THE PORTFOLIO APPROACH TO HEALTH BEHAVIOUR zyxwvutsrqponmlkjihgfedcbaZYXWVUTSR JACK DOWIE* University of Kent. Canterbury. England Most of the existing literature in the field of health behaviour has been generated within an inappropriate paradigm. a fact that partly accounts for both its internal lack of development and its external lack of impact[l]. Far too much time has been spent discussing the nuances of behaviour seen as ‘directly’ relevant to health and far too little to the very wide spectrum of behaviour whose ‘indirectness’ would be radically reassessed if the dominant paradigm. that of proximate biological causality, were to be overturned. The proper context for the discussion of preventive health behaviour has been too readily accepted as the ‘medical-scientific’ one, the consequence of such acceptance being the classification and legitimation of causes on a biological rather than social. cultural and psychological basis. (As exceptions which prove the rule we can point to ‘accidents’ and ‘mental illness’ which stand out like sore thumbs in any standard disease classification). In other words because medical science has made such enormous advances in the explanation and ‘cure’ of disease at the immediate biological level it has been assumed that the framework for the study of health must be erected around. and dominated by, the medical-scientific contribution to our understanding of health. Recent moves towards social and ‘ecological’ medicine fail to make sufficient break with this assumption to constitute the necessary paradigmatic shift. Such is the argument underlying the present paper. It represents an attempt-and little more-to offer a distinctly new framework. Apart from making clear its incomplete- ness and tentative character two other points need emphasising immediately. First it is not claimed that many of the broad implications of the new perspective have not been individually argued before, merely that they have not been put forward in the context of a coherent theory’of behaviour. Second. the argument is not conducted at the same level as that in Ivan Illich’s recent zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGF M edical Nemesis[2] though it has clear associations with it. We have no particular views (or indeed knowledge) concerning for example, the contribution of chemo-therapeutic drugs to disease reduction or of the extent of iatrogenetic illness. however defined. Even if these are as high and low as conventionally assumed (wrongly according to Illich) we would still argue that a paradigmatic shift is needed. In other words the framework offered below should be regarded as ideologically neutral in the sense that it assumes no particular structural determinants of the existing position. whatever it is. But it is certainly not neutral in its grounding in a individualistic-humanistic-purposive model of behaviour within any structure and in its sympathy towards the fullest possible realisation of this model as a structural goal. We can thus endorse enthusiastically some assertions in Illich, in particular the view that Health IS a task....Success in this personal task is in large part the result of the self-awareness. self-discipline and inner resources by which each person regulates his own daily rhythm and actions. his diet and his sex.. ..In determining their health. [men and women] create their physi- cal being. .just as. more generally. by determining their culture. they create themselves...‘.Most traditional health care was a programme for sleeping. eating. loving. working. playing. dreaming. singing and suffering... .‘Culture’ and ‘health programmes’ can be distinguished only by those soctal scientists who identify ‘medical culture’ with sick care....In fact. this aspect of culture... constitutes but a’tiny fraction of its health-granting wholeness. [2. pp. 168. 89-901. * Reprint requests to: J. Dowie. Eliot College. The University. Canterbury. Kent. England 619