevant tothe‘economic integration’ofpoorpeopleastheyconnect
thehouseholdtotheextendedfamily,neighbours,themarket economyandcivilandpoliticalassociations.
The‘whole economymodel’focuseson thehousehold’s production of livelihood because economic activities are
mergedwithotherlifegeneratingforces.Itpermitsan under-standing of wealth creation both associated to use value
productionandtoexchangevaluecreationandincome-earning activities. Use value production may involve both individ-ual activities(self-provisioningforfood, building yourown houseorfurniture,producingyourownclothes,etc.)aswell as collective activities (associative kindergartens, commu-nityhealthassociations,collectivebuildingmaintenanceby dwellers,etc.).
Income-earningactivitiesmayinvolveworkingforawage anddependontheopportunitiesofferedtopoorpeople by theformalemploymentsystem.Theseopportunitiesarevery context-dependentand are increasinglydependent on pro-activeagencyin orderto promoteaccess toavailablejobs. Thatisthe caseofbuilding‘pathwaysforemploymentand integration’.
Income-earning activities may also involve the mobi-lization of the potential for entrepreneurship among poor householdsaimedatsmall-scalebusinessactivities.‘Inclusive entrepreneurship’,requiresspecificaction.Besidesthe pro-visionofaccesstocapital,‘entrepreneurship’inthesecases mayrequire intensiveanimation, organizationaland coun-sellingefforts.Thispossibilityisnottobeexpectedasprimarily ‘spontaneous’and is understood as being highlydependent onpro-activeagency.Itrequiresanadequateconceptualand theoreticalbasisofactioninunderstanding‘firms’,‘markets’, ‘competition’andadequatefirmstrategiesforthiskindof organi-zations.
Thesestrategiesassumethatsuccessisnotdependenton anya-social,automatic,orautonomousmarketmechanism. Lowcapitalandabundantlabourrequire specificstrategies inordertoachieveadequateincome(wagesaboveminimum wage,etc.).Newanduniqueproducts,adequatetechnologies andnon-pricefactorsaresomeoftheaspectsinvolved.74,75
Therealization of the potential for entrepreneurship is highlydependentbothonpro-activeagencyandoncontext. Thatisthecaseofinstitutionallybuilteconomiccircuitsor non-pricefactorsinmarketingandcommercialization.
Accordingly,changes inthe situation of individual poor householdsdependontheoccurrenceoflastingchangesin context.Giventhe context-dependency ofits concreteness, theconceptof‘economicintegration’alsohasaconstitutive
territorialdimension.The‘survivalstrategies’ofpoor house-holdsare heavily dependentonterritorially embeddedsocial practices.Entrepreneurshipaswellasinnovationare depend-entontheterritorialcontext.Economicprocessesarenotonly
locatedinspace,theyareembeddedinterritoryandits institu-tions.
Territorial
cohesion
and
a
paradigm
shift
in
territorial
development:
‘territorial
disintegration’,
‘place-based’
initiative
and
organizational
capacity
in
controlling
and
mobilizing
resources
Aswasseenabove, theconcretenessofpoverty and‘social determinants’ofhealthiscontext-dependent.Soarethe last-ingchangesrequiredbyhealthycommunities.
Thekindofcontextualchangerequiredforlastingchanges tooccurisbeingunderstoodhereaslocalinitiativefor territo-rialdevelopment.Thus,inthispaper,territorialdevelopmentis understoodasthekindofchangeinalllocalcontextsthatmay leadtolastingpreventioninpovertyrelatedhealthinequities and‘socialdeterminants’ofhealthaswellaslastinghealth related ‘economic integration’ of poor households. Territo-rial developmentrecoversarichtraditionofreconstructing theveryconceptofdevelopmentaswellasthebasic-needs approachtodevelopment.76–80
Healthycommunitiesrequireconditionsforagency,local governance and policy integration enabling cross-sectoral publicactionandcommunityinvolvement.Ontheotherhand, iflastingchangesinpovertysituationsmaydependonlasting changesinterritorialcontext,thisalsoinvolvestheneedof furtherclarificationconcerningtherelationbetween‘health inequities’ and ‘territorial disintegration’,and between the natureof‘place-based’approachesandaction-oriented terri-torial development.Thisisparticularlyrelevantwhenlocal initiative aiming at the ‘reversal’ of ‘territorial disintegra-tion’cannotbeexpectedtooccurspontaneously.Territory-based capacity forinitiativeand organization isvitalfor mobiliz-ing the ‘endogenous potential’ oflocal communitiesto be usedinthecollectiveefforttofullycontrolandmobilizelocal resources.
Therefore,theimprovementof‘healthycommunities’may strongly dependon Municipalinitiative and organizational capacityindevelopingterritorialanimationaimingat ‘revers-ing’territorialdisintegrationprocesses.Buildingagencyand conditionsforcross-sectoralpolicyintegration,empowering civilsocietyandpromotinganimationfor‘economic integra-tion’(decreasingmarket-dependency,enlargingthescopefor income-earning activities, animatingthe ‘whole’real econ-omy,etc.),Municipalitiescanaimattacklingpovertyrelated health inequities acting on ‘social determinants’ ofhealth (accesstolandforself-provisioningofhealthy food, afford-ableandhealthyhousing,creatingconditionsforcooperatives involving unemployed in urban regeneration on deprived neighbourhoods,etc.).
Therecognitionoftheimportanceofterritory-based ini-tiativeand organizationalcapacityforthe fullmobilization ofresourcesisbecoming widelyaccepted inthecontextof currentEuropeanthinkingonthe futureofterritorial cohe-sionpolicysincetheLisbonTreatywassignedin2007.1This
1 TheEuropeanCommission’s“GreenPaperonTerritorial Cohe-sion:turningterritorialdiversityintostrength”(CEC,2008)was
representsaparadigmshiftinunderstandingconditionsfor regionaldevelopmentwhichoffersnewperspectivesforlocal initiativeandterritorialdevelopmentaction.
Territorialdevelopmentasanemergentparadigm
From the ‘spatial diffusion’ of development impulses to agency-dependentfullmobilizationoflocalresources, differ-entscientifictraditionscombinedinpreparingthisparadigm shiftinregionaldevelopmentstrategiesandpolicies.81–84
‘Endogenous’ regional development strategies and poli-ciesseethepossibilityofchangeofthelocalsocio-economic context as dependent on the role of local initiative and organizationalcapacity(agency).Theyemphasizetheroleof territorial pro-active agencyin mobilizing the ‘endogenous potential’ aimed at ‘selective reliance’ for an ‘alternative’
basic-needs oriented development.85–92 These contributions
emphasizeanexplicitconcernwithhumanneeds,withscale,
withdealienationandparticipation,withconflictuoussocialchange
orwithpoverty,unemploymentandsocialdisequilibria.Therefore, locallysustained‘impulses’forterritorial developmentmay notbeonly‘mobilizationoriented’.Theymayalsobe‘control ori-ented’.Localinitiativetostoptheerosionoflocalresourcescan beanexample.Powerrelationswillalwaysbeinvolved
Ina complementary way,values, concepts and theoret-ical contributions defending a ‘retreat to subsistence’ see thepossibilityofchangingthelocalsocio-economiccontext asdependingonthebasisofmobilizinglocalcommunities towardstheindividualandcollectiveproductionofusevalue
aswellasexchangevalueinmeetingneedsasdefinedbythe localcommunities.93,94
Restructuring theory and ‘locality studies’ emphasize the possibilityofchangeofthelocalsocio-economiccontextas highlydependentonpro-activeagency.Theyemphasizethefact thatagencymattersinshapingtheconcretenessofthe impli-cationsofglobal restructuring.They stressthe potentialof ‘localitystudies’toidentifystructuresandmechanisms lead-ingtoproblemsthatarethefocusforchangeandseelocalities as‘realcontextsofsocialinteraction’.Thisapproachpermits theanalysisofbothlocalandnon-localfactorsoflocalchange andpermitstheanalysisof‘conditionsofpossibility’for inten-tional‘localityeffects’tooccur.Asagencymatters,‘intentional’ combinations ofspatiallyvariable phenomenamaylead to creating‘localityeffects’.95
Thecontributionscomingfromwinningregionsapproaches areveryvariedandstartedbeingdevelopedintheearly1980s fromdifferenttraditions.Theyallattempttoexplainthe suc-cessesoftheeconomicperformanceof‘winning’ regionsas resultingfrominnovationandcompetitivenessinsmalland medium sized firms. The central issue in their consensus liesin theway therole ofcontext isstressed in explaining
draftedfollowingtheadoptionofthe“TerritorialAgendaofthe EuropeanUnion”attheinformalmeetingofMemberState min-istersresponsibleforspatialplanninganddevelopment,heldin May2007undertheGermanPresidencyoftheEuropeanUnion. AnindependentreportwrittenbyFabricioBarca,“AnAgendafor aReformedCohesionPolicy:aplace-basedapproachtomeeting EuropeanUnionchallengesandexpectations”(2009),takesan in-depthlookatthisperspective.
‘success’ofeconomicperformanceoffirms.Theyrecognize theroleofsocialcohesionfor‘territorialcompetitiveness’andthe roleofsocialinclusionandsocialempowermentin encourag-ingeconomiccreativitybyallowingdiversesocialgroupsand individualstorealizetheirpotential.Contributionsfromthis fieldshowhowpoliciestostimulateregionalentrepreneurship shouldrecognizethecentralityofpoliciestocombatpoverty
andsocialexclusioninthisprocess.96,97
Contributionsstemmingfrom‘losingregions’approaches, suggestthepossibilityofchangeinthelocalsocio-economic contextashighlydependentonpro-activeagencyaimedat counteracting‘localdisintegration’andaimingat‘integrated areadevelopment’.Contributionsfromthistraditionseethat theoretical developmentson ‘oldindustrial regions’, ‘local-itystudies’,‘industrialdistricts’and‘winningregions’cannot offerrelevantcontributionstotheanalysisandthe develop-mentstrategiesfor‘losing’or‘disintegratedlocalities’.98,99
Traditionscomingfromwithinthefieldofcommunity devel-opmentseesocio-economicchangeasdependingonchanges inattitudesandbehaviour.Building‘critical’awarenessand collectiveactionareseenaskeyfactorsforpossiblechange. Changesinattitudesandbehaviourinvolvechangesat indi-vidualandcollectivelevelsnamelyregardingthepossibilityof collectiveaction.Inthe60sworkingrelevantcontributionsto ‘communitydevelopment’camefromworkingwithvoluntary groups andorganizations, addressingindividual’sproblems onacollectivebasisandseekingtounderstandandworkon theexternalreasonsfortheirexistence.Promoting participa-tion,helpingpeopletoacquireconfidence,skills,knowledge andgreaterawarenessoftheirlife,promotingempowerment andeffectiveorganizationhavebeenmajorcommunity devel-opment contributions to the local development agendaof today.Asrecalledabove,‘criticalawareness’andcollectiveaction
playacentralroleinthetheoreticalcontributionscomingfrom thisfield.Notionssuchas‘participation’,‘capacitybuilding’or ‘empowerment’inlocaldevelopmentclearlyfindtheirorigins here.100–106
Territorial‘disintegration’and‘socialdeterminants’of health
The concept of territorial disintegration plays a central role in the attempt to link contemporary conditions and context-dependentmanifestationsofpovertyrelatedhealth inequities.Ithelpstodiscussthe‘manoeuvringspace’andthe substantivecontentofactionofMunicipalitiesactingfor ter-ritorialdevelopmentinordertoimproveconditionsinhealthy communities.
Asthepointofdepartureisnotstatic,thefocusiscentredon thoseaspectsoflocalchangewhereactingtothe‘reversal’of
territorialdisintegrationcanhelplinkinganti-povertyactionto focusonpovertyrelatedhealthinequitiesandtackling‘social determinants’ofhealth.Theroleofhistoryandlocal speci-ficityisrecognizedinacceptingthepath-dependentcharacter ofanypossibilityoflocalchange.
Territorial disintegration can be linked to ‘social determi-nants’ inmany differentways (lossofhope, emigrationof younghigherqualifiedpeople,nocontroloverpolluting activ-itiesofexogenouslybasedfirms,etc.).Itcanbeanalyzedas occurringinalocalitybutnotbeingrestrictedtolocalcauses.
Itcan beeasilyreduced tothe destiny ofaterritorial unit being‘cutoff’or‘divorced’fromexogenousdynamicsof cap-italaccumulation.Asitisthecaseof‘distressedurbanareas’,
territorialdisintegration mayemerge fromdeclineor dynam-icsproducedlocallyaswellaselsewhereintheurbancontext whosespatial andsocialdynamicsit maydependon (spa-tialsocialsegregation,spatialfunctional segregation,urban landrent,economic‘death’ofbuildings,etc.).Eventhe possi-blefragmentationofsocialrelationsintheseareascannotbe dissociatedfromspatialandtemporaldimensionsin contem-poraryglobalizingconditionsgiventhechangingroleofspace andtimein‘extendedsocialmilieux’.107
Differentkindsofhealthrelatedproblemscanberecalled: location,accessibilityandrestructuringofhealthcare facil-ities;emigrationandcommunitydisintegration; ageingand social isolation; commuting, family life and early detach-ment in child development; unemployment, suburban life and social isolation; water pollution in small river basins andunhealthyconditionsforfoodproduction.In contempo-rarycrisisconditions,unemploymentandprecariousformsof employmentrequirespecificattention.108
Allthesecanbeseenasexamplesofpotentialrelations betweenexogenouslydeterminedterritorialdisintegrationand ‘socialdeterminants’ofhealth.
Localunderdevelopment,territorialdevelopmentand territorialanimation
Anaction-orientedtheoryof‘localunderdevelopment’isneeded soastorelate‘territorialdisintegration’withthe‘non-emergence’ oflocal initiative and pro-active agencyin promoting local development and health related ‘economic integration’ of poorhouseholds.30
Sucha theory of‘local underdevelopment’may provide an explanation of how Municipalities can act in order to ‘counteract’theroleofstructuresandmechanismsleadingto theerosion,underutilizationorover-utilizationoflocalresources contributingtohealthinequities (emigrationofthe highest qualified members of localcommunities, health damaging pollutingactivitiesofnewproductiveplants,intensivewood cuttinginlocalforestsbyexogenousfirms,etc.).Itinvolvesthe complex interdependencyamong ecological, economic, polit-ical,socio-cultural and psychologicalfactors related tothe
inhibition of local initiative and the lack of local capacity in tackling ‘social determinants’ of health (lack of aware-nessamonglocaldecision-makers,healthrelated‘skillsgaps’ amonglocalplanners,etc.).
Agencycannotbeexpectedtoemerge ‘spontaneously’as aresultof‘territorialdisintegration’.Localinitiativemaynot emerge spontaneously and the meaning of action for local development may not be clear.109 Widely divergent points
ofviewon themeaningofthis transformation combineto reinforce local socialagents’ inhibition of organizing forms ofcollectiveaction,whether orientatedtowardspreventing andmitigatingproblems,ortowardsidentifyingandmaking the most of opportunities arising out of the transforma-tionprocess.Thisinhibitioncaninvolvedecision-makersin Municipalities.Howtocounteractthisinhibitioncould consti-tutethecentralfocusofreflectioninpublicpoliciesaimedat
reversing‘territorialdisintegration’processes.
Thatmaybetheroleofterritorialanimation.110
Counterac-tingthe‘non-emergence’oflocalinitiativemayplayacritical roleinactingforterritorialdevelopmentintheframeworkof centralaswellaslocalterritorialdevelopmentstrategiesand policies.
But,implementingterritorialanimationischallenging.It pre-supposes acknowledgementthattheaction’sdeparturepoint
is actually the arrival point of territorial disintegration pro-cesses.Itmeansrecognizingthatthe‘non-emergence’oflocal initiatives could be a consequence of those very processes. And it means admittingthat current public responsesare
non-existent, insufficient or inappropriate forbringing about a ‘reversal’oftheprocessesthatinhibitthoselocalinitiatives fromemerging.
On the other hand,if lasting changes in poverty situa-tionsmaydependonlastingchangesinterritorialcontext,this alsoinvolvestheneedoffurtherclarificationconcerningthe relationbetween‘healthinequities’and‘territorial disintegra-tion’,andbetweenthenatureof‘place-based’approachesand action-orientedterritorialdevelopment.
Thisisparticularlyrelevantwhenlocalinitiativeaimingat the‘reversal’of‘territorialdisintegration’cannotbeexpected to occur spontaneously. Territory-based capacity for initia-tiveandorganizationisvitalformobilizingthe‘endogenous potential’ oflocalcommunitiestobeusedinthe collective efforttofullycontrolandmobilizelocalresources.
Therefore,improving‘healthycommunities’maystrongly dependon Municipalinitiative in‘reversing’territorial dis-integration processes. Building agency and conditions for cross-sectoralpolicyintegration,empoweringcivilsocietyand promotinganimationfor‘economicintegration’(decreasing market-dependency,enlargingthescopeforincome-earning activities,animatingthe‘whole’realeconomy,etc.), Munici-palitiescanaimattacklingpovertyrelatedhealthinequities actingon‘socialdeterminants’ofhealth.
A
paradigm
shift
in
planning
for
territorial
development:
linking
knowledge
to
action
tackling
social
determinants
of
health
Poverty (as well as poverty-related health inequities), as a planning problem, is a wicked problem. It cannot be approached asifit were atame one.Concrete anti-poverty actionand concreteplanning taskscover awide varietyof dimensions.Thechoiceofmethodsandtoolstobe incorpo-ratedisnotindependentfromtheconceptualandtheoretical assumptions,orinstitutionalandorganizationalconditions, basedonwhichactionisconceivedandundertaken.Wicked
problemsinplanningreinforcethesubjectiveroleofplanners intheplanningprocess.Theinformationneededtosolvethe problemsdependsonone’sideaforsolvingthem.Havingno stoppingruledefinedinadvance,itdependsonplanner’s rea-sonswheretostop.Theidentificationofpotentialsolutions dependsontheplanner’sroleandthechoiceofexplanation forawickedproblemisarbitrarydependingontheplanner’s judgement.111
First,thisconcernstheconceptualandtheoretical assump-tions related with poverty and poverty related ‘health inequities’. Second, it concerns the nature of planning at
sub-national level which covers different national, scien-tific and professional traditions indealing with urbanand regionalplanning(landuseplanning,urbanform,locationand accessibilities,developmentpromotion,supportingcollective self-empowerment,etc.).
However,currentplanningremainsstronglydependenton ‘theproductionoftheplan’.Thisaspecthasrelevant implica-tions.Forexample,accesstolandmayplayacentralrolein anti-povertyactionandlandusecontrolplaysacentralrolein intentionalcontextualchange.Butterritorialplanningtheory remainsstronglyinfluencedby‘spatialseparatism’reflecting theeffectsofthe‘crisesoftheory’inplanning.
Aparadigmshiftinplanningforterritorialdevelopmentis movingthefocusawayfromtheproductionofplanning doc-umentsfollowingplanningphasestoexploredifferentwaysof
linkingknowledgetoactioninmakingplanningfunctions con-crete(diagnosis,planning,organizingforaction,evaluation, etc.).
Yet,concreteanti-povertyactionhasdifferentdimensions. Somedimensionsinvolveactionindomainswhereproblems canactuallyberepresentedastameones.Therelevant chal-lengeremainsinnotconfusingthenatureoftameandofwicked
problems.Itcanbeausefuldevelopmentonthebasisofwhich thechoicebetweenmethodsandtoolscanbebestunderstood. Plannersaresupposedtodevelopseveralrolesandfindthe mostadequate approachtothedifferentdimensionsofthe planningproblemstheyareinchargeofdealingwith. Differ-entplanningmodelsofferdifferentapproaches.Noneoffers atotallysatisfyingperspectivewhendealingwiththewhole rangeofissuesrelatedwithpovertyasaplanningproblem. Therefore,itmayberelevanttoclarifythenatureofactivities thatarefavouredandthedimensionsofconcreteanti-poverty actionthatcanbestbe‘solved’bytheframeworkofeach spe-cificplanningapproach.
The ‘Rational-Comprehensive’ approach is particularly adequatetodealwithtameproblems.Objectivedefinitionscan begivenandlogicalsolutionscanbesearched.Definingthe bestlocationforahealthcentre,designinganurban devel-opmentforlow-rent housingonpublicland,or findingthe bestfinancialengineeringmodelforbuildinganewschoolin adistressedurbanarea(giventheconstraintsofthebudgetof alocalgovernment)areexamplesofpossiblepovertyrelated planningproblemsthatcanbestbedealtwithusingthehelp ofthiskindofapproach.
Organizational outflanking is a reality which poor people quiteoftenface.Fragmentation,isolationanddiversityofthe multidimensionalityoftheexperienceofpovertyraise cru-cialissues onthe impossible formulation ofageneraland commoninterestamongthepooraswellasthecapacityfor strategicorganizationaimedatcollectiveself-empowerment. Intheshort-term,whenpoorpeoplelackthecapacityto orga-nizeforcollectiveactionandforinformeddiscussionabout planningalternatives,the‘Advocacyplanning’approachcan beapowerfulsourceofinspiration.Translatinginto techni-cal terms the implications of representing the interests of poorpeople inarelodging process aimedatslum eradica-tion,defendingaresidentialcommunityofpoorpeoplefrom thenegativeimpactofthelocationofapollutingindustrial plantordefiningcriteriaforthe implementationofa Mini-mumIncomeProgrammeinaspecificlocalityareexamples
ofproblemswhereplanningactioncanfindinspirationinthis approach.
Astructuralunderstandingofpovertyopensabroadscope of analysis for the identification of the relations between povertyandstructuralsocietalfeatures.Theanalysisofthe relationsbetweenthecapitalistnatureofsocieties,therole of the national state and the emergence of poverty under globalizingconditionsmaybeadomainwherecontributions emergingfromthe‘RadicalPoliticalEconomy’approachcan offerarelevantcontribution.Actingasrevealersofcontradictions
oractingasagentsofsocialinnovation,plannerscanget inspi-rationtodealwithproblemssuchasidentifyingthedrivers ofcapitalaccumulationinalocalityand bepreparedtobe informed aboutprospectsforlow-income andlow-qualified jobs,evaluatingthepotentialjobcreationofforeigncapitalin alocalityandassesstheriskofplant-closurebyforeigncapital ownedfirms.Afurtherexamplecanbefoundinanalysingthe contextofpowerrelationsinalocalityandreflectingabout thepotentialcontributionofunionsandprogressiveparties tothesupportofthecreationofworkerscooperatives.Those areexamplesofpotentialcontributionsemergingfromwithin thisapproach.
Whenpoorpeoplefaceorganizationaloutflanking,itisnot easytoarticulatetheirinterestsinthepoliticalarena,norisit easytointerfereinthediscursivefieldandchangethesocietal perceptionaboutpovertyproblems.Thecontributionswithin the‘EquityPlanning’approachaimatrepresentingpoor peo-ple in the directionof making allianceswith and working forprogressivepoliticians.Asproblemformulators,planners havethepowertoshapedebates.Asconceptualrestructuring
maybecrucialforchangingpowerrelationsaimedatassisting empowermentprocesses,plannersmayplayarelevantrole wheninspiredbythismodel.
Problemssuchasattemptingtochangethediscourseof non-poorpeopleabouttheexistentialproblemsofpoorpeopleand thatthenon-poordefineas‘poverty’,creatingmediaticevents todirectpublicattention,ordirectlyaddressingunionsand politicalpartiestocapturetheirsupportforanti-poverty strug-gles, areexamples ofproblemsthatcanbebest dealtwith in theframework ofthe ‘SocialLearning– Communicative Action’approach.Poorpeoplehavearichknowledgeabout theirownpovertyanddevelopgreatexpertiseabouttheir sur-vivalstrategiesindifficultexistentialconditions.Capturingthis knowledgeandbeingabletovalueitmaybeamajorchallenge inplanningforanti-povertyaction.
Thedirectinvolvementofpoorpeopleindealingwiththeir own poverty problems may be a challenge in anti-poverty action. Collective self-empowerment may not emerge sponta-neously,actionmayberequiredinordertofavourit.Planners withinthe‘RadicalPlanning’approachrecognizethevalueof thecontextualandexperientialknowledgethatthose belong-ingtothemobilizedcommunitybringtotheissues.Theyare opentolearningthroughaction,throughexperience.Above all,tobeeffectiveradicalpracticedependsoninterpersonal relationsoftrust andasociallearningapproach.The ‘Rad-icalPlanning’approachspecificallyaddresses theproblems raisedbythisperspective.Inworkingforsocialtransformation in community-based organizations, plannersbring to radi-calpracticegeneral,specificandsubstantiveskills.Problems suchashowtolistentopoorpeopleandhowtointerpretthe
problems they experience, how to open the debate about povertyproblemsastheyareactuallyexperienced(notjust aimingatsolvingthem), howtocommunicate andmanage groupprocesses,howtodeveloprelevantknowledgeaboutthe formalemploymentsystem,andhowtorealizethepotential forjobcreationamongpoorpeople,areexamplesofproblems thatcanbebestbedealtwithonthebasisofcontributions emergingfromwithinthisapproachtoplanning.
Towards
an
action-oriented
theory
of
local
underdevelopment:
municipal
action
possibilities
in
improving
‘healthy
communities’
Thispapersuggestssomecontributionstodiscusshow Munic-ipalitiescanimprove healthycommunitiestacklingpoverty relatedhealthinequitiesinterritorialplanningforlocal devel-opment. The paper discussed paradigm shifts in several domainsandtriedtodiscusstheimplicationsoftheseshifts inmakingactionconcreteincontemporaryconditions.
Localinitiative andlocalavailabilityofresourcesarenot
sufficientconditionsforlocaldevelopment.‘Passive’reliance on‘spatialdiffusioneffects’or‘active’attractionofexogenous capitaland entrepreneurialinitiative arenotaguaranteeof localdevelopment.
Aswas discussed above,local developmentcan be pro-moted,orblocked,bycentralaswellasbylocalauthorities.It wasunderstoodasamethodtopromoteabasicneedsoriented regionaldevelopment,i.e.aterritorialapproachto‘another’ development,andassuchitinvolvesthecentralizationaswell asdecentralizationoftheroleofthestate.
Wideningperspectives foraction, Municipalities can be reorientedfromthereductionoftheirscopeofactiontothe relationsbetweenstateandthe market.Municipalitiescan developnewpossibilitiesofrelationshipswith civilsociety andwiththesocialandsolidarityeconomy.Thisalsoinvolves otherpriorities,otherattitudesandotherplanning method-ologies. This involves listening, responding, capacity building, catalyzing,leading,governingandlearningindialoguewiththeir communities.112
Municipal anti-poverty action was already discussed elsewhere.30Thisperspectivewillbefurtherillustratedbelow
onthebasisofsevendomainsofaction.Thesedomainscan illustrate the possibility of widening the understanding of potentialactionon‘socialdeterminants’ofhealth,tackling ‘health inequities and promotinghealth related ‘economic integration’ of poor households: reinforcing conditions for effective‘agency’and‘localgovernance’(healthoriented cross-sectoral action, local initiative and organizationalcapacity focusingonlocal‘healthinequities’,etc.),buildingastrategic ‘vision’forchange(buildinghopeandtrust,creatingimages andprojectsofpossiblefuturesofhealthierlife,etc.), organiz-ingpoorhouseholdsforthecreationof‘localities’(animating democracyandparticipation,buildingassociationsand coop-eratives, widening organizationalsolutions for self-help in thecommunities,etc.),decreasingmarket-dependencyin meet-ingintermediateneeds(foodsecurityandself-provisioning, conditions for healthy food, introducing local currencies for consumption diversification, creating conditions for
accessing seeds for bio-diversity and healthy food, etc.), stimulating non-conventional possibilities for income-earning
alternatives(animating‘inclusiveentrepreneurship’solutions forincomeonthe basisofteam starters,centralizing mar-keting and commercialization, etc.),promotingpathways to integration taking advantage of job creation and competi-tiveness of local firms (job matching, involving employers indesigningtrainingpossibilities,etc.),promoting‘inclusive entrepreneurship’and stimulatingthethicknessofthelocal
wholerealeconomy(reinforcingintra-localinterdependencies andsynergy,buildinglocaleconomiccircuits,mobilizingthe fullpotentialofsub-contractingbylocalfirms,etc.).
Actionaimingatreinforced‘agency’andlocalgovernance for‘selectiveself-reliance’
Concretewaysofspecificlocalactiontoface‘local underde-velopment’ requirelocalcapacitytocontrolthe use oflocal resourcesandthelocalcapacitytosupportentrepreneurship and toanimatethe emergenceofinitiativesfrom thesocial andsolidarityeconomy.Thatisthereasonwhythe Munici-palrolemayrelystronglyonanimationissues(institutional animationforcross-sectoralactionandorganizational capac-ity, animation forcitizenship,animation forthe ‘economic integration’ofpoorhouseholds,etc.).Basicchangesin insti-tutional response,collectivemobilizationandattitudes and behaviourofindividualsand groupsare aimedat.Thisisa complextaskandmuchhastobedonetoprepareadequate interventionmethodologies.Eachsituationisparticularand eachsolutionisspecific.
Municipalities‘causalpowers’canbeactivatedindifferent ways.Thisconcernsanadequateunderstandingof‘power’.38
The‘discursivefield’ofpower(understandingpovertyas dis-tinct from deprivation, recognizing the structural causes of poverty, assuming the responsibility of society on its emer-genceanderadication,understandingofclaimsofpoorpeople as rights,defending anti-poverty actionas an imperativeof socialjustice,etc.)andthe‘organizationalfield’ofpower (ani-matingthecreationoforganizationsaimedatthecollective empowermentofpoorpeople,counter-actingtheir
‘organiza-tional outflanking, political commitment atcentraland local leveltofacilitatetheaccessofpoorpeopletoresources,etc.)
bothofferopportunitiestotheactivationofMunicipal‘causal powers’.Therelationbetweenthe‘worldview’andthepriority ofanti-povertyactionmaybedirectlyaddressed.29
Infact, formal politicaland planning legalcompetences maybeapointofdeparturebuttheydonotexhaustthekey issuesconcerningtherelevanceofpower.38 Alsotheactual
controloverrelevantlocalresourcesdependsbasicallyonthe understanding ofthe ‘web’ of power relations inthe con-text ofwhich the “manoeuvringspace” istobe ‘conquered’. Buildingalliances,animatingthecreationofpartnershipsand networkingonatrans-localnationalandinternationalbasis ortakingadvantageofopportunitiesofferedbyinternational organizationsare examplesofinitiatives thatmayhelpthe achievementofobjectives(‘strategic’traditionofpower).
Municipalities canacttowardsbuildingagencyand rein-forced local governance for the control of local resources (avoiding the closure of public health care services, land use control,preservingfoodproductionintowns,enlarging
possibilitiesforhealthyorganic foodproduction, etc.).This canevensignify thatinthe contextofhealthrelated anti-povertyaction,Municipalinitiativemayhavetobedirected
againstinitiativesfromboththecentralgovernmentorfrom business (mobilization against health damaging polluting productive plants, unhealthy food diets in schools, health damagingworkingconditions,etc.).
That is a central aspect in building local governance. OECDshowedhowthecriticalfactorsunderlyingthe possi-bilityoflocalcross-sectoralpolicyintegrationrelyonsectoral flexibilityandcentraldecisionmakingcombinedwithlocal governments’leadershipinanimatinglocalgovernanceand cross-sectoralpolicyintegration.113,114
LegalcompetencesofMunicipalitiesmayhavetobeused forthedefenceofpoorpeople’srightsorofthe‘territorial inter-est’andtopreservethepossibilityofsubordinatingtheuseof localresourcestolocallydefinedstrategicpriorities(tostop initiativesfromfirmsaimedatavoidablecollectivedismissals, tosupportinitiativesfromthesocialandsolidarityeconomy, protectingnaturalresourcesandfosteringcollectiveusevalue foodproduction,etc.).
Actiontobuild‘hope’andstrategic‘visions’ofpossible anddesirablefutures
Atlocal communitylevel, Municipalities must identifythe globalstructuralconstraintstolocalactionand establish a frameforlocalalternativestrategies.Inhealthycommunities, thepointofdepartureisnotstaticinanti-povertyaction.
Thecontext-dependency ofpoverty and poverty related healthinequitiesrequiresanunderstandingofthecausesof itsemergenceandpersistence.Thetheoreticalcontributions discussedelsewhereinrelationto‘losing’regionsandthe con-ceptof‘localdisintegration’areusefulheretounderstandthe particularaspectsofpovertyin‘distressedurbanareas’asa specificformof‘localdisintegrated’areas.Thetheoretical con-tributionsstemmingfrom‘localitystudies’helpunderstand thelocalityasasocialcontextof‘realinteraction’allowing thenon-localcausesofpovertyaswellasnon-localconditionsto beidentifiedonthebasisofwhichlocaldevelopmentmaybe sustained.
Infact,localdevelopmentimplicitlyassumesthe possibil-ityofthepreviousexistenceofa‘projectofhope’associated witha‘searchformeaning’inlife.115Thiswouldalsomean
thattheexistenceofaprojectmightdependontheprevious ‘creation’ofthelocality.30
Localdevelopmentimpulsessuggestthecapacityto cre-ate‘images’aboutdesirablefutures.In‘distressedurbanareas’ of‘disintegratedlocalities’desirablefuturespresupposehope andthepossibilityof‘hope’emergesfrom‘trust’inthe con-textofpersonalinteraction.Thismeansthatthespecificityof ‘endogenous’mobilizationinregionalandlocaldevelopment issuescannotbereducedtothequestionofthe‘availability’ ofresources.Resourcesthemselvesarenotindependentofthe purposesofhumanagency.Itrefersmainlytothepossibility that‘endogenouspotentials’maybemobilizedtomeetlocally definedunmetneedsofpoorhouseholdsaccordingtolocally definedpriorities.That iswhytheconceptoflocal develop-mentcannotbestrictlyreducedto‘locallyinducedeconomic growth’and islinkedtoaconceptof‘another’development
involvingdifferentprioritiesinusinglocalresources.Iflocal initiativetoface‘localdisintegration’isneeded,community mobilizationaroundalocaldevelopment‘vision’willbe nec-essary and a ‘vision’ linkedtoa ‘desirable future’ requires ‘hope’.However,hopeisdifficulttofindamongpoorpeople in‘disintegratedlocalities’.
Thisraisestwodifferentkindsofproblems.First,itraises anepistemologicalproblemontheidentificationofthe con-ditionswhichmaybethebasisofanon-observablereality(a desirablefuture)andofanti-povertyaction.Second,itraises the difficulty ofbuilding hopeand trustamongpoorpeople caughtina‘disintegratedlocality’.Even iftheirplace-bound
identityofferssomeformofcollective identityitis associ-atedto placeswhereit isdifficulttoimaginespontaneous waysoutofviciouscircles,cumulativecausationandnegative identities.
Thatiswhy‘fiction’isincreasinglyrelevantindevelopment promotion.Videoandfilmarebeingusedincreasinglyastools toofferpositiveidentities,‘images’ofpossible‘realities’and the‘illustration’ofwaysoutofdespair.2
Nevertheless, ‘images’ of desirablefutures must involve
boththepoorand thenon-poor.Thisaspecttouchesa cen-traldomainofthe‘discursivefield’introducedaboveandhow itcanbecomeacentraldomainofMunicipalaction. Under-standingpovertyissuesnotasasocialdivisionofgroupsbut asprocessesthatmaytouch allthecommunitymaybevery relevant.Thepooroftodaymaybecomenon-poorasaresult ofanti-povertyaction.Andthenon-pooroftodaymaybecome poortomorrowifnoanti-povertyactionhappenstoday.
Actiontocreate‘localities’organizingpoorpeoplefor empowerment
Municipalitiesmayplayanimportantroleinanimatingthe wholecommunityfordevelopment.Helpingpoorpeopleto self-helpisaprivilegeddomain.Giving‘voice’andreinforcing existing associative forms(immigrants associations, sports associations, etc.) may be an initialform of counteracting ‘organizationaloutflanking’.38Giventhe‘collectiveisolation’
of poor people small steps are needed. Rebuilding social relations and bridgingthe ‘social void’ may becomeeasier bybuildingsmall-scaleorganizationalformsintheformof ‘communitiesofinterests’.116Initialactioncanstartby
build-ing solutions to ‘felt’ problems and be graduallylinked to strategic objectives of alocal developmentproject. Follow-ingthe‘inspiration’offeredby‘communitydevelopment’and by the ‘socio-anthropological model’6,117 community centred approachescanbeausefulmethodologicalpositionin devel-opmentpromotion.
Therebuildingofsocialrelations,ascentralissuein pro-moting mentalhealth, becomespossible.Accordingto this way of acting, local development may help bring together individuals sharing problems, wishesor projects and help them build‘interestcommunities’. Thesecommunitiescan
2 Thisistheessentialbasisofthemethodologybeingfollowed byLeãoLopes,formerMinisterofCulture ofCaboVerde.Leão Lopesisfilmmakerandcreatorof“AtelierMar”anNGOinvolvedin developmentactionintheislandsofSantoAntãoandSãoVicente.
