Twenty years ago
the cultural critic Raymond Williams predicted that
by the millennium the radical means of cultural production
in British society would be forced to the margins, but
there they would re-group and become mainstream.
This rather cryptic prophecy becomes clearer in the
context of social exclusion. The margins are not geographical
but social - instances of exclusion can be found in
most communities. If arts interventions are to be pervasive
and of quality they will also, on occasion, be radical
and challenging - to participants, to artists, and to
the sectors that support and fund them. It is inherent
to the effectiveness of arts in health intervention
that it is permitted, within safe and supportive parameters,
to engage with the 'madness' of art and its making.
By its very nature, art pushes against barriers, boundaries
and preconceptions and its creative energy in promoting
social inclusion may necessarily be volatile. This is
why qualitative evidence from participants repeatedly
affirms the felt experience through art as a counter
to the circumstances and symptoms of ill-health. The
most successful projects are those that lay down a social
pathway to channel awakened enthusiasms.
The sheer size and complexity of the arts in tackling
social exclusion means that at present gaps both in
practice and the evidence base are inevitable. As the
British Medical Journal (BMJ) pointed out in July 2001,
social inclusion is much more than simply targeting
services to certain groups but is rather a problem for
society as a whole:
'Policies to address the problems of target groups are
welcome, if they work, but essentially provide micro
solutions for a macro problem. Targeting misses large
numbers just above the arbitrary threshold. Sinking
the iceberg, rather than attacking its tip, is a better
basis for public policy.'
Moving from ice to fire - and hopefully not mixing metaphors
like Derek of Spinal Tap - we offer an example of an
arts in health project tackling social inclusion in
The Happy Hearts Lanterns event in Wrekenton. This brings
together arts, health, education, the voluntary sector
and local people and demonstrates how individual involvement
in collective creativity can lead to communal change.
Wrekenton is a corner of the borough of Gateshead, with
an unenviable, undeserved reputation as a blackspot.
It has a poor health profile, in a borough with one
of the highest morbidity rates in coronary heart disease
in England. Education results are poor too, and there
is a high percentage of teenage pregnancies.
A large heart lantern is the centrepiece of an annual
procession of 500 or so local people carrying lanterns
they have made over the previous fortnight. At the end
of the walk it is hoisted up a hill for all to see.
Then, it is seen from a distance, as part of that landscape
under a night sky. There it becomes, in the words of
the locals - 'the heart of the community lantern.' This
sense of metaphor is important - at the core of this
event, as of much arts in health work, is the nurturing
of emotional intelligence and informal learning. As
a nine-year old commented: "When the lanterns light
up everyone turns into my friend."
This association of good times and positive self-image
with an ephemeral arts event and its processes is potent.
The after-image, the heart on the hill, is left in the
mind's eye. That is why hulking 16-year old lads come
to lantern workshops of their own volition and don't
think that making beautiful objects and talking about
how you feel is cissy. The congenial space of the workshops
consists of a spirit of high energy, laughter, purposeful
creative activity and the beginnings of trust, credibility
and confidence.
These lanterns are made from willow sticks, tissue paper
and are lit by candles. As dusk falls, they are revealed
as delicate, lacy structures, glowing amber, bobbing
along on an incoming tide of darkness, each individual
effort finding its place in the collective stream; none
is dispensable.
This is a rite of transformation, not just for the people
involved but of the streets as well.
As a local woman pointed out "Some of us don't get on.
But at Lanterns we put all that to one side. You see
each other different at Lanterns".
This year saw the tenth lantern procession. Developments
have occurred that couldn't have been planned. Every
lantern has the image of a heart secreted in it by its
maker. Lanterns are made in memory of those who have
died and for those newly-born. It continues to develop
beyond an annual event, spawning activities that will
take place throughout the year. Participants have gained
confidence for themselves and for where they come from.
This is the space from which latent talents can emerge.
It isn't only the usual suspects who show an aptitude
for civic participation. This year, interest came from
regeneration schemes in Newcastle and Sunderland. Happy
Hearts will be passing on the skills to other communities
who have realised that this can hit spots that other
methods can't, and will be using it to deal with more
complex intercultural scenarios.
All involved feel that the strong, collective and good-time
nature of the event feeds individual and communal health
needs. Indeed, it is now a very particular tradition.
Ali Magee, a Happy Hearts participant from the beginning,
put it like this: "In Wrekenton, there's Christmas and
there's Lanterns... It's definitely made me think about
my health and my kids' health, and given me the confidence
to do something about it - we can choose to be healthier."
Happy Hearts isn't the only celebratory lanterns event
with a health focus. Zindaagi Kai Noor (Light up our
lives) is centred in a school in Manningham, inner city
Bradford. Initial evidence following the first event
shows a persistent increase in attendance in the targeted
year group and much improved communication between school
and parents.
We have identified several others and are planning a
longitudinal research programme to look into their potential
influence on public health. This will mean new participative
methodologies, involving participants not merely as
data collectors but as analysts alongside a research
team.
Wrekenton shows how collective creativity can make a
committed expression of public health. This is what
distinguishes arts in health work from art therapy and
connects it into social inclusion work. On the setting
up of the NHS in 1948 Aneurin Bevan observed that "the
maintenance of public health requires a collective commitment".
The lanterns event shows how health awareness can become
a felt experience and even have a commonly-owned iconography.
Grounded in local arts development, it joins up theory,
strategy and practice. We could build on this with research
to examine the therapeutic benefits and communal change
that the arts activity helps motivate. The delivery
partners behind projects like this enter into social
relationships with the community. It is a learning process
for all involved, illuminated by what the arts do best
in turning complexity into revelation. Arts activity
can also address concern in the NHS to maintain trust
between healthcare professionals and the public. As
the Health Secretary said at our conference two years
ago, "The arts can play a very important role in ensuring
that messages about healthy lifestyle and about engagement
between the service and the communities they serve can
be enhanced."
The arts in health field is now so diverse we are starting
to see some emerging 'specialisms' in differing approaches.
CAHHM's research associate Tom Smith has visualised
the field as a diamond-like configuration. This maps
out different approaches and objectives that look for
measures and outcomes appropriate to the creative intervention.
We draw attention in particular to the concept of social
capital (top left-hand segment) where 'Unity is Health'.
These are arts projects that start from the point of
using creativity to enhance social relationships, reflecting
growing evidence that good relationships are a major
determinant of health.
There is presently a window of opportunity to realise
a social model of health. The move to multi-agency working
is new to the NHS, and arts can have an integral and
a catalytic role in this. What used to be understood
as the preventative approach to healthcare is increasingly
about building capacity for change, externally in developing
social capital and internally in improved training and
holistic approaches - approaches that the arts can help
define and contextualise, as our diagram suggests. This
thinking is becoming 'mainstream', though the diversity
of funding partnerships that support it may mitigate
against it being taken on as a mainstream financial
commitment by any one sector.
To demonstrate their effectiveness in tackling exclusion,
arts in health practitioners want to share their practice
more, as a basis for collaborative research programmes.
This could then prise out the evidence base already
implicit in the qualitative testimony of participants
in these projects. Networking of well-founded community-based
arts in health projects is necessary to take the research
agenda forward. But an improving dialogue between arts,
health, medical and education sectors is helping us
see the way forward.
The call for dialogue is not coming solely from the
arts. A BMJ editorial last December advocated a 0.5%
shift of the health budget to the arts because "if health
is about adaptation, understanding and acceptance, then
the arts may be more potent than anything medicine has
to offer".5 That 0.5% would increase Arts Councils'
funding by 70%.
CAHHM has recently set up a national advisory group
for the evaluation of community-based arts in health,
supported by the Health Development Agency and Nuffield
Trust. It plans a survey of arts in health organisations
and NHS trusts to determine what each sector expects
of the other with regard to research and evaluation.
The results of this will be published along with an
agreed lexicon of terms and definitions guided by the
question 'What would constitute useful and valid evidence,
and how should it be obtained?'
Dr Malcolm Wrigler, a GP in the Midlands who long ago
embraced the contribution the arts could make to his
practice said recently "My 24 years as a family doctor
have convinced me that many of the medical complaints
reported by patients are in fact the physical manifestations
of social, psychological and emotional problems. To
create a healthier nation we must start by encouraging
inclusive and harmonious relationships in a society
where so many find themselves socially excluded. The
principal killers are not cancer and heart disease but
lack of social support, poor education and stagnant
local economies."
We are now testing the validity of that viewpoint through
community-based arts in health.
Many arts in health projects are attempting to establish
a continuum of support for people to improve both their
well-being and creative skills. Much of the practice
and learning going on in this field can usefully contribute
to wider health promotion strategies and the development
of participatory arts with the general public. They
need not be seen simply as specialist services for an
excluded minority, but rather as core applications of
the arts to encourage a healthy culture in a healthier
nation.
Contact: Mike White
cahhm.info@durham.ac.uk
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