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Health Sociology Review (2008) 17: 124128

EDITORIAL

Chris Beasley
University of Adelaide and

Megan Warin
Durham University

his Special Issue arose in the first instance out of the work of a Research Cluster within the University of Adelaide, South Australia. The Research Cluster was organised around a common concern amongst researchers regarding Preventive Health. The aim was to develop a broad research grouping with interdisciplinary interests which would, in particular, provide an opportunity to draw together scientists and social scientists. The intention of the Preventive Health Research Cluster was specifically to move beyond a narrow biomedical understanding of health. Many researchers had particular health issues they wished to focus on (such as obesity), but a smaller sub-grouping sought funding to investigate the possible limits of theoretical frameworks employed in the field of Preventive Health, on the basis that the discussions undertaken concerning this field all too often presumed certain frameworks and understandings that at the least required clarification and analysis. The subgrouping gained funding under the rubric of Social, Cultural and Economic Influences on Health and organised public lectures followed by a colloquium on the subject of Re-imagining Preventive Health: Theoretical Perspectives. The
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colloquium was held in February 2007 and involved University of Adelaide researchers from a number of disciplinary/institutional locations, including General Practice, Public Health, Politics, Psychology and Philosophy, as well as Gender Studies in the Social Sciences.1 The colloquium formed part of a broader initiative of the Preventive Healthcare Research Cluster that aimed to develop new thinking on theory in Preventive Health. The initiative was designed to consider theories shaping the field today, and to critique and re-imagine these theories, in order to provide the grounding for robust debate and to advance a more developed theoretical base for that field. In short, the subgrouping and the colloquium which its members organised started from the position that while many Public Health experts remain unconvinced by the relevance of theorising, these experts nevertheless employ frameworks which may be more or less implicit in that they are precisely not recognised as involving theoretical presumptions (Kickbusch 2006:561; Dean and McQueen 1996:7,9). This context, far from producing an absence of theorising within Public Health, tends to result in a flourishing of particular sorts of theoretical approaches. Yet, the dominance of certain ways of thinking such as atomistic individualism (with its asocial prescriptive agendas regarding individual health disconnected from material social conditions) and unreflective empiricism (a theory that rejects the need for theory, Jones and Walker 1997: 58-60), remains relatively invisible and under-examined. The result is what Green refers to as the theory practice gap
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in public health (Green 2000:125). To the degree that such presumptions remain relatively implicit they are likely to remain less than transparent, undeveloped (Dunn 2006:572) and, most problematically of all, less amenable to discussion, critique and possible reassessment. In this setting, contributions to the colloquium (and to this Special Issue) were marked by an inclination to perceive theory as intrinsic to Preventive Health, whether acknowledged explicitly or not, and thus to refuse any notion of Preventive Health as a self-evident, commonsense field of endeavour. Rather than constituting this field as an objective arena of knowledge external to us (Sayer 1992:41), the implication is that health is a social product, and consequently is suffused by interpretative contestation and by its conditions of production, including existing power relations. While debates over the notion of social capital provide an obvious instance of the conceptual and socially situated character of what is deemed healthy (Moore et al 2006:729), the same is said of issues which might appear more simply biomedical such as workplace injuries and so-called lifestyle concerns such as obesity. Preventive Health does not, in this understanding, exist at a distance from sociality but is imbedded in it. Such a stance is clearly at a critical distance from a self-evident/objective account of Preventive Health (often aligned with a strongly biomedical orientation), yet this stance continues to be located at the margins of mainstream debate about health matters (Bambra et al 2005:187). Public Health generally, and Preventive Health within that rubric, has evolved from a biomedical framework and for the most part contemporary socio-political thinking remains thinly integrated into the theoretical foundations of health and its promotion (see, for example, Parker and Harper 2006). Indeed, some commentators would go so far as to argue that there is in fact little existent theoretical work which might provide the means to invoke and reflect upon the social relational aspects of health (Potvin et al 2005:591; Macintyre et al 2002). Whether one sees contemporary socio-political theorising as poorly integrated into analysis of Preventive Health or Preventive Health as simply
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lacking much in the way of a theoretical foundation, the point here is that the interpretive social dimensions of the field appear presently underdeveloped. We, the guest editors of this edition, thus specifically invited papers seeking to engage in critical debate concerning current theoretical frameworks for understanding preventive and interventionist elements in health. Our concern was to move away from popular theoretical assumptions and to offer theoretical innovations in the arenas of Population and Public Health. It was expected that contributors would extend existing theoretical paradigms and/or concepts, consider their limits, challenge them, or even step beyond them and offer new directions/ models. There was no expectation that the perspectives developed by the contributors would present a singular viewpoint or that such theorybuilding would result in a one all-encompassing mode of analysis (Szreter and Woolcock 2004:704). Rather we saw the rich theoretical project informing Preventive Health as broad, complex, drawing upon many disciplines and involving diverse conceptual possibilities. The contributions to this volume are indeed testimony to this assessment. Despite the breadth of the collection, inevitably a collection like this one has certain contours. All of the contributors are Australian-based, bar one exception and even this contributor was located in Australia until recently. While the Special Issue is dominated by directions and subject matter which have been the material of international debate, nevertheless the clustering of contributors may also enable a focus on particular issues that have formed the locus of contestation within a specific cultural context. This might generate potential comparative insights for readers located in other contexts. Additionally, it is relevant to note even if an obvious point that the contributors do not and could not provide an exhaustive coverage of all critical theoretical endeavours in Preventive Health. There are some important absences in the collection: in particular, attention to Indigenous issues. Clearly, there are significant debates concerning Indigenous health in Australia (see, for example, Langton 2007 for a recent commentary in the Griffith Review).
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Many of these point to entrenched racism, misguided academic discourse, and glaring policy failures. In this Special Issue, Bacchis paper on the gap between what we know about the social determinants of health, and what we do about them, may well be relevant to interrogating the researchpolicy nexus within Indigenous health. There are certain thematic regularities in this Special Issue, arising no doubt from the call to engage in critical debate in order to re-imagine and reinvigorate theorising in Preventive Health. Critical engagements in the field have drawn attention to its inherently social constitution: both in the sense of it being necessarily an interpretive terrain and in the sense of its implication in existing power relations. Such engagements have more specifically registered a critique of that sociality: a critique of modernity (Potvin et al 2005:591). Not surprisingly, certain theoretical consistencies appear in this critique. Leading theoretical frameworks recur, such as Michel Foucaults account of the operations of power in modernity, Ulrich Becks analysis of the risk society, the notion of social capital in the work of writers like Robert Putnam, and the broad concept of the social determinants of health. The latter evokes axes of power associated with socio-economic status, gender, and ethnicity amongst others, as well as questions about hierarchical relations between unequal actors in health systems and the role of lay voices in offering challenges to the exclusive authority of expert knowledges (Popay 2006), enabling a return to Foucaults concerns regarding regimes of power/knowledge. Such agendas and topics are well established in international debate concerning Preventive Health, but here they are extended and/or re-appraised and sometimes subjected to reassessment, rather than being taken as given. In this way the Special Issue offers a critical lens upon existing critical agendas with the intention of substantively furthering the development of theoretical frameworks in the field. For instance, while Kickbusch suggests some limits to Foucaults concept of medicalisation in light of the impact of the market (Kickbusch 2006:561), Foucaults work is nevertheless reexamined in innovative ways in this Special Issue by several contributors. Coveneys focus on

Foucaults later work concerning governmentality and Diproses coupling of Foucault with other theoretical paradigms offer two possible modes of enquiry, amongst others in the volume. These papers (and many others) examine embodied ever yday lives (shaped by multiple and intersecting power relations such as sexuality, consumption, gender and class), and the complex practices involved in knowledge construction as well as in strategies of resistance and pleasure.

Outline of the Special Issue


A brief description of the contents of the collection indicates that the list of theoretical contributions (if not exhaustive) is undoubtedly wide-ranging. While the papers may be distinguished and ordered in a variety of ways, perhaps the most obvious distinction may be found between the first four papers and the last three. The first four, by Broom, Diprose, Beasley, and Bacchi, all in different ways question the enterprise of Public Health. The first three of these are especially concerned to question the risk orientation of Preventive Health and to offer a critical perspective on the field as a form of governance by prevention/pre-emption. Broom establishes a strong foundation for the volume by demonstrating how risk creates inadvertent blind spots in our contemporary paradigms. Her analysis of preventing smoking-related harm demonstrates how underdeveloped analytical reflection has led to inadequate recognition of class and gender factors in relation to smoking, and in consequence unintentionally fostered the reproduction of health inequalities. Diprose builds upon this analysis through her examination of the 2006 quit smoking campaign in Australia. Drawing on philosophies of the body (specifically Foucaults biopolitics and Merleau-Pontys phenomenology), Diprose argues that there is a new emerging paradigm of preemptive risk in public health discourses (analogous to biosecurity and anti-terrorism measures) that has implications for diminishing the creative and resistant possibilities of embodied social life. Beasley also considers the questionable impact of a risk orientation in Preventive Health, but in this case with regard to sexuality. Beasleys work initially suggests some qualification of Foucaults claims concerning the proliferation of sexualising
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discourses in modernity. She argues that heterosexuality within Preventive Health, and in Gender/Sexuality thinking which informs it, is largely absent as a potential source of pleasure and over-determined as a source of repressive domination. In consequence preventive sexual health projects are unable to frame hetero-sex beyond the defensive language of risk avoidance. Re-imagining sexuality and sexual health frameworks, she asserts, involves developing new modes of thinking which do not discount pleasure and its creative potentialities and offer ways of constituting an ethical erotics. These perspectives on risk put forward by Broom, Diprose and Beasley enable consideration of what risk problematically prioritises, what it may inadvertently privilege and what is absent from its purview. The analysis of this risk orientation has implications for the whole arena of Public Health. The fourth paper by Bacchi offers another take on the framing of Public Health and is concerned with the structures of governance. This paper attends to funding arrangements, the narrowing of complex plural knowledges, and unacknowledged institutional regulatory processes. Bacchi critiques the ways in which the knowledge gap between research (what we know) and policy (what we do) is articulated, suggesting that research management has now aligned itself to a delimited research agenda which veils a particular set of assumptions with the supposedly value-free language of efficiency and realistic goals to produce a certain kind of fit between research problems, questions and expected outcomes. This fit amounts to the curtailment of intellectual diversity and debate. The latter three papers by Meyer et al, Warin et al and Coveney, have a somewhat different orientation. All concentrate upon detailed analysis of existing critical vocabularies in the Preventive Health field, with a focus upon trust, consumption and governmentality respectively. These writers aim to provide a more rigorous and expansive understanding of widely used terminologies in the critical literature. Meyer et al examine dominant theories of trust in health systems from Giddens and Luhmann, and suggest that a more comprehensive model (enabling recognition of significant social factors and the complex,
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multidimensional webs that activate trust) is required in Public Health research. Importantly, this paper also problematises the argument that trust is quantifiable; asking: can we ever really measure and bring into view the linkages between knowledge and ignorance? In many ways, this question points to wider positions and arguments raised by the Special Issue as a whole: to value those things that cannot be measured; to recognise that not everything that can be counted counts and that not everything that counts can be counted (Sillitoe 2007). While Broom and Diprose refer to the topic of smoking, Warin et al and Coveney offer careful assessments of the issue of obesity. Using ethnographic techniques of participant observation Warin et al critique the ways in which consumption has been taken-for-granted in obesity discourses and policy initiatives, suggesting that commodification of bodies, spaces and health are not simply part and parcel of the negative effects of a consumer society, but fundamentally concerned with the paradoxes and possibilities of consumption. An ethnographic approach to a Public Health issue allows us to rethink and redefine key questions of the obesity problem, particularly as they relate to contexts of gender and class. Coveneys timely paper illustrates how childhood has become a major point of engagement in the war on fat, and the ways fatness in children has allowed for the availability of different subjectivities or subject positions in which children are framed as sick, slothful and dangerous, or innocent helpless victims (and extending to new subject positions for parents, industries, and organisations). Such governing of the girth is positioned within Roses characterisations of new forms of government (Rose 1996), which emphasise networks of governance and pluralisation of social technologies. In short, all the contributors to this Special Issue of Health Sociology Review (ISBN 978-1-92134800-6) are committed to re-imagining theoretical perspectives in Preventive Health. We recognise that no single discipline has a monopoly, and that both biological and social science perspectives are important to unpacking the complexity of patterns and experiences of health and disease. We hope that the papers in this collection will continue to
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challenge and extend our existing stock of social and political theories of health and prevention, and contribute to new theoretical directions.

Acknowledgments
The editors would like to thank the anonymous reviewers who generously assisted in reviewing manuscripts for this Special Issue, and the hard work of the HSR editorial team. We would also like to thank participants of the Preventive Health Research Cluster at the University of Adelaide and Professor Ilona Kickbusch for their stimulating intellectual engagement. Anne Hayes deserves special mention for her instrumental role in organising the original forum from which the idea for this Special Issue arose.

Endnote
1. The on-going members of this sub-grouping were Carol Bacchi, Chris Beasley, Annette BraunackMayer, Teresa Burgess, Anne Hayes (administrative coordinator), and Vivienne Moore.

References
Bambra, C.; Fox, D. and Scott-Samuel, S. (2005) Towards a politics of health Health Promotion International 20(2):187-93. Dean, K. and McQueen, D. (1996) Theory in health promotion: Introduction Health Promotion International 11(1):7-9. Dunn, J. (2006) Speaking theoretically about population health Journal of Epidemiology and Community Health 60:572-3. Green, J. (2000) The role of theory in evidence based health promotion practice Health Education Research 15(2):125-129. Jones, I. and Walker, D. (1997) The role of theory in public health in Scally, G. (ed) Progress in Public Health Royal Society of Medicine Press: London.

Kickbusch, I. (2006) The health society: The need for theory Journal of Epidemiology and Community Health 60:561. Langton, M. (2007) Trapped in the Aboriginal reality television show Griffith Review Edition 19 Re-imagining Australia Griffith University: Sydney. Macintyre, S.; Ellaway, A. and Cummins, S. (2002) Place effects on health: how can we conceptualise, operationalise and measure them Social Science Medicine 55:125-129. Moore, S.; Haines V.; Hawe P and Shiell, A. . (2006) Lost in translation: A genealogy of the social capital concept in public health Journal of Epidemiology and Community Health 60:729-34. Parker, M. and Harper, I. (2006) The anthropology of public health Journal of Biosocial Science 38(1):1-5. Popay, J. (2006) Whose theory is it anyway? Journal of Epidemiology and Community Health 60:571-2. Potvin, L.; Gendron S.; Bilodeau A. and Chabot, P (2005) Integrating social theory into public . health practice American Journal of Public Health 95(4):591-5. Rose, N. (1996) Governing in advanced liberal democracies in Barry, A.; Osborne, T. and Rose, N. (eds) Foucault and Political Reason University College Press: London. Sayer, A. (1992) Method in Social Science: A Realist Approach (2nd edition) Routledge: London. Sillitoe, P (2007) (ed) Local Science vs Global . Science: Approaches to Indigenous Knowledge in International Development Berhahn Books: Oxford, New York. Szreter, S. and Woolcock, M. (2004) Rejoinder: Crafting rigorous and relevant social theory for public health policy International Journal of Epidemiology 33:700-704.

ANNOUNCING DECEMBER 2008WATER POLICY AND GENDER


Edited by Kathleen Bowmer, Professor of Water Policy at CSU Post-Retirement Fellow with CSIRO Land and Water
ISBN 978-1-921348-11-2 s/c ii + 110 pages a special issue of Rural Society (ISSN 1037-1656) - volume 18/3 In most cultures men and women are affected differently by challenges of water scarcity or excess. This issue argues that gender should be explicit in developing policy and aid programs, and in designing communication and education programmes. Women are often more sensitive to environmental conservation, bear the brunt of generating off- farm income in depressed rural communities, and are more often responsible for selection of food and water saving appliances, yet are less represented in politics, policy making, corporate governance and regional decision making. This special issue includes research, cases and commentary on issues that connect water and gender from international, regional and national perspectives.

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Hazardous good intentions? Unintended consequences of the project of prevention


ABSTRACT
KEY WORDS Health promotion, class, gender, sociology, latent functions

Preventing disease is by definition a valuable objective, and most debates have revolved around improving the effectiveness of prevention. In this discussion, I explore the latent functions the unintended consequences of what I call the project of prevention. Although many latent functions are welcome, some have undesirable effects, and it is therefore important to instigate a rich exchange between innovative theory and rigorous research to minimise such effects. I argue that the hazards are particularly acute in the absence of a reflexive and critical awareness of the political environment and the cultural economy within which prevention occurs. In the paper, I sketch the challenges to mobilising that awareness, show some of the limitations of the conventional theoretical approaches to prevention, and point to directions for developing more fruitful perspectives.
Received 7 November 2007 Accepted 5 March 2008

Dorothy Broom
National Centre for Epidemiology and Population Health The Australian National University Australia

he project of prevention as it is defined and practised in the early 21st century arises from a history of good intentions. The prevention of disease and injury, and the maintenance of good health, have long been recognised as preferable to therapeutic intervention. Prevention averts pain and suffering, and is generally believed to be more cost-effective than medical care. The term prevention, however, is not limited to stopping health problems before they start. Particularly when clinical care is being discussed, prevention is typically subdivided into primary, secondary and tertiary types. Only primary prevention involves avoiding ill-health before onset. The term secondary prevention is used to refer to early detection of asymptomatic people, while tertiary prevention has become another name for medical care that strives to restore an optimal level of health and functioning
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in a person with established disease (U.S. Preventative Services Task Force 1996). Although my interest is mainly in primary prevention (particularly community-based rather than clinical), I touch on the other forms, and note here that the distinctions between them presume boundaries that are empirically and experientially more blurry than the definitions might suggest. The proliferation of meanings complicates the task of re-imagining, but it is indicative of the contemporary discursive and socio-political context within which health care and prevention occur. This context, and the way the definitions and implementation of prevention have developed, contribute collectively to the unintended effects which form the subject of this paper. I begin by over viewing several key characteristics of the contemporary context, touching on illustrations of the unintended consequences. Then, I refer briefly to the example of cigarette smoking to show that public health has yet to mobilise a thoroughly classed and gendered analysis of this most significant health risk, and has therefore subverted its explicit agenda and paradoxically contributed to the
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reproduction of health inequalities in the process of advancing prevention.

Characterising prevention
Contemporary prevention could be described in many ways. Here, I discuss four of its key characteristics: 1. Its focus on the individual; 2. The increasing emphasis on an evidence base; 3. Medicalisation and the expansion of the field of health; and 4. The location of prevention in a distinctive neo-liberal political economy and a cultural economy of modernity. These characteristics are closely interrelated, although a systematic deconstruction of their relationships is beyond the scope of this paper.

Individualised health
The focus of contemporary prevention is fixed largely on the individual, and especially on individual behavioural risk factors (Lin and Fawkes 2007; Pitts 1996). An emphasis on individuals is hardly surprising, in light of contemporary ideology and political culture. For example, in Australias 2005 National Research Priorities, the priority of Promoting and Maintaining Good Health is quickly glossed as enabling individuals and families to make choices that lead to healthy, productive and fulfilling lives, noting that all Australians stand to benefit from preventive health care through the adoption of healthier attitudes, habits and lifestyles. Even the priority goal Strengthening Australias social and economic fabric which might be expected to have a strong structural dimension, emphasises enabling people to make choices (DEST undated). The apparent success of this approach is evident from improvements during the 20 th century in the prevalence of certain risk factors such as saturated fat intake and smoking, and the accompanying decline in cardiovascular disease. Health promotion through education continues to be the most popular intervention for improving health-related behaviour, although clinical interventions (such as nicotine replacement therapy, lipid lowering drugs, and medications to manage hypertension) are believed to contribute to improved health, as are the development and

marketing of food products with lower saturated fat content. Health education is, in some ways, an ambiguous case: spanning both individuals and populations, since it is designed to influence the behaviour of individual persons, but it is often delivered to groups or whole populations. Similarly, regulation and legislation designed to improve health (such as laws requiring the use of seat belts, prohibitions on drink-driving and cigarette advertising, or regulations forbidding smoking in public venues and prohibiting the sale of alcohol and tobacco products to minors) are also delivered to entire populations within the relevant jurisdiction. However, individual behaviour change is still typically the axis on which these interventions turn. But even when it is partly successful (or perhaps especially then), the emphasis on the individual as the target of prevention entails at least three undesirable unintended consequences: stigmatising the sick, occluding structure, and increasing surveillance (of self and others).

The guilty victim: stigma Perhaps the best documented downside of targeting individuals is the resulting tendency to blame people who fail to adopt the health-promotion message and, by extension, those whose health is poor (Blaxter 1990). Some health professionals have explicitly attributed illness to personal sins such as greed and sloth (Knowles 1977) , but lay people including those with impaired health can also attribute difficulties to the failure to exert sufficient willpower (Blaxter 1993). Apart from the distress of being unwell and being blamed for causing (or failing to prevent) ones own suffering, this emphasis on individual behaviour can provoke apparently perverse responses in which people consciously engage in risky behaviour in an effort to restore their spoiled identity. For example, our study of adults with diabetes type 2 found that some people used deliberate refusal of medical regimens in order to reassert themselves as adults and competent moral agents in the face of disease prevention language that tended to infantalise and insult them for their failure to maintain rigorous blood sugar control
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Hazardous good intentions? Unintended consequences of the project of prevention

(Broom and Whittaker 2004). That is, they reestablished their adult agency by consciously flouting medical advice, since the exercise of such freedom is denied to children. Another example of perverse unintended consequences is the pattern of explicitly disparaging people who conform to health promotion advice as being killjoys or goodygoodies. People who wish to establish themselves as independent, friendly, sociable and not up tight may be attracted to hazardous behaviour as a way of establishing and displaying such identities. That is, individualised prevention can inadvertently create new subject positions defined by resistance to health promotion.

as socioeconomic gradients, gender and ethnic differentials in health (Cockerham 2007) are rarely explained by the composition of the relevant groups alone, that is by the characteristics of the individuals who comprise socioeconomic or ethnic categories (Wilkinson and Marmot 1998). Furthermore, the very balance between the individual and the social (agency and structure) is itself heavily shaped by structural considerations (Williams 2003). Consequently, we can ill afford to ignore elements of structure if the health (particularly of vulnerable populations) is to be improved (Crawford 1980).

Invisible structure Theories of health and disease prevention are redolent with terms that appear to signify the centrality of individual behaviour. Words such as personal habits, choice and lifestyle are readily applied to people who are apparently solitary individuals, even though the most cursory sociological analysis identifies environmental (GilesCorti 2006), class, culture, ethnicity, gender, and geography as elements of social identity and social relations that are significantly correlated with the distribution of health and illness (Cockerham 2006, 2005). However, because it is often asserted that health service providers and policy makers cannot intervene in such elements as the economy, urban design, or cultural and socioeconomic inequality (and indeed it can be intellectually and politically challenging) (Lin and Fawkes 2007), the default option of the individual as author of their own destiny is constantly reinstated. An understandable policy interest in practical interventions and modifiable factors becomes a self-fulfilling prophecy; we foreground, and ultimately only investigate and act on, the factors that are already defined as modifiable. Elements of politics, the economy, culture and social structure that are believed to be beyond the scope of public policy either disappear altogether, or are disposed of in a sentence or two. As long as problems can be avoided and health promoted by solitary individuals, ignoring structure does no harm. However, such patterns
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Intensified surveillance Surveillance is a virtually inevitable consequence of contemporary prevention, amplified by what has been called the project of the body. As new tests become available, responsible people are urged to subject themselves to medical surveillance through tests for bone density, blood sugars and fats, and cancers such as breast, prostate, colon and cervix. In addition to medical testing, many of the technologies of the self that involve working on ones body (including diets, gym memberships and exercise machines and food supplements) are justified partly in terms of their alleged health benefits. Consequently, people are being incited to pay compulsive attention to various kinds of behaviour, particularly what they eat and drink. Commercial weight loss programs such as Weight Watchers incorporate such attentiveness through the meticulous balancing of physical activity and calorie intake. This kind of self surveillance also fosters the surveillance of others. For example, evidence about the hazards to the unborn baby of maternal alcohol consumption and smoking have authorised a propensity to police the consumption behaviour of pregnant women, sometimes literally. At least one US state (Wisconsin) has a statute defining certain forms of prenatal maternal behaviour as prenatal child abuse. Indeed much health related surveillance has been strongly gendered. Men have tended to regard a keen interest in health as an unmasculine propensity, and there is evidence that women are much more prone to such attentiveness, particularly as far
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as their own body shape and weight are concerned. Furthermore, womens bodies have been more intensely subject to the gaze, thus reinforcing womens potentially obsessive concern with appearance, and the related fragmentation and fetishisation of body parts (Broom and Dixon 2008). These gender dynamics may be shifting somewhat as the male body is mobilised as an object to be deployed in advertising and consumed visually. Gay male interests in gym culture and bodily appearance seem to have been taken up in the heterosexual male population. Additionally, more men are apparently becoming engaged in diets, particularly masculine diets such as those entailing high meat intake (Bentley 2004) because of concerns about appearance as well as health. Note however, that such changes do not constitute instances of de-gendering, but rather signal the mobile and adaptable character of gender and its value in consumer culture (Broom 2008).

Evidence-based prevention: Just the facts?


Following the rise of evidence-based medicine is a growing emphasis on developing an empirical foundation for prevention and health promotion (Asthana and Halliday 2006). Policymakers are keen to identify interventions that have been subject to evaluation, and especially to obtain a list of best buys with which to address particular population health problems so that public funds can be well spent. Once again, admirable intentions. Unfortunately, this borrowing from evidencebased medicine is far from straightforward. For one thing, what constitutes gold standard evidence in medical care (the randomised controlled trial, RTC) is of limited practical value even in clinical settings, and becomes virtually impossible to conduct where questions of population health are concerned (Rogers 2004b). Furthermore, the results of RCTs can probably be applied only to pharmacological (plus a very few surgical) interventions administered in hospitals, and cannot be generalised for use of medicines or other therapies in the community. Such

limitations are compounded in the case of prevention where both problems and solutions are usually multifactorial. The quality of evidence for preventive interventions has been undermined by the individualistic focus (discussed above). The assumption (often implicit) is that health education is a straightforward means to inform people about behavioural risk factors; and that when individuals know which personal behaviours lead to illness, rational people will take the appropriate action. The unproblematic reliance on professional medical and public health reasoning to define rational choice, however, is a weakness of the model, eroding its effectiveness. Neither the content of health education nor the nature of what constitutes a rational response appear to yield to simple definition (Broom 1984; Kavanagh and Broom 1998). Health risks taken by ethnic minorities, working-class people and women are often construed as irrational, while the vices of middle-aged professional white men go unremarked, despite their substantial impact on individual or environmental health. Paradoxically, the difficulty assembling rigorous evidence of the effectiveness of certain preventive interventions has not discouraged their use (Rogers 2004a). For example, in the current climate of moral panic about the rising prevalence of obesity, people in rich countries are being exhorted to control their weight, despite the fact that the evidence supporting the link between promoting weight loss and improving health is, at best, contentious (Aphramor 2005:315). The discrepancy poses important questions about the ethics of persisting with weight loss propaganda, as well as raising the issue of public expenditure on this agenda. The history of medicine is replete with examples of rigorous evidence that has been ignored or even actively suppressed. In the first few decades of the 20th century, pellagra was widespread in the American South, especially among the poor and among inmates in institutions such as mental hospitals, prisons and orphanages. It affected about three million people of whom 100,000 died of the disease. At the time, it was widely believed to be caused by a germ, but the young doctor sent by
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the predecessor of the National Institutes of Health to investigate the epidemic could find no evidence to substantiate that belief. He tried the simple intervention of improved diet, and documented dramatic results; but because this view contravened the prevailing theory, his findings were discounted and his competence disparaged. Thinking that more rigorous proof would persuade the sceptics, he assembled ever more detailed evidence, but he had not reckoned on the power of racism, classism and regionalism to overcome science. As the New York Jewish son of poor Hungarian migrants, he antagonised both the New England establishment and Southern pride with his health heresy. The result was decades of delay accepting his hypothesis and diminishing the burden of this disease (http:// history.nih.gov/exhibits/goldberger/index.html). Prevention of pellagra is simple once the focus shifts from disreputable filth to dietary deprivation, but the social, cultural and political obstructions to achieving the shift proved more difficult than the empirical research. Lest we imagine that such errors are a product of a bygone era, contemporary researchers have documented an intransigent refusal on the part of experts to acknowledge evidence of rickets among children in Bangladesh because it is well-known that adequate exposure to sunshine prevents this condition (Uphoff and Combs 2001). The story parallels the pellagra case, with elaborate alternative diagnoses and explanations persisting despite abundant evidence. It seems that even in the presence of plenty of sunshine, calcium deficiency can cause rickets, and many children in poor countries have suffered because of the unwillingness of medical authorities to acknowledge that their paradigms were incomplete. How many other empirical blind spots do our contemporary paradigms create for prevention? It has been suggested that adhering to poor theory as a kind of scientific safety blanket is worse for public health than reliance on commonsense, because it obstructs access to effective interventions as well as imposing ineffective or even counterproductive ones (West 2005, 2006). A kind of intellectual hubris can arise from the belief common in every age that we now know the whole truth about health and human body.
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The germ theory of disease has fostered a belief in single causes, a belief that can be hazardous even when germs are implicated, since as epidemiologists tell us exposure, host and environment are all elements of the puzzle of health and disease. Furthermore, some of the most significant public health questions require a capacity to tolerate high levels of uncertainty, an attitude that appears to pose a considerable challenge to evidence-based prevention (Gard and Wright 2001). The determination to base prevention on evidence thus may require the cultivation of a subtle blend of empirical rigour and humble agnosticism, a rare and difficult combination.

Medicalisation and the expanding field of health


The century long process of medicalisation has generated an ever expanding range of questions to which health is thought to be relevant, and on which health professionals are presumed to be appropriate authorities (Zola 1972). Early discussions of medicalisation expected that moral judgments of undesirable conditions (arising from defining them as sins) would be attenuated by their redefinition as medical matters (Conrad 1992; Conrad and Schneider 1980). And indeed, some conditions do appear to have become less stigmatised as a result of being redefined as diseases. Alcoholism, hyperactivity, occupational overuse syndrome (RSI) and chronic fatigue syndrome are examples of this change to an extent (Broom and Woodward 1996; Woodward et al 1995). However, the shift from religious to medical authority (Leichter 2003) appears to have done little to alleviate the moral opprobrium provoked by violations of health nor ms regarding behavioural risk factors. Indeed, Metcalfe referred to doctors and health promoters as secular missionaries (Metcalfe 1993), which suggests that medicine is becoming a kind of lay religion. Some conditions that had been de-medicalised are now being re-medicalised, even as others (such as aspects of male ageing) are being added to the list of health problems requiring medical treatment (Conrad 2007). And with increasing numbers of conditions now defined as questions of health and
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illness, medical authority continues to proliferate. Medicalisation entails not only a lengthening list of problems that come to be defined as diseases, and amplified medical authority, but also an expansion in the scope of time that may be subject to surveillance and judgment. Together with discourses of prevention, medicalisation now incorporates the manifestation of certain health risk factors, even in the absence of impaired function or any other symptom. New labels are devised for new conditions (such as pre-diabetes or pre-cancer), placing the persons so labelled in a liminal space between health and disease. The medical management of hypertension or serum cholesterol, for example, is justified on the basis that doing so prevents disease in the future. However, through a kind of verbal slippage, high blood pressure or excess weight are now often defined as diseases in their own right, prompting the fat acceptance movement to assert that obesity is not a disease. In combination with a kind of risk factor bracket creep, the definition of what constitutes healthy weight or blood pressure and the threshold for classification as disease continues to shift downwards (Rose 1985). Thus, more and more bodily states become objects of preventive interventions. Perhaps none of these trends entail obviously undesirable consequences. However, the worthy objective of improving health can bring with it medical dominance and the erosion of peoples confidence in their ability to manage problems of life without professional supervision. Being diagnosed with pre-cancer, many women who had investigations for abnormal Pap smears reported feeling sexually stigmatised in ways that may have affected their sex lives and personal identity (Kavanagh and Broom 1997; Posner 1993). That is, an apparently factual test result in the medical sphere may carry personally and socially ominous connotations to the person whose body is thus redefined.

Neoliberalism, commodification and modernity


Preventive care is subject to particular constraints in the context of the currently dominant neoliberal political economy, the rise of consumerism and the culture of modernity. The valorisation of the

individual is a key element of neoliberal ideology, and we have already glimpsed some of the undesirable effects of this focus. The redefinition of citizens as consumers, and the ascendancy of privatisation and commodification have created circumstances in which health problems (and their prevention) become matters for the market rather than for civil society or the state (e.g. Collyer 2007). As health and its protection have become commodified, commercial firms advertise what they claim are health promoting products, and in the process, generate an ever louder cacophony of supposedly authoritative voices telling people what to do to be healthy (Dixon and Winter 2007). This proliferation of experts further complicates the already difficult task of health promotion, particularly in the environment where 1000 flowers (and many more weeds) bloom on the internet. Far from being singular risk factors, most of what is required for disease prevention entails repeated, intricate, subtle and often quite sophisticated management of testing, symptoms, therapies and supplements, diet, and physical activity, all enacted in specific social and physical environments. And all of these are deeply embedded in identities, social relations, gender, class, ethnicity and culture: indeed everything that contributes to the formation and enactment of what Bourdieu calls habitus. Most people are not keen on living in a clinic (Metcalfe 1993), but instead aim to balance health with an array of competing priorities where health is one objective, but rarely the only or even the primary one. Consequently, we should not be too surprised that so many people have so much difficulty conforming to the numerous (sometimes conflicting) injunctions of health promotion, and are often reluctant to accede to the imperatives of healthism. Paradoxically, the convergence of commodification and individualism can have the effect of permitting the appropriation of individual rights discourses by private biotechnology and pharmaceutical corporations which are all too ready to locate human rights in the market (Kickbusch 2006). In Australia, we have seen selfhelp organisations mobilised by international drug companies to assist with lobbying to add new prescription products to the Pharmaceutical Benefits Scheme. Patients are encouraged to hope
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that the drugs will prevent symptoms and complications of their disease. There is a dynamic tension between genuine and responsible patient empower ment on the one hand, and the exploitation of human suffering for corporate profits on the other. The neoliberal regime can also directly thwart efforts at disease prevention, health education and health promotion. Return to shareholders can take precedence over the health of workers, clients or the population more broadly. And the protection of commercial in confidence documents can obstruct the access by citizens and civil society groups to information crucial to the agenda of prevention. Just as health is not the sole aim of individual citizens, it is almost never the main aim (or an aim at all) of the corporate persons who wield increasing power over the allocation of human and other resources. International trade agreements compound these difficulties, and their consequences supply some of the most dramatic examples of how health promotion can become a casualty of commercial activity. The familiar case of inadequate access to essential drugs in poor countries is only one instance of how trade agreements function to protect private industry rather than public health. Privatising health care and water supplies are also being driven by commercial interests in the first world, and authorised by international finance and trade agreements. In these circumstances, only the richest and most powerful nations are in a position to protect public health (if they will) when international agreements stipulate that any regulation or tax infringing on unfettered trade must be demonstrably necessary, and that no less commercially restrictive alternative measure was possible (Zeigler 2006). Despite rhetoric to the contrary, trade disputes tribunals have typically required a very high level of evidence of health harm to justify restraint of trade, even in the case of such demonstrably dangerous products as asbestos and tobacco. These cases are not so much of unintended consequences of prevention, but collateral health damage of neoliberalism. However, neoliberalism includes the ideology that unfettered commerce is the best route to improved health, a view endorsed by many governments.
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Dynamic inequalities: The case of smoking


One of the most disturbing consequences of contemporary health care (including prevention) has been its failure to diminish health inequalities. Most health risk factors are distributed according to socioeconomic position: people with less wealth, lower incomes, worse jobs, less education, and living in poor neighbourhoods are more likely than their counterparts to manifest health risks and impaired health status (Murray et al 2005). In the first half of the 20th century, these gradients were believed to be products of poverty that would be alleviated by better material conditions and improved access to health care. The famous Black report in the UK showed that better living conditions and the advent of the NHS diminished premature mortality overall, but did nothing to shrink the socioeconomic differentials in health (Black 1980). The health of the whole population improved, but the gaps persist. How might prevention have contributed to that persistence? Smoking provides an informative case in point. Cigarette smoking follows the inverse socioeconomic gradient in the Anglo-American democracies and in Northern Europe (the gradients are much less marked and, especially for women, even reversed in Southern Europe) (Mackenbach 2006). People lower down the socioeconomic scale are more likely to smoke than wealthier, higher status people. Additionally, the gradient shifted during the 20th century. Initially a signifier of discretionary income, cigarette smoking was democratised, particularly by war. As knowledge of its health hazards became more widespread, its popularity among elites declined, gradually transforming it into a marker of workingclass status or poverty (Barbeau et al 2004; Turrell and Mathers 2000). In an equally striking shift, only men smoked at the beginning of the 20th century (Berridge 2001), but nearly equal proportions of women smoke now, at least in the Anglo-American democracies (there is more variation in nations of the EU (Graham 1996). Globally it is still true that the majority of smokers are men, but the gender differential is shrinking in many nations; and in
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North America, the UK and Australia, there is no longer any consistent sex difference (McDermott et al 2002). Australia has experienced a century of antitobacco activism, the last 50 years of which have become increasingly medicalised, legitimised, and supported by legal regulation (Walker 1984), and tobacco control has been one of Australias health promotion success stories. Nevertheless, the class gradient persists, and the gender dynamics remain largely unaddressed. That is, the political, economic and cultural setting of both health risks and health promotion continue to serve the interests of the commercial sector, while the general failure of health promotion to generate research informed by appropriately sophisticated theory (Dunn 2006; Kaplan 2004; Vagero 2006) has left it ill-equipped to address classed or gendered targets. For example, some of the factors driving smoking and obstructing quitting may differ subtly between the sexes. Smoking appears to be more strongly linked to emotional distress and concern about weight among women (Berlin et al 2003; Camp et al 1993; Honjo and Siegel 2003), factors which may contribute to womens generally lower rates of cessation (Abrams et al 1995; Jeffery et al 2000; Patton et al 1998). Men, especially young men, may be particularly motivated to abstain from smoking by their participation in sporting activities and a desire for physical fitness (Rodriguez and AudrainMcGovern 2004; Thiri Aung et al 2001). Cigarettes are often given or shared rather than purchased, (Castrucci et al 2002), and giving and receiving cigarettes may contain strongly gendered elements. Sociologically oriented studies show that smoking and sharing cigarettes operate to support sociability and to build solidarity (Barbeau et al 2004; Bialous 2005; Dichter 1947; Greaves 1993), elements that are also likely to be gendered and have implications for health promotion. At the time when virtually no women smoked, cigarette manufacturers were eager to enlarge their exclusively masculine market. Throughout the 20th century, cigarette advertising and promotions were targeted specifically to each sex, including the development of brands intended to appeal to women. For example, when it was originally

released in 1924, Marlboro (later associated with the independent cowboy Marlboro Man) was intended to be a womens brand with the catchphrase mild as May. In the 1950s, it reappeared with its new masculine profile, followed by a campaign to attract female consumers who were encouraged to try the cigarette for men that women like. That campaign signals the way a supposedly unisex brand (smoked by both women and men) can nevertheless be imbued with genderspecific signification. In the second half of the 20th century, the development and promotion of explicitly feminine brands (such as perfumed, menthol and pastel-coloured cigarettes, or ad campaigns quoting feminist slogans) was supplemented by more subtle forms of gendered marketing designed to appeal to particular images, identities and segments of the female market (Anderson et al 2005). Furthermore, like smoking itself, new antihealthist subject positions relating to smoking appear to be particularly gendered (Broom 2008). Because of the associations between smoking and disreputable female sexuality, some young women smoke in order to resist the good girl stereotype and render themselves socially approachable (Banwell and Young 1993; Lennon et al 2005). Another example is evident in the case of a new commercial venture in the USA that proudly labels itself The Heart Attack Grill. It sells large highfat steaks and hamburgers (such as The Doublebypass Burger), beer, and cigarettes, all served by nubile waitresses in the scanty costumes of naughty nurses (www.heartattackgrill.com). This initiative would appear to be targeted particularly at working-class males (Mosher 2001) who have been disempowered and disenfranchised by globalism, corporatism and feminised professions.

Conclusions
Good intentions are not enough to ensure that the project of prevention achieves its promise of better health, and that it does so without unacceptable inadvertent social and health costs. The implicit assumptions of individualism, rational choice, perfectibility and the superiority of what passes for expert and scientific knowledge can authorise prevention interventions with ineffective
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or occasionally perverse consequences, such as when refusing health promotion becomes a form of resistance and a means to reclaim spoilt identity. An inadequately theorised approach to preventing smoking-related harm has fostered the persistence of health inequalities, and left the door open for systematic unintended consequences to arise from health promotion efforts. These consequences are particularly likely to occur in the absence of a reflexive and critical awareness of the political environment and the cultural economy within which prevention is practiced. Thus, a much more self conscious and self critical view of health promotion and preventive care will be needed to diminish these (and perhaps other) unintended consequences. That is, continuing to devise and implement prevention as it has traditionally been practiced is likely to continue to reproduce or even exacerbate health inequalities. One way of modifying a default-option approach to prevention is for practitioners and researchers to strive for a theoretically sophisticated and empirically informed understanding of the social structure, political economy and culture which form the context of contemporary prevention. Finally, I suggest that the purview of prevention should be broadened to include diminishing health inequalities, as well as the improvement of health overall. This priority has been forcefully articulated as an objective for health and social policy in the UK (Acheson et al 1998; Graham 2002; Graham and Kelly 2004, 2006; Marmot 1999), but to date it has been difficult to develop and advance politically in Australia (Lin and Fawkes 2007). Prevention has yet to become a consistently effective and equitable resource for improving public health. To fulfil its potential, it will need detailed research grounded in innovative theory, not more of the same decontextualised individualism and relegation of structure and culture to the too-hard basket.

References
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Acknowledgments
I am grateful to two anonymous reviewers for constructive suggestions, and to Carol Bacchi and the editors of this special issue for stimulating discussions and their encouragement to develop these ideas.
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Hazardous good intentions? Unintended consequences of the project of prevention Jeffery, R.W.; Hennrikus, D.J.; Lando, H.A.; Murray, D.M. and Liu, J.W. (2000) Reconciling conflicting findings regarding postcessation weight concerns and success in smoking cessation Health Psychology 19(3):242-246. Kaplan, G.A. (2004) What is wrong with social epidemiology, and how can we make it better? Epidemiologic Reviews 26:124-135. Kavanagh, A. and Broom, D. (1997) Understanding abnormal Pap smears: A qualitative interview study British Medical Journal 314:1388-1392. Kavanagh, A. and Broom, D. (1998) Embodied risk: My body, myself? Social Science and Medicine 46(3):437-444. Kickbusch, I. (2006) The health society: The need for a theory Journal of Epidemiology and Community Health 60(7):561-562. Knowles, J. H. (1977) The responsibility of the individual in Knowles, J.H. (ed) Doing Better in Feeling Worse: Health in the United States Norton: Near York, pp.57-80. Leichter, H.M. (2003) Evil habits and personal choices: Assigning responsibility for health in the 20th century The Millbank Quarterly 81(4):603-626. Lennon, A.; Gallois, C.; Owen, N. and McDermott, L. (2005) Young women as smokers and nonsmokers: A qualitative social identity approach Qualitative Health Research 15(10):1345-1359. Lin, V. and Fawkes, S. (2007) Health promotion in Australia: 20 years on from the Ottawa Charter Promotion and Education 14(4):203208. Mackenbach, J.P (2006) Health Inequalities: . Europe in Profile Erasmus Medical Center: Rotterdam. Marmot, M. (1999) Health and the psychosocial environment at work in Marmot, M. and Wilkinson, R.G. (eds) Social Determinants of Health Cambridge University Press: Cambridge, pp.105-131. McDermott, L.; Russell, A. and Dobson, A. (2002) Cigarette Smoking among Women in Australia Commonwealth Department of Health and Ageing: Canberra. Metcalfe, A. (1993) Living in a clinic: The power of public health promotions Australian Journal of Anthropology 4(1):31-44. Mosher, J. (2001) Setting free the bears: Refiguring fat man on television in Braziel, J.E. and LeBesco, K. (eds) Bodies Out of Bounds: Fatness and Transgression University of California Press: Berkeley, pp.166-193. Murray, C.J.L.; Kulkarni, S. and Ezzati, M. (2005) Eight Americas: New perspectives on U.S. health disparities American Journal of Preventive Medicine 29(5S1):4-10. Patton, G.C.; Carlin, J.B.; Coffey, C.; Wolfe, R.; Hibbert, M. and Bowes, G. (1998) The course of early smoking: A population-based cohort study over three years Addiction 93(8):12511260. Pitts, M. (1996) The Psychology of Preventive Health Routledge: London. Posner, T. (1993) Ethical issues and the individual woman in cancer screening programs Journal of Advances in Health and Nursing Care 2(3):55-69. Rodriguez, D. and Audrain-McGovern, J. (2004) Team sport participation and smoking: Analysis with general growth mixture modeling Journal of Pediatric Psychology 29(4):299-308. Rogers, W.A. (2004a) Evidence-based medicine and women: Do the principles and practice of EBM further womens health? Bioethics 18(1):50-71. Rogers, W.A. (2004b) Evidence based medicine and justice: A framework for looking at the impact of EBM upon vulnerable or disadvantaged groups Journal of Medical Ethics 30(2):141-145. Rose, G. (1985) Sick individuals and sick populations International Journal of Epidemiology 14:32-38. Thiri Aung, A.; Hickman, N.J. and Moolchan, E.T. (2001) Health and performance related reasons for wanting to quit: Gender differences among teen smokers Substance Use and Misuse 38(8):1095-1107. Turrell, G. and Mathers, C.D. (2000) Socioeconomic status and health in Australia Medical Journal of Australia 172(9):434-438. U.S. Preventative Services Task Force (1996) Guide To Clinical Preventative Services (Second edition) Williams and Wilkins: Baltimore. Uphoff, N. and Combs, J. (2001) Some Things Cant Be True But Are: Rice, Rickets, and What Else? International Institute for Food, Agriculture, and Development (CIIFAD), Cornell University: Cornell. Volume 17, Issue 2, August 2008

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Dorothy Broom Vagero, D. (2006) Where does new theory come from? Journal of Epidemiology and Community Health 60(7):573-574. Walker, R. (1984) Under Fire: A History of Tobacco Smoking in Australia Melbourne University Press: Melbourne. West, R. (2005) Time for a change: Putting the Transtheoretical (Stages of Change) Model to rest Addiction 100(8):1036-1039. West, R. (2006) The Transtheoretical Model of behaviour change and the scientific method Addiction 101(6):774-778. Wilkinson, R. and Marmot, M. (1998) Social Determinants of Health: The Solid Facts World Health Organization: Geneva. Williams, G.H. (2003) The determinants of health: Structure, context and agency Sociology of Health and Illness 25(3):131-154. Woodward, R.V.; Broom, D.H. and Legge, D.G. (1995) Diagnosis in chronic illness: Disabling or enabling the case of chronic fatigue syndrome Journal of the Royal Society of Medicine 88(179/94A):1-6. Zeigler, D.W. (2006) International trade agreements to challenge tobacco and alcohol control policies Drug and Alcohol Review 25(6):567-579. Zola, I.K. (1972) Medicine as an institution of social control Sociological Review 20 (November):487-504.

CALLS FOR PAPERS - 2009 SPECIAL ISSUES


EXPERT PATIENT POLICY
Deadline for Papers: 30th August 2008 GUEST EDITOR Sally Lindsay Institute for Social, Cultural & Policy Research, University of Salford, UK Reducing the incidence of chronic disease and health inequalities is a key priority for governments. Sociologists of health and illness have sharpened the realisation of the extent to which the management of chronic conditions is not in the direct control of health professionals but rather in that of patients and their informal carers. The notion of expert patients has recently emerged in health policy and is pivotal to government plans to modernise health care by linking patient expertise to ideas of empowerment, a better quality of life, self-esteem and a user-driven health system. This special issue of Health Sociology Review aims to stimulate debate on the controversy around expert patient initiatives by providing a forum to discuss whether instilling information is adequate for patients to be able to self-manage their condition. Further, this issue aims to develop a better understanding of the mechanisms of engaging patients in self-care and the impact this has for patients, health care providers and larger social structures. Authors are invited to contact the Guest Editor with their Abstract in advance S.Lindsay@salford.ac.uk

AGEING, ANTI-AGEING, GOVERNANCE AND GLOBALIZATION


Deadline for Papers: 20th February 2009 GUEST EDITORS Associate Professor Brett Neilson and Beatriz Cardona Centre for Cultural Research, University of Western Sydney, NSW The purpose of this special issue of Health Sociology Review is to facilitate discussion on current research about ageing cultures and globalisation in order to explore how transnational developments impact on the construction and management of the ageing experience. It aims at stimulating conversations on issues such as current structures for the governance of ageing and the tensions and limitations that emerge from such models, the impact of global demographic transitions across localities, the role of science and biotechnology on the social and cultural understanding of later life and the rise of anti-ageing cultures and interventions as strategies for the governance of the ageing experience. Abstracts should be submitted via email no later than 8 November 2008. Authors are invited to contact the Guest Editors to discuss their approach in advance of submitting papers (email: b.cardona@uws.edu.au; b.neilson@uws.edu.au). Guidelines for manuscript preparation are available at: http://hsr.e-contentmanagement.com/page/22/author-guidelines
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Biopolitical technologies of prevention


ABSTRACT
This paper examines the way some public health campaigns in Australia have been caught within a paradigm shift in the management of risk society. It details this paradigm shift in terms of an intensification of political technologies of pre-emption in response to incalculable threats to physical security. The challenge this presents to public health programs, particularly those dealing with life style health problems such as obesity, depression, and drugs (illegal and legal), is that, in pursuing admirable aims of the prevention of ill-health in the population, such campaigns need to avoid reproducing (and indeed should counter) the harmful effects of the pre-emptive approach to security. Using the example of quit smoking campaigns of 2006-7, key features of the preemption paradigm are outlined, particularly the conservative comportment toward the future that it fosters. With reference to Foucaults concept of political technologies of bodies and Merleau-Pontys ideas about the temporality and intercorporeality of bodies, the paper also explores deleterious effects of this approach to risk and health on human agency, well-being, and social relations in general. The negative impact of the pre-emption approach is outlined in terms of the way it tends to dampen the openness (or potentiality) of bodies toward the future, the world, and other people. However, the temporality and intercorporeality of bodies also explains the operation of resistance by human agents to both the paradigm of pre-emption and the health prevention strategies that employ its way of thinking. This provides the basis for a gesture toward a more democratic, respectful, and effective approach to the promotion of health and well-being.
Received 10 August 2007 Accepted 5 March 2008

KEY WORDS Pre-emptive paradigm, embodied agency, temporality, intercorporeality, sociology

Rosalyn Diprose
School of History and Philosophy University of New South Wales Australia

here is increasing recognition among risk theorists that we are undergoing a paradigm shift in the way we understand and enact societys obligations for [ensuring] the physical security of its members (Ewald 2002:273). 1 Alongside the focus on managing calculable risk, which Ulrich Beck argued characterised the organisation of Western societies for much of the 20th Century (Beck 1992), there has been an intensification of what I will call political technologies of pre-emption in response to incalculable threats to physical security threats
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that have a low probability of occurring but would have potentially catastrophic effect.2 This focus on preventing low probability but high consequence risks is most obvious in the arenas of biosecurity and anti-terrorism measures. However, there are also indications that features of the paradigm have infiltrated approaches to the management of public health more generally. The paradigm presents a special challenge for public health programs in Australia that involve life style health problems such as obesity, depression, and drug addiction (illegal and legal). In pursuing admirable aims of preventing ill-health in the population, it is necessary that such programs avoid reproducing (and indeed would have some role to play in countering) any deleterious effects of this pre-emptive approach to health and physical security. In this paper I will, first, outline
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the key features of the emerging paradigm, particularly the attitude about the future that it fosters. Second, I consider the impact of the paradigm on human agency, the health of human bodies, and social relations in general. Third, by pointing to the operation of resistance by human agents to both the paradigm of pre-emption and the health prevention strategies that employ its way of thinking, I will gesture toward a more ethical and effective approach. The analysis draws on aspects of the 2006-7 quit-smoking campaigns in Australia as an example of one public health measure that takes the pre-emption approach to risks to health and physical security.

The pre-emption approach to risks to health and physical security


Different risk theorists describe the principle underlying this shift in thinking about physical security in terms of either precaution (Elward 2002), preparedness (Rabinow 2003; Collier and Lakoff 2008) or pre-emption (Derrida 2003; Cooper 2006). For the purposes of this analysis, I adopt the latter descriptor, pre-emption, although all three share similar features. This approach to threats to health and physical security is about being in a constant state of readiness (alert not alarmed) about possible threats and it is about being pro-active in preparing for such a threat or in warding it off. The paradigm of pre-emption originates in concerns with low probability but high consequence threats to health and physical security (such as fear of nuclear attack during the Cold War of the 1960s and 1970s, actual medical and industrial accidents and environmental disasters in the 1980s, terrorism since the 1970s, and, to take some more recent examples, the threat of tsunamis and avian influenza). The application of the approach has intensified since the events of September 11 2001 and has spread to include attention to social practices (such as smoking) and biotechnologies (cigarettes, drugs, etc.) that might be considered to pose a high probability of some risk to health, but a risk that is characteristically incalculable. While the risk to health of such practices and technologies that come under the paradigm may be high, the nature and extent of actual harm in the future remains incalculable.

Hence, in outlining four features said to differentiate the new paradigm from previous approaches to physical security, I include consideration of how the pre-emption approach has infiltrated approaches to the management of population health to turn banal risks into dangers that are incalculable but deemed to have catastrophic consequences. The first distinctive feature of the pre-emption paradigm is the assumption that risks and threats to health and physical security are incalculable, unpredictable, but always imminent (Collier et al 2004; Ewald 2002:285; Luhmann 1993). This epistemological uncertainty is exemplified in the field of population health by recognition of the complexity of relations between biological and social determinants of health. Second, adding to this uncertainty is the recognition that, in the absence of a single cause of harm (such as God, nature, or a single external enemy) the salient cause of harm is now taken to be unpredictable and fallible human agency. That is, harm is said to be caused by our own decisions and actions, that of individuals, corporations, and government agencies charged with managing health and physical security (for example, harm arising from risky behaviour of individuals, from the previous unbridled use of biotechnologies, human error in the biomedical lab or clinic, or failure on the part of an individual or health agency to act to ward off future harm to ones health and physical wellbeing). While these first two features alone are not a problem, and indeed signal a move away from either biological or social determinism in understandings of human well-being, when combined with the third feature, a moral dimension enters the health agenda with an attendant return to determinism. This third distinctive feature of the paradigm is the cautious and fearful comportment toward the future it fosters: in the face of immeasurable risk it has become necessary to take into account what one can only imagine, suppose or fear [and] to consider the worst hypothesis (Ewald 2002:286). A poster of the 2006 quit smoking campaign in Australia exemplifies this tendency to posit the worst possible future arising from what is deemed risky practice: above an image of two cigarette
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packets carrying photographs of a cancerous mouth and a gangrenous foot is a headline banner What you see is what you get. The message is neither subtle nor appropriately qualified: if you smoke, mouth cancer and gangrene are what you will get in the future; not: you might get this if a myriad of other determinants of ill-health are also in place. Finally, this kind of orientation toward the future renders responsibility futural and conservative: against such bleak future-scenarios, social agents (governments, individuals and relevant organisations) have a responsibility to take measures to pre-empt a future that is continuous with the past (Ewald 2002:284).3 It is better to be safe than sorry and preserve what is deemed good about the past that is still present. These features of the pre-emption paradigm, particularly the attitude toward the future it fosters, are apparent in a series of quit smoking television advertising campaigns run throughout Australia in 2006-7. The excuses campaign illustrates the points well.4 This depicts four examples of smokers (probably in their mid to late 30s) expressing typical excuses for not giving up smoking. Each excuse involves a gesture toward possible futures with or without smoking and acknowledges the incalculability of the future per se. For example, My pop smoked all his life lived til he was eighty; or I could be hit by a bus (that is, I could give up smoking but, if I did, I could be hit by a bus, so what is the point). Each excuse is followed by an image of some other person about the same age who is seriously ill (presumably from smoking) and who expresses a feeling that mockingly echoes the consequences of adhering to the smokers excuse. In the case of the man who says he could be hit by a bus, the image that follows is of a man (of about the same age) in a darkened hospital room who says, weakly: I feel like Ive been run over by a truck. Two themes about the future are apparent in these quit-smoking campaigns. First, scenarios of a bleak future if the risky practice of smoking continues, juxtaposed with preferred (healthy, smoke-free) futures, imply a reductive causal link between risky present practice and a catastrophic future. Second, the message that health and future security will be assured with a cessation of the risky practice
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implies the body would be thus returned to a natural order of becoming thus allowing a continuous progression from past to future. Together these themes associate moral prudence, rational intelligence, and maturity with individuals who would live in an ideal world of zero risk. The problem with this paradigm of pre-emption is that instead of viewing a life-threatening event, disease, biotechnology, or practice as specific to context or type, its occurrence is generalised as prototypical of events threatening to health, physical security, and biological life of a population in all situations. (And underlying this tendency to generalise is that the events, practices and technologies deemed most risky and irresponsible are those that are seen to threaten economic security.) When combined with a general politics of fear, this way of thinking justifies a move away from harm minimisation policies toward control measures and technical solutions to health and physical security that aim to dampen the unpredictable aspects of the future, of bio-material life, and of human agency and to thereby predetermine a future of a nation, group, or individual that is continuous with the past. There are two problematic consequences of the pre-emption approach to physical security of most relevance here. First, risk theorists point to how the paradigm fosters conservative government in all senses.5 Not only is ensuring continuity of the future with the past counterrevolutionary by definition (Ewald 2002:284), but also the proliferation of imagined potential threats justifies totalising and paternalistic government characteristic of overmanaged democracy. Totalising government involves the increasing saturation of all spheres of life with regulatory complexes that enframe life in a way that delimits what is defined within the paradigm as risky practice and that, in combination with a moralism about particular forms of risk, discourages contestation of the status quo (including gover nment policy). This stifling of the unpredictable elements of human agency and material life can be blatantly anti-democratic (Hardt and Negri 2005): for example, antisedition measures as part of anti-terrorism legislation. But, more typically, this dampening
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of agency and dissent is subtle. As Foucault and others have shown (for example, Rabinow and Rose 2006), in governance of the health and security of the biological life of populations, disciplinary power joins forces with a political rationality of improving health and welfare authorising techno-scientific experts (including within government) to determine what the future self and healthy nation should look like and fostering compliance with health-prevention, security and surveillance measures. The second problem with the pre-emption approach is the suspicion that it decreases rather than ensures health and physical security. Not only is there the worry that dependence on the technoscience mobilised against perceived threats increases our vulnerability or may be ineffective,6 but also, some argue, strategic protection against incalculable threats fosters autoimmunity where a living being works to destroy its own protection (Derrida 2003:94). Pre-emptive warfare as an anti-terrorism measure is the most often cited example of how the logic of autoimmunity plays out in this paradigm, but overuse of antibiotics would be a comparable example in the biomedical field. I suggest, and go on to argue, that, in the context of the management of life-style illnesses, the stifling of agency (by prohibiting or discouraging par ticular practices or by circumventing democratic participation in solutions to health problems), as well as fostering a bleak and conservative orientation toward the future, contribute to the proliferation of those illnesses. The mobilising of the paradigm in some public health campaigns in Australia intensifies the nexus between medicine and science, on the one hand, and, on the other, a wider moral rhetoric about the proper future one should pre-empt for oneself and for the good of the nation (read economy). At the same time medicine is given a central place in a totalising government that places responsibility for both the health and security of the population on the shoulders of the individual and the family in the private sphere. It is a wider trend that demonises and infantilises particular groups in the population who fail to aspire to a specific preferred image of the future

self. In saying this I am expressly not positing a notion of individual rights and freedom against this trend (the co-constitutive relation between human bodies, bio-material life, and socio-political regimes of meaning, is too complex to posit such a simplistic counter-force to totalising government). Nor am I pointing the finger at health agencies and health workers involved in designing these campaigns: there is no telling from the consumers perspective how much these campaigns are shaped by government or advertising companies. Further, the pre-emptive paradigm operates as a general attitudinal atmosphere rather than being imposed by a single agency and is most often explicit in the soundbites of politicians (Federal and State) reported in the popular media rather than in the views of health practitioners. Nevertheless I do want to draw on two of philosophies of the body (biopolitics and phenomenology) to account for the impact of the wider pre-emptive paradigm on the health of human bodies. And, by formulating a model of both embodied agency and resistance to such to government of life, I want to indicate why such pre-emptive campaigns are unlikely to achieve their expressed aims.

Political technologies of bodies


Foucaults reformulation of the political in terms of disciplinary and biopower, and the link he makes between political power and technology, is helpful to account for the impact of pre-emptive mode of governance on human bodies, particularly the way it stifles the unpredictable elements of human agency and bio-material life. First, following Foucault and assuming the Aristotelean meaning of techne as skill or knowledge directed toward production, the political is technological by analogy. The target of both disciplinary (political) power and biotechnologies are bodies and both combine empirical and calculated methodologies of intervention with technical knowledge of bodies. Both are directed toward the production of particular sorts of bodies. Just as biotechnologies intervene into bodies at the muscular, neurological or molecular level to reorganise corporeal processes, disciplinary power operates at the
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micro-level of the bodys movements, spatiality, and temporal rhythms to realign the bodys forces and powers (Foucault 1979:136-8). It is this combination of the knowledge of bodies with disciplinary techniques that allows Foucault to deem regimes for the government of bodies political technologies of the body (Foucault 1979:26). Pre-emptive approaches to health and physical security are political technologies of the body in this sense. Moreover, unlike exercises in sovereign power, disciplinary modes of government operate with the same banality as technology in general, that is, without a single coordinating agent with sinister motives. Second, and conversely, bio-technologies are political insofar as they are mobilised within these disciplinary regimes and so participate in the reproduction of normalised, productive, compliant subjectivities that are compatible with a neo-liberal political economy. Technologies of the body (including cigarettes and other drugs) are political insofar as they are embedded within what Heidegger has called an instrumental way of thinking (or a way of enframing material life) (Heidegger 1977). Ways of thinking are paradigms involving a chiasmic relation between socio-political meaning, technical devices, and human beings and so reorder the world that produces them. Instrumental thinking however, orders the world in a par ticular way. Smokers use cigarettes instrumentally, for example, to mark time. Similarly, labouring, productive human bodies can become instruments of government and the economy. The pre-emptive paradigm of responding to threats to health and physical security treats human bodies in this instrumental way and, in so far as the paradigm is mobilised to discipline a population to aspire to reproduce a future continuous with the past, it involves political technologies that aim toward political and biological determinism. Foucault explains how this instrumental way of thinking and its disciplinary techniques impacts on the bio-material life of bodies:
Discipline increases the forces of the body (in economic terms of utility) and diminishes these same forces (in political terms of obedience). In short, it dissociates power from the body; on the one hand, it turns it into an aptitude, a capacity,
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which it seeks to increase; on the other hand, it reverses the course of the energy, the power that might result from it, and turns it into a relation of strict subjection (Foucault 1979:138).

But disciplinary power that renders bodies docile in this way does not exhaust, or even best characterise, the political dimension of biotechnologies. While these can be co-opted or rendered problematic in political paradigms intent on reproducing useful bodies with enhanced capacities and aptitudes, biotechnologies rarely aim at obedience or compliance. Rather, discourses surrounding biotechnologies (whether medicinal or recreational) would suggest that they aim at the enhancement of life for its own sake. Whatever else, scientifically speaking, a biotechnology does (stopping the course of pain or cell disintegration, or speeding up neurological events, metabolic rates, or whatever), it is more likely to disrupt the disciplined compliant body and reopen the bodys forces onto the realm of potentiality. In other words, biotechnologies (cigarettes, pain medication, food) along with anything or anyone that touches a human body (including visual images of public health campaigns and other mediums of socio-political meaning), participate in a re-temporalisation of the body with attendant effects and affects. The phenomenologist Maurice Merleau-Ponty explains the complex social, biological, and physical relations involved in the temporalisation of the body as follows:
[T]he life of consciousness cognitive life, the life of desire or perceptual life is subtended by an intentional arc which projects round about us our past, our future, our human setting, our physical, ideological and moral situation, or rather which results in us being situated in all these respects (Merleau-Ponty 1962:136).

This temporality of the body and its intentional arc (meaning-giving and receiving activity embedded in a world) is, for Merleau-Ponty, the ground of conditioned freedom where, through encounters with elements of the life world within a social horizon, I carry forward to an open future a collective history intermingled with experience of my personal history (Merleau-Ponty 1962:433).
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Others from the same philosophical tradition call this complex relation between the human body and its biological, environmental and meaningful situation, bios embodied human being that is at once historical but also opened (by encounters with a physical environment, biotechnologies, other persons etc.) to a undetermined future or potentiality (Arendt 1998:97, 200-1). Human being as bios is affective (involves pleasure and pain) in excess of habit and utility and it is intercorporeal, that is, directed toward, and intertwined with, things and other people. And bios is the condition of agency, the capacity to break with the past or to at least transform it (as distinct from zoe: mere life determined by biology alone and the forces of nature). And the futural paths that human being as bios takes and the impact of its acts are necessarily unpredictable. Smoking is a social practice that temporalises human being as bios in this way (as does eating, sexual activity, work, cleaning ones teeth, or any body ritual). The stubborn ordinariness of smoking, to coin Helen Keanes phrase, suggests that the smoker is not a passive victim of addiction to a substance that will inevitably ruin ones life (Keane 2006:107).7 Rather, smoking punctuates the passing of time with openings to a different future. People who do not smoke resort to other biotechnologies and rituals to temporalise the body. While such body rituals can become habit, as can any means of introducing duration into human existence, each repetition of the practice is marked by this pre-reflective intentional arc or opening of the body to an undetermined future. Conversely, it is the intentional arc that goes limp in illness (Merleau-Ponty 1962:136). Such are the pleasures and dangers of an intelligent, rational, and ordinary human life. While disciplinary power and compliance are features of the political dimension of biotechnologies, so is the undoing of disciplined forces and the attendant opening of new directions via the bodys temporality. Foucault describes this differently to Merleau-Ponty: in terms of the disruption and realignment of corporeal forces or emergence of the singularity of events from within the interstices of corporeal and social struggles with an attendant transformation of

meaning (Foucault 1994:376-8). However, in so far as biotechnologies are involved in this enhancement and temporalisation of life itself, they enter the second political register that Foucault claims attends disciplinary power in modern liberal democracies: biopower. Biopower refers to the idea that modernity is characterised by a bio-politics of the species body (as distinct from the individual body), which, alongside the government of anatomical bodies through disciplinary power, consists in interventions and regulatory controls that exercise the power to foster life or disallow it in the interests of maintaining, not so much individual bodies, but the biological existence of a population (Foucault 1980:137-139). Diversity of biological human existence is not the aim of biopower. On the contrary, biopower mobilises modes of governance and technologies of the body (including generalised technical solutions to health problems) aimed at achieving overall equilibrium in a population, an equilibrium that reassures with the promise of protecting the security of the whole from internal dangers (Foucault 2003:249). It is in this context that practices that are deemed to present internal dangers to health, physical and economic security, and national uniformity, particularly use of biotechnologies like drugs (recreational and illicit), become problematised under the paradigm of pre-emption. Taking into account the human bodys temporal dimension, the harm of political technologies of pre-emption (apart from any harm arising from the practices they seek to control) can be explained in terms of how measures aimed at limiting the unpredictable effects of human agency affect a closure of potentiality. Such a closure of an open future may aim toward producing compliant subjectivities whose aspirations are directed toward a particular preferred image of the future self, but such measures would also make us sick. That is, just as the potentiality of bios (or the intentional arc as Merleau-Ponty puts it) goes limp in illness, it also goes limp in subjection. Another way to put this is to say that governance of the health of bodies that pre-empts a future self that is continuous with the past participates in the reduction of bios (embodied human being open to potentiality) to zoe (bare biological life or
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nature).8 While the human body has a foot in both camps of zoe and bios, (in both biological life and the potentiality that is a condition of sociopolitical agency), reducing bios to zoe would return embodied human beings to biological destiny: a kind of uninterrupted progression of biological existence or immersion in the timeless present. Any appeals to a natural body as the proper determinant of culture (and therefore of the future self), that is, socio-political appeals to a future continuous with the past, in turn risks justifying ideological-political determinism on the basis of the assumption that elimination of what are now defined as risky or irresponsible practices will restore human bodies (and the nation) to biological destiny. This is a problem for democracy because ideological-political determinism is its most obvious adversary. But it is also a problem for the effectiveness of such public health campaigns. The overriding problem with the way the preemptive paradigm configures human agents, aside from ethical issues related to democratic pluralism and demonising sections of the population, is that such measures will meet with resistance from the bodies they target.

Resistance and ethics


It is widely acknowledged that Foucault, while recognising that human bodies resist disciplinary and biopower and any normalising techniques of government, did not elaborate how and why.9 There are two ways to think about how this resistance might arise. Or rather, there are two ways that we might understand how bodies transform regimes of control and regulation and thereby thwart paradigms of pre-emption mobilised in public health measures. The first is the idea that the same political technologies that aim to pre-empt the future health and security of human bodies (along with the biological and socio-political determinants of health), also participate in the constitution of consumer agency and, indeed individual agency in general. Kane Race has provided a compelling genealogical analysis of how this consumer agency works with and against modes of governance aimed
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at controlling the consumption of drugs (both medicinal and recreational) (Race 2005). On the one hand, he argues, the self-administration of drugs conforms to the rise of consumer citizenship in post WWII consumer cultures. Drug consumption also aligns with discourses of self-administration applicable to both patient compliance in medicine and notions of individual responsibility and selfgovernance in general. That is, self-administration of drugs is a practice consistent with disciplined, compliant subjectivity. On the other hand, this culture of the individual consumer, not surprisingly, has also given rise to experimentations in techniques of consumption and of self-formation, a kind of excessive conformity, as Race puts it, where restraint in consumption gives way to exercises in expressive, erotic, and experiential pleasure (Race 2005:2). This excessive consumption can take many forms shopping beyond need, risking ones savings on the stock market, smoking, or consumption of illicit drugs. Once ignited and trained, it is difficult to control consumer agency and direct it toward one externally designated end rather than others, even when attitudes about the moral status of particular consumption practices change over time. The inevitable disjunction between compliant, disciplined productivity that governments would prefer and excessive conformity, or what would be deemed risky and irresponsible practice, presents government with the problem of mediating between the two. Rather than harm minimisation strategies, which would arguably be a more effective (and certainly a more democratic) way of dealing with the potential risks of consumer agency in general, a government that finds more comfort in a conservative recreational state (Race 2005:9) tends to resort to a paradigm of pre-emption that I have been discussing. Managing excessive conformity through a paradigm of pre-emption involves what Race calls exemplary power:
[Exemplary power] relies on high profile media and police presence, making certain practices of cultural consumption a bad example. The sample and moral example [e.g. of a future self] are its favorite tools, the sample claiming to measure objectively the extent to which an individual has complied with medico-moral regimes making a

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biochemical example of the propriety of individual behaviour. Exemplary power marks the bounds of legitimate consumer citizenship by declaring a stop to (what it designates as) non-medical activity. It is haunted by the memory of a discipline at once paternalistic and protective, which it seeks to supplant by installing as its vision of control a medico-moral imagery of the self (Race 2005:10).

Extending Races analysis to include consideration of the bodys temporality, we can suggest that, because government by medicomoral example appeals to the same regimes of self-administration and consumer agency that it seeks to dampen, its examples appear on a stage of choices of possible futures that are no more or less compelling than those the consumer is already living. In this game of presenting a range of possible futures, the ones that would be most convincing are those within the individuals past and present experience. The smoker in the excuses advertisement could indeed be run over by a bus tomorrow, as he claims, and there is nothing to suggest that the alternative future with which we are presented is any more probable (he could be in hospital with some life-threatening smoking-related condition that would make him feel like hes been hit by a truck). A second way to explain how human bodies thwart the pre-emptive paradigm is consistent with the first but relies more centrally on the phenomenological view of the temporality of the embodied self discussed earlier. Like Races idea of excessive conformity, this account does not appeal to an original freedom or a self uncontaminated by biological, social, or governmental determinants of health. Rather, on this model, a key precondition of both health and agency (personal, social, and political) is a body open to potentiality, that is, a body inclined toward encounters with others, and with its physical and social environment, encounters that, in concert with the bodys temporality, keep open an undetermined future. It is impossible to completely suppress this potentiality. It certainly cannot be suppressed by projecting a threatening future or an ideal future that are unrelated to a persons current or past experience. Or as Merleau-Ponty (1962) puts it, however sick or subjected a body is, it never loses

its futural orientation toward its material, social, and meaningful world and the unpredictability this implies. Unless it is dead. A body subjected to paternalistic, infantilising, totalising modes of governance will try to emerge from the sense of timelessness that such governance can effect and re-orientate itself toward an undetermined future. It will do this by reaching for material at hand, most likely what has worked before to punctuate time. It might be a cigarette. The question that some biotechnologies and the corporeal, temporal basis of unpredictable human agency raise, then, in the context of the spread of biopolitical and totalising government, is which kind of approach to governance of the future of human life is preferable: that which fosters democratic pluralism and participation of people in their own health solutions or government by preemption based on faith in someone elses image of the biological destiny of a nation. What the analysis above suggests is that strategies of harm minimisation or health promotion that also cultivate the political agency (and hence potentiality) of members of the community being targeted would be more ethical and more effective. Harm minimisation programs may contain some elements of the pre-emptive paradigm: they usually assume, for example, some causal link between particular practices (smoking, consumption of illicit drugs) and ill health. But they also allow that the causal link between a practice and future (well- or unwell) being is dependent on a range of factors; that the relationships between a person, their habits, the material world, and other persons are open and indeterminate; and, as a consequence, that it is impractical (if not unethical) to exclude the person from participation in their health solutions. Further, by emphasising education and by considering health to be a communal and a personal matter, harm minimisation programs tend not to treat their subjects like irrational deviants. Scare campaigns that demonise parts of the population in terms of health and that resort to moral rhetoric about the failure of individuals to live up to someone elses imagined future are counter-productive to the promotion of well-being and are no more than pseudo-scientific solutions to incalculable risk that are badly formulated (Stengers 1997:217).
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There are examples of the more viable alternative approach to public health already available in Australia. These include harm minimisation approaches to heroin addiction operating in Sydney the 1990s and, in the same era, some of the grass roots approaches to safe sex and HIV-AIDS prevention operating in gay communities (as opposed to the grim reaper TV advertising campaign of 1987). The former Federal Minister for Health, Tony Abbot announced (in February 2007) a ten million dollar budget to counter the 40% increase in reporting of new HIVAIDS infections since 2000.10 One remains hopeful that the pre-emption paradigm does not swallow up that budget. Government would do well to listen to health workers working with gay communities who are warning against general scare campaigns (like the grim reaper ad) and who are urging that the money be spent within those communities most at risk, that it be used in educating a new generation of gay men who, like all youth, tend to think that they are immortal, and whose friends have not yet died of the disease, and that any such education and harm minimisation measures treat those men with respect (see Rier 2007.) Respect involves treating members of target groups of public health campaigns as agents with more than a passing stake in re-imagining their specific futures and in deciding what works for them in orientating themselves toward an undetermined, incalculable future per se.

Endnotes
1. While Ewald is usually credited with first outlining, in retrospect, this paradigm shift, it was foreshadowed earlier by others such as Luhmann (1993) and Beck (1999). 2. The way I outline the paradigm in the first two pages of this paper is adapted from a collaborative research project undertaken with colleagues at the University of New South Wales and the University of Sydney (see Diprose et al 2008). 3. For similar arguments see, for example, Collier et al (2004:5), Derrida (2003), and Nowotny (2006:4). 4. The excuses adver tisement and similar advertisements could be viewed online at http:// www.health.nsw.gov.au/cancer_inst/campaigns/

media/ until the end of 2007. They have since been removed from websites of both the NSW Department of Health and the Cancer Institute NSW. 5. See, for example, Collier and Lakoff (2005); Ewald (2002); Hardt and Negri (2005), and Nowotny (2006). 6. For a general analysis along these lines see Foucault (2001) and, with special regard to biosecurity and biowarfare, see Cooper (2006). 7. Helen Keane has provided a provocative and compelling account of the relation between smoking and time (2006). While drawing on different conceptual resources to that in this account, one of Keanes salient points is similar: that smoking is a complex practice that temporalises the body beyond the extended present rather than simply the act of a passive body at the mercy of biological forces. 8. Georgio Agamben argues, following Foucault but with reference to Arendt, that the spread of biopower is characterised by this collapse of the classical distinction between zoe and bios where zoe is included in the polis as bare life, the subjected target of political power (1998:1-14). 9. Maurizio Lazzarato has provided a useful account of how a model of resistance to normalisation can be derived from Foucaults work (Lazzarato 2002). 10. The causes of this increase are complex. Significantly, there has been no increase in rates of infection in Sydney since 2002, and it is in Sydney that harm minimisation strategies have had the highest profile. Research suggests that the increase in the number of HIV-AIDS infections elsewhere may in part be due to the availability of treatments that, while unpleasant and problematic, nevertheless give the impression of relative safety leading to some complacency (Van de Ven et al 2002).

References
Agamben, G. (1998) Homo Sacer: Sovereign Power and Bare Life (trans. Heller-Roazen, D.) Stanford University Press: Stanford CA. Arendt, H. (1998) The Human Condition Canovan, M. (intro) University of Chicago Press: Chicago IL. Beck, U. (1992) Risk Society: Towards a New Modernity (trans. and intro by Lash, S. and Wynne, B.) Sage: London. Volume 17, Issue 2, August 2008

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Rosalyn Diprose Beck, U. (1999) World Risk Society Polity: Cambridge. Collier, S. and Lakoff, A. (2005) On regimes of living in Ong, A. and Collier, S. (eds) Global Assemblages: Technology, Politics, and Ethics as Anthropological Problems Blackwell: Malden MA and Oxford. Collier, S.J. and Lakoff, A. (2008) Distributed preparedness: The spatial logic of domestic security in the United States Environment and Planning D: Society and Space 26(1):728. Collier, S.; Lakoff, A. and Rabinow, P (2004) . Biosecurity: Proposal for an anthropology of the contemporary Anthropology Today 20(5):3-7. Cooper, M. (2006) Pre-empting emergence: The biological-turn in the war on terror Theory, Culture, and Society 23(4):113-135. Derrida, J. (2003) Autoimmunity: Real and symbolic suicides in Borradori, G. Philosophy in a Time of Terror: Dialogues with Jgen Habermas and Jacques Derrida University of Chicago Press: Chicago IL, pp.85-136. Diprose, R.; Stephenson, N.; Hawkins, G.; Mills, C. and Race, K. (2008) Governing the future: Political technologies of risk management Security Dialogue 39(2):267-288. Ewald, F. (2002) The return of Descartes malicious demon: An outline of a philosophy of precaution (trans. Utz, S.) in Baker, T. and Simon, J. (eds) Embracing Risk: The Changing Culture of Insurance and Responsibility University of Chicago Press: Chicago, IL, pp.221-228. Foucault, M. (1979) Discipline and Punish: The Birth of a Prison (trans. Sheridan, A.) Penguin: Harmondsworth. Foucault, M. (1980) The History of Sexuality: Volume 1 (trans. Hurley, R.) Vintage Books: New York. Foucault, M. (1994) Nietzsche, genealogy, history in Faubion, J. (ed) Essential Works of Michel Foucault 1954-1984, Volume 2: Aesthetics, Method, and Epistemology Penguin: London, pp.326-349. Foucault, M. (2001) Security and dependence: A diabolical pair (1983) in Faubion, J. (ed) Power: Essential Works of Foucault 1954-1984 Volume 3: Power Penguin: London, pp.365381. Foucault, M. (2003) Society Must be Defended: Lectures at the Collge de France 1975-76 (trans. Macey, D.) Bertani, M. and Fontana, A. (eds) Picador: New York. Hardt, M. and Negri, A. (2005) Multitude: War and Democracy in the Age of Empire Penguin: London. Heidegger, M. (1977) The question concerning technology (trans. Lovitt, W.) The Question Concerning Technology and Other Essays Harper and Row: New York. Keane, H. (2006) Time and the female smoker in McMahon, E. and Olubas, B. (eds) Women Making Time: Contemporary Feminist Critique and Cultural Analysis University of Western Australia Press: Perth, pp.94-115. Lazzarato, M. (2002) From biopower to biopolitics (trans. Ramirez, I.) Pli: The Warwick Journal of Philosophy 13:100-111. Luhmann, N. (1993) Risk: A Sociological Theory Aldine de Gruyter Press: New York. Merleau-Ponty, M. (1962) Phenomenology of Perception (trans. Smith, C.) Routledge and Kegan Paul: London. Nowotny, H. (2006) The quest for innovation and cultures of technology in Nowotny, H. (ed) Cultures of Technology and the Quest for Innovation Berghahn Books: New York and Oxford, pp.1-23. Rabinow, P (2003) Anthropos Today: Reflections . on Modern Equipment Princeton University Press: Princeton NJ. Rabinow, P and Rose, N. (2006) Biopower today . Biosocieties 1:195-217. Race, K. (2005) Recreational states: Drugs and the sovereignty of consumption Culture Machine 7 available at http:// culturemachine.tees.ac.uk/frm_f1.htm Rier, D. (2007) The impact of moral suasion on Internet HIV/AIDS support groups: Evidence from a discussion of seropositivity disclosure ethics Health Sociology Review 16(3-4):237-247. Stengers, I. and Gille, O. (1997) Drugs: Ethical choice or moral consensus (trans. Bains, P in .) Stengers, I (ed) Power and Invention: Situating Science University of Minnesota Press: Minneapolis MN and London, pp.215-232. Van de Ven, P Rawstorne, P Crawford, J. and .; .; Kippax, S. (2002) Increasing proportions of Australian gay and homosexually active men engage in unprotected anal intercourse with regular and casual partners AIDS Care 14(3):335-341. Volume 17, Issue 2, August 2008

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The challenge of pleasure: Re-imagining sexuality and sexual health


ABSTRACT
Men have a stake in ending gendered violence but this stake has not yet been widely embraced by men. Thus we must think carefully about our future strategic directions. Taking the case of sexual violence, I suggest that these directions involve re-thinking sexuality and sexual health by considering absences in the scholarly and policy literatures. While young people are constantly exhorted in popular media to be sexual and to undertake sex, young men have not been engaged by critical analyses of sexuality. The critical literatureswhich include writings in Gender/Sexuality studies and Preventive Healthaim to offer alternative understandings of heterosexuality which move beyond the imperatives of the popular media. Yet such critical approaches remain undeveloped, largely negative and/or focussed upon danger rather than considering heterosexuality in positive terms that might offer a substantive alternative and encourage young men in particular to embrace the aim of egalitarian sexual practices, including ending sexual violence. Tensions in Gender/Sexuality scholarship, and Preventive Health sex education materials which draw upon that scholarship, produce significant absences with regard to analysis of heterosexuality and heterosexual subjects. In this context, existing research indicates that recognition of pleasure in sexual health has resulted in increased use of condoms by men and greater involvement of women in the negotiation of sexual practices. Such research is not just relevant to prevention of disease, but has implications for strategies regarding sexual violence. Re-imagining the theoretical framing of Gender/ Sexuality studies and Preventative Health to take account of pleasure in sexuality and sexual health is not just a theoretical issue but has some very practical implications.
Received 1 May 2008 Accepted 23 May 2008

KEY WORDS Sociology, pleasure, heterosexuality, sex education, gender, masculinity

Chris Beasley
School of History and Politics University of Adelaide Australia

Introduction

he paper begins with the question of developing effective strategies in relation to sexual violence and argues that such strategies require a re-thinking of sexuality and sexual health, a re-thinking which attends to significant existing absences in the scholarly and policy literatures. In par ticular I assert a requirement to re-imagine the theoretical framing
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of both Gender/Sexuality studies and Preventive Health in the arena of sexuality. Attention to the former is associated with its influential input into the latter. In discussing strategies with regard to sexual violence, my intention is to take up the work of Masculinity studies scholars such as Michael Kaufman and Michael Kimmel, who insist that men along with women have a stake in ending violence, including sexual violence (Kaufman 2001; Kimmel, Interview). While I agree with Kaufman and Kimmel that theoretically men may well have a stake in ending violence, including sexual violence, this stake has not yet been widely and actively embraced by men. Thus I consider
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we must think carefully about our future strategic directions for scholarship, activism and public policy. My concern is that existing cultural discourses do not provide much that might encourage mens theoretical stake in ending sexual violence to be actualised in everyday life. I suggest that while young people are constantly exhorted in popular media to be sexual and to undertake sex, young men have not been engaged by critical voices (scholarly or policy literatures) attending to sexuality. These critical voices which include writings arising from Gender/Sexuality studies, and from the Preventive Health field such as sex education policy materials aim to offer alternative understandings of heterosexuality and masculine sexuality to those which are on offer in the popular media. Yet such critical approaches remain undeveloped, largely negative and/or focussed upon danger/risk rather than considering heterosexuality in terms that might encourage young men in particular to be inspired by the possibilities of egalitarian sexual practices and embrace the aim of ending sexual violence. My aim is to develop this overall analysis by outlining four interconnected arguments: 1. The Foucauldian thesis regarding the modern proliferation of sexualised discourses may well require qualification in relation to critical noncommercial voices arising from Gender/ Sexuality studies and Preventive Health. 2. The Gender/Sexuality field involves approaches which inform Preventive Health with regard to sexual health. Yet this field contains (a) heterogeneous trajectories which have had the effect of (b) leaving heterosexuality stuck in the mire of the old sex wars debates, such that it remains almost exclusively aligned with the second-wave Modernist sex-as-danger camp of the sex wars debates. 3. Preventive Health agendas attending to sexuality in particular, sex education in schools draw upon these Gender/Sexuality writings. Despite certain elements of the prosex approach, the crucial focus on prevention/ pre-emption of danger and risk within Preventive Health (including sex education) also predisposes it to fall back upon the

primarily negative sex-as-danger orientation with regard to heterosexuality. 4. The critical non-commercial voices which are the focus of this paper far from proliferating sexualised discourses are not able to attend to hetero-pleasure. Yet, existing research indicates that recognition of pleasure in sexual health education results in increased negotiation of sexual practices. This has ramifications for the theoretical framing of noncommercial voices dealing with sexuality and, in particular, for their anti-violence strategies.

The Foucauldian thesis and its potential limits


Foucault challenges what he called the repression hypothesis, the hypothesis which for example Freud outlined in describing social relations as founded upon the repression of sexuality (Foucault 1981). By contrast, Foucault asser ts that discourses about sexuality have proliferated and have in the process created new norms of behaviour: he describes this in terms of an economic exploitation of eroticisation. We are told we must behave in certain ways. Now we must be sexual. These new sexual norms, in Foucaults terms, come to discipline us, such that we find a new mode of investment no longer in the form of control by repression but that of control by stimulation (Foucault 1980:57; Rubin 2005).1 It would seem at first sight that Foucaults approach is self-evident: the modern world does appear to be saturated in (hetero)sex. A sexual freedom consisting of insistent cultural exhortations to engage in heterosex appears omnipresent in our modern society. And yet, I am not so sure this is the whole picture. On the one hand, I too have a sense that we are all and perhaps young people in particular constantly bombarded with images of sexual identity by a range of cultural forms. This bombardment amounts to provision of sexual education by privatised commercialised sources with sexuality presented in terms of material consumption. Such sources say in essence, Buy this, be sexy. On the other hand, I have a sense of missed opportunity in relation to the possibilities offered by non-commercial voices regarding sexuality.
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Commercial and non-commercial representations of sexuality are by no means entirely dichotomous arenas. Commercial popular media may provide socially critical perspectives and, as Kickbusch (2006) notes, health policy discussions are not isolated from market forces. The distinction between popular commercial and critical non-commercial arenas is not straightforward and requires further analysis beyond the scope of this paper. Nevertheless, there are discernable and important differences between themat least in relation to sexuality which can provide opportunities and spaces for enhancing diversity in views and practices, including resistance to the hegemony of commercialisation. In this context, mainstream popular cultural discourses are not explicitly shaped, in the way that Gender/Sexuality and Preventive Health writings on sexuality presently are, by socially critical agendas in relation to heterosexuality and masculinity. Yet, despite these agendas, non-commercial voices regarding sexuality seem to me to be offering a decidedly limited alternative to the constant bombardment of sexual imagery from privatised commercial sources. I suggest in particular that there is a significant gap between the cacophony of popular commercial voices about (hetero)sexuality and the comparatively silent and largely negative critical voices in Gender/Sexuality studies and Preventive Health sex education materials that might be expected to provide a counter-point. Gender/ Sexuality writings and Sexual Health literature, by contrast with the popular media, largely do not attend to hetero-pleasure; they neither proliferate (hetero)sexual discourses in terms of the demand to be sexual nor do they proliferate such sexual discourses in terms of a demand that we not be sexual. Rather heterosex remains unspoken for the most part and, when meagrely acknowledged, is simply cast as a problem. This scarcely fits with Foucaults account of a mode of eroticisation and control by stimulation. Instead the gap between commercial and non-commercial modes leaves heterosexual pleasure to privatised voices and effectively abandons a strategy for alternative visions and social change.
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If I am correct about this mismatch between commercial monopoly over heterosexual pleasure as against the paucity and comparatively bare and negative framing of non-commercial voices (both scholarly and policy), then this suggests we may need to re-assess the scope of Foucauldian claims regarding the proliferating expansion of sexualising discourses in modernity. The Foucauldian challenge to the repression hypothesis may at least require some qualification when we consider these non-commercial spaces and publics. Noncommercial discursive spaces may well not offer the same sexualising norms and sexualised identities. In short, the Foucauldian sexualisation thesis (Seidman 1991:67,123) may underestimate the unevenness of the social in modernity.2 To suggest that non-commercial voices might differ somewhat from the proliferation of sexualised discourses in popular media is to suggest that these non-commercial discourses are perhaps maintaining a more repressive treatment of sexuality, which in my view has implications for the way they address and their capacity to address sexual violence. Non-commercial voices regarding sexuality may not be taking up the challenge of providing alternative, potentially more reflective perspectives that move beyond the limits of medicalised discourses and genuinely embrace a more holistic treatment of bodies and desires. I suggest that insofar as these noncommercial voices offer a limited challenge to the increasingly prevalent discourse of sexuality as consumption, they do young people a disfavour, effectively giving them little purchase on the diverse possibilities of fashioning their own sexuality and sexual citizenship. In this setting, reimagining the theoretical framing of Gender/ Sexuality studies and Preventive Health in the arena of sexuality is not just a theoretical issue but has some very practical implications.

Heterogeneous trajectories in the Gender/Sexuality field


The Gender/Sexuality field involves socially critical and theoretically sophisticated approaches which flow into and inform the limits of Preventive Health approaches with regard to sexuality. However, the Gender/Sexuality field (which is a crucial source
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for alternative understandings of masculine sexuality and anti-violence agendas) contains disparate sub-fieldsimportantly, the three major sub-fields of Feminist, Sexuality and Masculinity Studieswith distinguishable trajectories. Tensions between heterogeneous trajectories in the Gender/Sexuality field then impact upon analyses of heterosexuality. I suggest in other works that the three subfields of Feminist, Sexuality and Masculinity Studies are not simply commensurable bits that fit together neatly like pieces of a jigsaw. The subfields contain differing knowledge cultures involving (amongst other things) different theoretical underpinnings and emphases (Beasley 2005; Beasley forthcoming). On this basis I argue that, since the 1960s/70s, the subfields have aligned in shifting ways, and that this is particularly evident in relation to sexuality. Initially Feminist and Masculinity Studies developed closely linked Modernist theoretical paradigms under the rubric of the term gender. However, with the rise of Postmodern approaches Feminism and Sexuality Studies have moved closer to one another in terms of overarching theoretical frameworks. By contrast, Masculinity Studies has increasingly appeared as the odd man out. If the scholarly subfield which is particularly focused on men and masculinity is at something of a distance from other major subfields in the Gender/Sexuality field, this may signal a problem in the context of developing theoretical frameworks and strategies intended to involve men in ending sexual violence. In brief I would note two points in support of my claims regarding these developments. Whereas Butlers work has become a cornerstone of both Feminist and Sexuality Studies theoretical frameworks,3 major gate-keeper theoreticians in Masculinity Studies such as Connell remain rather resolutely Modernist and highly skeptical concerning Postmodern agendas and Butlers work (Connell 2005:xix, 2002:71, 2000:20-1). Secondly, theorising in both Feminist and Sexuality Studies now largely take as given that gender and sexuality cannot be reduced to one another: a Postmodern perspective strongly associated with Queer Theory (see Richardson 2001). Writings in both Feminist and Sexuality

Studies for the most part nowadays do not presume that gender produces sexuality.4 Feminist and Sexuality Studies do not presume that men as a group have a specific and different sexuality from that of women as a group. In contrast, Masculinity Studies thinkers remain aligned with (second-wave) Modernist views which presume that gender does effectively determine sexuality. Michael Kimmel, for example, supports the claim that heterosexual men and gay men are largely alike in terms of their sexuality (Kimmel 2005:1621; Kimmel and Plante 2004:xiv). He approves the statement that straight men might have as much sex as gay men, if women would only let them (Kimmel 2005:74). Such a view may be said to reduce sexuality to gender in that men as a gender group are said to have a particular sexuality and women to have another kind of sexuality. Such a view is decidedly at odds with Postmodern and Queer critiques which reject prioritising gender over sexuality and resist stable distinct gender identity categories. The point here is that the different trajectories of Feminist, Sexuality and Masculinity Studies have shifted in relation to their differential uptake of Postmodern perspectives. Whereas Feminist and Sexuality Studies have taken up Postmodernism with enthusiasm, in Masculinity Studies this is much less evident. This differential uptake has particular resonance around sexuality and sexual violence. It became explicit in the 1980s so-called sex wars.

Feminist/Sexuality/Masculinity studies and the sex wars


Feminist and Masculinity Studies literaturesthat is, Gender Studies literatureshave been in an ongoing conversation with Sexuality Studies writings. A crucial theme in this conversation may be summarised as the pleasure and danger sex wars. The sex wars amounted to a debate between on the one side Modernist radical Feminist (Gender studies) thinkers like Catherine Mackinnon, Andrea Dworkin, Susan Griffen and Mary Daly, amongst many others, talking about sex as danger in the 1970s/80s, and on the other side the growing influence from the late 1980s/ 1990s of Postmodern thinkers associated with
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Sexuality Studies, talking usually from a Foucauldian and Queer Theory perspective about sex as pleasure: the pro-sex position. In short, the sex-as-danger stance became aligned with Modernist thinking and the pro-sex stance with Postmodern thought. Modernist radical feminist writers such as Catherine Mackinnon and Andrea Dworkin in the 1970s/80s drew attention to the ways in which sexuality was socially constructed along gendered lines to uphold mens social dominance. They noted the links between normative heterosexuality and displays of mens power over women such as rape, and were rather courageously critical of penis-centred conceptions of sexuality. They were consequently inclined to depict women as a group as vulnerable and men as a group as predatory. Such a perspective dovetailed with womencentred radical feminist viewpoints such as those of Adrienne Rich and Mary Daly which gained considerable force in the 1980s. In these forms of radical feminism men and women were categorically divided. The emphasis was on gendered power and in this context mens sexual power over women. The Modernist radical feminist approach was, in short, focussed on the danger of heterosex, and the evils of prostitution, pornography and rape. In brief, in this account men were all hegemonically abusive (Heise 1997:423). Though they had access to pleasure, it was nasty oppressive sexual fun. Lesbians, by contrast, engaged in gentle womanly forms of sexual pleasure. Heterosexual women, owing to foolishly consorting with men, appeared predominately as passive victims who had no fun at all (Kanneh 1996:173). Importantly, this sex as danger position remains the most common viewpoint in Masculinity Studies today sincealong with feminist work on violenceit remains one of the last bastions of support for Modernist radical feminist agendas. However, such a position increasingly came under fire from the 1980s onwards and reached a head at a conference at Barnard College, NY, in 1982 titled Pleasure and Danger. At this conference a so-called pro-sex position was put forward which rejected that all women were as one, that all women had the same
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sexuality, and that all women liked gentle vanilla sex (Echols 1983, 1984; Rubin 1994; Califia 1996; Sullivan 1997; Epstein and Renold 2005). The pro-sex stance was increasingly critical of Feminism which was cast as mumsy and sexually repressive (Beasley 2005:158-170). The pro-sex position set itself in opposition to radical feminism in particular and was strongly associated with the rise of Foucauldian Sexuality Studies and Queer theory developed by theorists like Judith Butler, Gayle Rubin and Steven Seidman. Sex in this approach was precisely about embracing danger, power and even consensual violence. The pro-sex position was however primarily, even almost exclusively about queer sexualities. In the related literature on sexual citizenship, the focus remained firmly on queer minorities, particularly gay men (Bell and Binnie 2000; Evans 1993). In such pro-sex theorising, queer minorities were discriminated against, but at least they now all had access to sexual pleasure. Heterosexual men were still sexual and still nasty. Heterosexual women largely disappeared from sight (Beasley 2005:122-3; Jackson 1999:13-15). The upshot of theoretical tensions and shifts in the Gender/Sexuality field expressed in the sex wars debates is that heterosexuality is simply rarely examined nowadays in Gender/Sexuality studies writings. There are, for example, very few current (post 1998) books on heterosexuality.5 Heterosexuality is largely taken to be of little critical interest, as simply to be equated with heteronormativity, and remains mired in the old sex wars divide.6 In that debate heterosexuality is cast by the sex as danger perspective as immured in gendered inequality with an emphasis on its nasty and normative features. More recently, the combined Feminist/Queer pro-sex perspective has become prevalent in analyses of sexuality, but in this approach queer becomes the site of subversive, transgressive, exciting and pleasurable sex, while heterosex continues to be locked into its earlier constitution as problematic. Insofar as heterosex is mentioned at all in such pro-sex theorising, the emphasis only shifts somewhat from nasty and normative to its boring and normative features. These existing accounts of heterosex as either primarily nasty or boring,
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but in any case normatively exclusionary, do not provide much room for manoeuvre. In essence, critical scholarly voices in the Gender/Sexuality field have almost frozen and remain largely undeveloped regarding heterosexuality. To the extent that it is discussed, these voices effectively confine heterosexuality to the abandoned backblocks of theoretical history by leaving it stuck in the predominately negative sex-as-danger camp. For example, it is almost impossible to find any account of heterosexual mens pleasure in Masculinity Studies that does not presume desire=damage. Only gay mens desire involves permissible pleasure. Similarly, if we look at International Studies writings attending to sexuality it would seem that predatory penises and vulnerable vulvas abound (Peterson and Runyan 1999; Bayliss and Smith 2001; Tickner 1992, 2001). More specifically, most of the limited debate on sexuality in a global context has been fashioned by themes of trafficking, slavery and rape in war, themes largely dominated by gendered representations of male victimisers and feminine victims (Sabo 2005; Re-public: reimagining democracy 2008; Womens Worlds Congress 2008). Such themes are unquestionably crucially significant. However, I do want to challenge heterosexualitys comparative absence in contemporary Gender/Sexuality thinking and challenge its continuing restrictive constitution as unremitting cruelty and pain in the service of oppressive normativity. Heterosexuality is a majority orientation but, relative to other sexualities, is under-theorised as a potential source of pleasure, interest and transgression, and over-determined as a source of domination.7 Such a stance offers little in the way of strategic directions for positively engaging young men in the development of an egalitarian heterosexuality. This failure regarding strategies relevant to young men is perhaps particularly ironic in the case of Masculinity Studies.8 It is here that the intriguing status of Masculinity Studies as the odd man out in Gender/Sexuality thinkingas at a distance from the now more thoroughly pro-sex agendas of Feminist and Sexuality frameworkscomes home to roost,

since Masculinity Studies general advocacy of a sex-as-danger stance has implications for its capacity to re-conceptualise heterosexuality and sexual violence strategies. The problematic analysis of heterosexuality in Gender/Sexuality theorising reoccurs in odd ways in the Preventive Health field and thus in sex education materials.

Preventive health, sexual health


Preventive health has constituted itself as a field of thinking which moves beyond the narrowly instrumentalist medical model of health emphasising disease and illness, and the rationalist scientific calculation of the body as in need of fixing or management. This medical model focuses on what is awry and how the mutinous body can be brought to heel. It is a model in which doctors save us from the failings of our bodies. Preventive health asserts its difference from this negative framing of our embodiment by emphasising a more holistic engagement with the body, by attempting to expand the meaning of the field of health beyond what is wrong with the body (cf: The Medical Institute for Sexual Health). The way in which the more expansive Preventive Health theoretical framework is expressed in sexual health is evident in the definition of the World Health Organization (WHO 2002). This definition states:
... [s]exual health is a state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.

In the Preventive Health framework sexual health not only has physical and mental aspects, but is also defined within a social framework. Sexual health is further defined in an affirmative way, stressing well-being and not just stating the absence of negative qualities. In other words, there are important links here with the pleasure oriented
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pro-sex position I outlined in the sex wars debate previously. This association is evident in the WHO definition of sexuality:
... [s]exuality is a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviours, practices, roles and relationships.

WHOs definitions of sexual health and sexuality have a utopian cast. Given the worldwide prevalence of heteronormative sexual prejudice, most, if not all, sexual minorities face discrimination. Moreover, phenomena such as sexual violence and sex-trafficking, and also more generally the construction of women as sexually passive, form serious limitations to the sexual health of women. The Preventive Health framing of sexual health as defined by the WHO may be seen as offering a worthwhile goal to aim for, rather than a representation of most peoples current condition. However, what it indicates is an expansive account of the field of health exceeding any medicalised model: sexual health within this Preventive Health framing is construed as a prerequisite for peoples (sexual) quality of life and as linked to conceptions of (sexual) justice and full citizenship. Yet while Preventive Health sometimes has a rhetorically expansive pro-sex framing, it frequently fails to live up to its promise, often falling back into more traditional models of health. This is because Preventive Health as a field at least in relation to sexuality draws upon a dual legacy: the influence of Gender/Sexuality theorising (evident in its attention to gender/ sexuality justice) and a concern with health as management of risk. Broom (2007, 2008) and Diprose (2007,2008) amongst others, have outlined and problematised the crucial focus on prevention/pre-emption of danger and risk within Preventive Health.9 However, such a focus in Preventive Health, when associated with sexual health, induces a predisposition to fall back upon the primarily negative sex-as-danger orientation with regard to heterosexuality. In many, if not most, accounts of sexual health the sex-as-danger
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feminist position I discussed earlier is reborn as populations and individuals being exposed to health risk. More affirmative and expansive accounts of (hetero)sexuality, which enable consideration of hetero-pleasure, become sidelined. Sexual Health becomes aligned with danger and risk with regard to sexuality in the first instance by lapsing into an instrumental medicalised account of sexuality, reinforcing a focus on sexual problems conceived in biomedical terms. For an example of this, consider the first World Congress for Sexual Health in April 2007, with a classic Preventive Health conference theme of Achieving Health, Pleasure and Respect. The main topics were as follows: Sexual Health, Basic Science on Sexual Function, Desire Disorders, Arousal Disorders, Orgasm Disorders, Sexual Pain Disorders, Sexually Transmitted Infections, Cultural Studies on Sexuality, Sexuality Education, Endocrine Disorders, Gender Dysphoria, Sexual Paraphilias, Sexual Violence, Issues in Reproductive Health, Sexuality in Special Populations, Studies in Human Sexuality, Sexual Orientation, Ethics. This rather grim and decidedly medical looking list contains rather a lot of disorders, infections and dysfunctions [www.sexsydney-2007.com/callabstracts.htm]. The list reveals the tendency in Preventive Health to discard its more expansive claims in favour of returning to medical management. Secondly, even when Preventive health models of sexuality do not lapse into miserable medicalisation, more socialised versions of risk frequently still dominate. For example, in the 4th Edition of The Puberty Book (Darvill and Powell 2007:127) a book recommended by a doyen of Preventive Health in the arena of sexuality, Family Planning Australia, in answer to the question can sex be fun? the answer is:
Sex can be lots of fun it depends on the circumstances. If both partners want to have sex together and are protected against unwanted pregnancy or catching an STI, it is more likely to be enjoyable.

A pro-sex agenda quickly becomes, avoid pregnancy and dont get STIs. Tellingly the clitoris
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gets four lines in this book, while vaginas get over 20. This is, I should add, one of the better Australian books for adolescents. Non-consensual heterosexual sex and sexual violence is undoubtedly a world-wide concern. For example the Australian Study of Health and Relationships (ASHR 2003) and the National Survey of Australian Secondary Students (NSASS 2003) both show a significant pattern of forced sexual activity (Combes and Hinton 2005). The first study showed 21% of women in the broad population and the second indicated 26% of 15 17 year old secondary students repor ted unwanted sex. The latter study showed 13% of secondary students reporting unwanted sex under pressure from their partner. In this context, as Kimmel notes, it is evident that rape, for instance, is not perpetrated by a lunatic fringe but rather is a crime marked by its ordinariness (2005:189). Relatedly, there is research evidence from a range of locations that young men face considerable peer pressure from other young men to engage in heterosex (Schubotz et al 2004). Yet sex education is not compulsory in Australian schools and there is no nationallyconsistent curriculum for teaching teenagers about relationships or sexual and reproductive health. This is not a problem in Australia alone. Furthermore, most sexual health education programmes remain restrictively focussed upon biomedical information. As the 2003 Australian Study of Health and Relationshipsthe largest and most comprehensive survey of sexuality undertaken in the countryhas revealed, sex education in schools gained top marks from young people in terms of learning about technical mechanics, but apparently gave little clue about the interactive including pleasurable aspects of the enterprise (Powell 2007; ARCSHS 2003). SHine SA (Sexual Health Information Networking and Education), a sexual health agency in South Australia, also reports that 80% of young people regard sex education in schools as useless or fairly useless [sexual_health_statistics_2008.pdf]. Similarly, a joint report to the British government on sexual health in 2005, fuelled by the risk of teenage pregnancy rates, stated that sex education in schools provides basic factual biological

information but beyond that was extremely limited and even confused (Campbell 2005). Sex education of even this meager sort is of course under threat in the USA (Irvine 2000). However, perhaps an even more important limitation of sex education programs is the insistent use of fear and risk of disease to try to motivate people to practice safer sex (Philpott et al 2006). In this setting it is no wonder that there is considerable evidence that the official discourse of sex education [does] not relate to teenage lives (Chambers et al 2004). Specifically, the sex education curriculum all too often neglects the complicated process of choices regarding sexual behaviour, and is de-eroticised. While sex education almost entirely evades queer sexualities, it also neglects heterosexual female sexual pleasure and characteristically denies heterosexual young men a positive and legitimate sexual subjectivity (Harrison and Hillier 1999; Allen 2006). This is a serious problem for sexual health strategies intending to promote egalitarian sexual practices including ending sexual violence. As both Broom (2007, 2008) and Diprose (2007, 2008) point out, the inadvertent consequence of employing scare tactics associated with preventing risky behaviours may well be increasing resistance to Preventive Health approaches. This analysis is also relevant to sex education. My point here is that a proudly pro-sex agenda in sexual health agendas can still involve a heavy dosage of regulatory imperatives and does not necessarily produce attention to pleasure, even to hetero-pleasure. Sexual health education programs remain dominated by a framing of sex as risk and dangerby assumptions which reflect the Modernist feminist sex-asdanger position I outlined earlieroften depicting women/girls as vulnerable and men/ boys as culpable. This Preventive Health focus on fear and danger with regard to heterosex is problematic precisely because it is likely to be counter-productive. Even programs which we would rightly judge to be at the forefront of a Preventive Health sex education are constrained by the already minimal cultural space afforded sexual pleasure, as Janice Irvine (2000) puts it. For example, the SHARE Project (a sexual health program for upper level
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high school students in South Australia which ran between 2003 to 2005 under the auspices of SHine SA) strongly emphasised its holistic Preventive Health framing, presented itself as having a healthy, neutral, non-moralistic approach to sexuality and implicitly therefore as not about suppressive regulation of sexuality (SHine SA 2003:8-9). Yet SHARE was explicitly shaped by concerns about risk and danger. For instance, SHARE was highly attentive to teenage pregnancy and STIs, stressing rational knowledge-based choice, safety, and service usage. The program did stress being positive about sex, but, at the same time, the program could barely mention pleasure. This is not a criticism of SHARE, which faced vitriolic attack by Christian Right-Wing lobbyists precisely for its pro-sex stance (Gibson 2007), but simply to point out, that Preventive Health in sexualityeven in its more progressive manifestationsis rarely in practice about sexuality. It is rarely about doing sex, let alone about experiencing or giving pleasure, and much more about health as regulatory management of social risk. Debra Lupton (1995; Petersen and Lupton 1996) argues that rational calculation and managing risk associated with social inequities and lifestyle choices is the mainstay of the Preventive Health agenda (including sex education), which ties it into regulatory governance. I would add, in common with the perspectives of Hage (2003), Burke (2007) and Diprose (2007, 2008), that it is also strongly associated with the present dominance of public discourses throughout the Western world prioritising security. Debra Lupton, along with many others who offer critical perspectives on Preventive Health, employs Foucaults work on the modern surveillance of bodies to discuss its risk/danger orientation (Lupton 1994:20-40). Is this the answer? Should we simply turn away from the Modernist sex-as-danger approach and adopt a Postmodern Foucauldian pro-sex stance? While I see advantages in the latter perspective, I am not sure this analysis is sufficient either. As I pointed out at the beginning of this paper, in the first instance there is reason to qualify Foucaults thesis regarding the proliferating sexualisation of the modern public realm at least
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when considering the non-commercial arenas of Gender/Sexuality scholarship and Preventive Health. The Foucauldian critique may be a problematic framework for assessing the treatment of heterosex in non-commercial arenas. Secondly, Luptons Foucauldian analysis casts the Preventive Health framework as still mired in the sex-asdanger camp. In other words, she reiterates in many ways the binary enunciated in the sex wars debate. We are faced here in her view either with sex as danger and risk OR with Foucaults embrace of bodies as pleasure. The Foucauldian pro-sex camp does at least bring Queer sexualities into view. However, it is inclined to equate pleasure almost exclusively with Queer sexualities, while heterosexuality=heteronormative and heterosexual women simply disappear from view. The Foucauldian pro-sex stance may not be the answer. Indeed, as I have noted in relation to sex education programs such as SHARE, a pro-sex framework, affirming sex is healthy, does not get us very far.

Recognition of pleasure in sexual health and strategies for gender equity


What if we refused the sex wars binary of danger versus pleasure and took a different direction? What if a concern with riskwith making sex safeand a concern with pleasurable sex are not mutually exclusive. In this context, existing research indicates that recognition of pleasure in sexual health has resulted in greater safety, in increased use of condoms by men and greater involvement of women in negotiation of sexual practices. (Philpott et al 2006; Ingham 2005; The Power of Pleasure undated; Holland et al 1992). Recognition of pleasure paradoxically appears to produce more egalitarian rather than non-consensual sexual relations between men and women. This research information is not just relevant to prevention of disease, but has implications for strategies regarding sexual violence. Recognition of hetero-pleasure can in other words inform a shift towards positively reconstructing mens identities in ways that exclude violence against women (White 2000; Jenkins 1990).
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I have attempted here to indicate the limits of a primarily negative (an always already punitive) orientation which emphasises danger and warnings. I have suggested that both Gender/Sexuality scholarly writings and Preventive Health sex education materials remain captured by precisely such a narrow agenda. Yet it is possible, even likely, that young heterosexual mens sense of entitlement about non-consensual sex cannot be effectively reconfigured if anti-violence discourses continue to constitute heterosexuality in ways that do not pay attention to pleasure. Moreover, without engaging young men such anti-violence discourses run the risk of continuing by default to leave young women with the task of being responsible for risk management of sexuality and sexual violence (Carmody 2005). We must face growing evidence that promoting pleasure when discussing sex is likely to encourage forms of sexuality that are safer and more egalitarian. Talking about pleasure is not necessarily at odds with safety but instead may well produce it.

identification with forms of heterosexual masculinity attuned to egalitarian sexual practices. Though I have suggested some difficulties with current directions in Masculinity Studies scholarship in this regard, in common with Michael Kimmel I too see the aim as refashioning our sexualities away from control, aggression and violence and toward mutuality and equalitya loving lust that is equal parts heat and heart (2005:xiv). As Moira Carmody (2005) puts it, we need an ethical erotics. Making safe sex hot may well provide a more attractive counter-discourse than the existing emphasis on heterosexuality as monolithically normative, inequitable and risky. But how do we do this without also energising conservative and/ or religious forces? Putting hetero-pleasure back into Gender/Sexuality studies and into sex education is not just a question of getting out the aromatic oils and an exotic massage book, but is a deeply political question.

Endnotes
1. My thanks to Carol Bacchi for discussions which helped clarify my thinking on aspects of the Foucauldian sexualisation thesis. 2. McNay and Bland, amongst other commentators, offer related observations regarding the difficulties attached to an account of disciplinary power as monolithic and uniform, though their particular concern is to indicate the gendered limitations of this account (McNay 1992:38-47; Bland 1981:58-9). 3. The telling exception here is feminist work on violence, which largely retains a second wave Modernist framing. 4. As noted above, the exception is feminist work on violence. 5. See, for example, Jackson 1999; Holland et al 1998; Johnson 2005; Scott and Jackson 2007; Hockey et al 2007; Ingraham 2008. 6. This problematic equation of heterosexuality with heteronormativity will be the subject of more extensive analysis in a forthcoming co-authored book, titled Adventures in Heterosexuality. 7. I am indebted to Heather Brook for this way of expressing the problem. 8. The comment is also relevant to feminist work on violence. Volume 17, Issue 2, August 2008

Conclusion
I suggest we may need to move away from the standard binary thinking of the old sex wars. Both Gender/Sexuality writings and Preventive Health in the form of the sexual health literature tend to be populated by vulnerable wombs and vaginas and troublesome penises. Perhaps we could instead learn from aspects of the HIV/AIDS work and refuse to accept the established binary of pleasure versus danger, such that safe sex can also be hot sex. My concern here is that, to the extent that critical non-commercial voices do not attend to hetero-pleasure and the libidinal body, they are unable to provide an enticing alternative to the seductive barrage of consumerist messages about (hetero)sexuality and, relatedly, fail to engage young men in particular. Indeed they may inadvertently produce a counter-productive resistance amongst young men to sexual health strategies, including those which aim to promote gender equity. Strategies to encourage egalitarian (hetero)sexuality, and hence to end sexual violence, must move beyond conceptions of heterosexuality simply as a problem and instead generate positive

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The challenge of pleasure: Re-imagining sexuality and sexual health 9. The limits of a risk orientation have associations and implications for related protective vocabularies including care and social capital (see Beasley and Bacchi 2007). Campbell, D. (2005) Sex lessons planned for all children The Observer Sunday December 4. Carmody, M. (2005) Ethical erotics: Reconceptualising anti-rape education Sexualities 8(4):465-80. Chambers, D.; Tincknell, E. and Van loon, J. (2004) Peer regulation of teenage sexual identities Gender and Education 16(3):397415. Combes, J. and Hinton, T. (2005) Making choices: Young people and pregnancy in Tasmania Final Report, Department of Health and Human Services, Tasmania. Connell, R. [1995] (2005) Masculinities (2nd edn) Allen and Unwin: Sydney. Connell, R. (2000) The Men and the Boys Polity Press: Cambridge. Connell, R. (2002) Gender Polity Preess: Oxford. Darvill, W. and Powell, K. (2007) The Puberty Book (4th edn) Hodder: Sydney. Diprose, R. (2007) Biopolitical technologies of prevention Colloquium on Re-imagining Preventive Health: Theoretical perspectives Preventive Healthcare Research Cluster, University of Adelaide 9 February 2007. Diprose, R. (2008) Biopolitical technologies of prevention Health Sociology Review 17(2): 141-150 Echols, A. (1983) The new feminism of yin and yang in Snitow, A.; Stansell, C. and Thompson, S. (eds) Powers of Desire: The Politics of Sexuality Monthly Review Press: New York, pp. 62-81. Echols, A. (1984) The taming of the Id: Feminist sexual politics 1968-83 in Vance, C. (ed) Pleasure and Danger: Exploring Female Sexuality Routledge: London, pp. 50-72. Edwards, J. and Cheers, B. (2007) Is social capital good for everyone? The case of samesex attracted women in rural South Australian communities Health Sociology Review 16(34):226-236. Epstein, D. and Renold, E. (2005) Introduction (Special issue on Carol Vances Pleasure and Danger) Sexualities 8(4):387391. Evans, D. (1993) Sexual Citizenship: The Material Construction of Sexualities, Routledge: London and New York. First World Congress for Sexual Health (2007) available at www.sex-sydney-2007.com/ callabstracts.html

References
Allen, L. (2006) Looking at the real thing: Young men, pornography, and sexuality education Discourse 27(1):69-83. ARCSHS (Australian Research Centre in Sex, Health and Society) (2003) Sex in Australia LaTrobe University: Melbourne. Bayliss, J. and Smith, S. (2001) The Globalization of World Politics: An Introduction to International Relations (3rd edn) Oxford University Press: Oxford. Beasley, C. (forthcoming) Theorising the Gender/ Sexuality field: The emerging mnage of feminist, sexuality and masculinity studies and its discontents Address presented at McGill Centre for Research and Teaching on Women, McGill University, Montreal, 3 November 2005. Beasley, C. (2005) Gender and Sexuality: Critical Theories, Critical Thinkers Sage: London and Thousand Oaks. Beasley, C. and Bacchi, C. (2007) Envisaging a new politics for an ethical future: Beyond trust, care and generosity towards an ethic of social flesh Feminist Theory 8(3):279-98. Bell, D. and Binnie, J. (2000) The Sexual Citizen: Queer Politics and Beyond Polity Press: Cambridge. Bland, L. (1981) The domain of the sexual: A response Screen Education 39:56-68. Broom, D. (2007) Hazardous good intentions? Unintended consequences of the project of prevention Colloquium on Re-imagining Preventive Health: Theoretical Perspectives Preventive Healthcare Research Cluster, University of Adelaide 9 February 2007. Broom, D. (2008) Hazardous good intentions? Unintended consequences of the project of prevention Health Sociology Review 17(2): 129-140. Burke, A. (2007) Beyond Security, Ethics and Violence: War Against the Other Routledge: London and New York. Califia, P (1996) Feminism and sadomasochism . in Jackson, S. and Scott, S. (eds) Feminism and Sexuality: A Reader Edinburgh University Press: Edinburgh, pp. 230-44.

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Chris Beasley Foucault, M. (1980) Power/Knowledge: Selected Interviews and Other Writings, 19721977 Harvester: Brighton. Foucault, M. (1981) The History of Sexuality (Part I) Penguin: London. Gibson, S. (2007) The language of the right: Sex education debates in South Australia Sex Education 7(3):239-250. Hage, G. (2003) Against Paranoid Nationalism: Searching for Hope in a Shrinking Society Pluto Press: Melbourne. Harrison, L. and Hillier, L. (1999) What should be the subject of sex education? Discourse 20(2):279-288. Heise, L. (1997) Violence, sexuality and womens lives in Lancaster, R. and di Leonardo, M. (eds) The Gender/Sexuality Reader: Culture, History, Political Economy Routledge: New York and London, pp. 412-39. Hockey, J.; Robonson, V. and Meah, A. (2007) Mundane Heterosexualities: From Theory to Practice Palgrave Macmillan: Basingstoke. Holland, J.; Ramazanoglu, C.; Scott, S.; Sharpe, S. and Thomson, R. (1992) Risk, power and the possibility of pleasure: Young women and safer sex AIDS Care 4(3):27383. Holland, J.; Ramazanoglu, C.; Sharpe, S. and Thomson, R. (1998) The Male in the Head: Young People, Heterosexuality and Power Tufnell Press: London. Ingham, R. (2005) We didnt cover that at school: Education against pleasure or education for pleasure? Sex Education 5(4):37588. Ingraham, C. (2008) Heterosexuality: A Reader Routledge: London. Irvine, J.M. (2000) Doing it with words: Discourse and the sex education culture wars Critical Inquiry 27:58-76. Jackson, S. (1999) Heterosexuality in Question Sage: London. Jenkins, A. (1990) Invitations to Responsibility: The Therapeutic Engagement of Men who are Violent and Abusive Dulwich Centre Publications: Adelaide. Johnson, P (2005) Love, Heterosexuality and . Society: Sociological Perspectives on Love and Heterosexuality Routledge: London. Kanneh, K. (1996) Sisters under the skin: A politics of heterosexuality in Jackson, S. and Scott, S. (eds) Feminism and Sexuality: A Reader Edinburgh University Press: Edinburgh, pp.172-9. Kaufman, M. (2001) Strategic planning to end mens violence: The White Ribbon Campaign Aggressive Behaviour 27(3):158. Kickbusch, I. (2006) The health society: The need for theory Journal of Epidemiology and Community Health 60:561. Kimmel, M. (2005) The Gender of Desire: Essays on Male Sexuality SUNY Press: New York. Kimmel, M. (undated) Interview, No safe place: Violence against women available at www.pbs. org/kued/nosafeplace/interv/kimmel.html Kimmel, M. and Plante, R. (2004) Sexualities: Identities, Behaviours, and Society Oxford University Press: New York and Oxford. Lupton, D. (1994) Medicine as Culture: Illness, Disease and the Body in Western Societies Sage London and Thousand Oaks. Lupton, D. (1995) The Imperative of Health: Public Health and the Regulated Body Sage: London. The Medical Institute for Sexual Health [www.medinstitute.org]. McNay, L. (1992) Foucault and Feminism Polity: Oxford. Petersen, A. and Lupton, D. (1996) The New Public Health and Self in the Age of Risk Allen and Unwin: St. Leonards, NSW. Peterson, S. and Runyan, A. (1999) Global Gender Issues (2nd edition) Westview Press: Boulder Co. Philpott, A.; Knerr, W. and Boydell, V. (2006) Pleasure and prevention: When good sex is safer sex Reproductive Health Matters 14(28):2331. Plummer, D. and McCann, P (2007) Girls Germs: . Sexuality, gender, health and metaphors of contagion Health Sociology Review 16(1):4352. Powell, A. (2007) Sexual pressure and young peoples negotiation of consent ACSSA (Australian Centre for the Study of Sexual Assault) Newsletter 14 (June). The Power of Pleasure, Institute of Development Studies, University of Brighton. Available at http://www.ids.ac.uk/ids/news/ powerpleasure.html Re-public: re-imagining democracy (2008) Gendering border crossings [www.re-public.gr/ en]. Richardson, D. (2001) Sexuality and gender International Encyclopaedia of the Social and Behavioural Sciences Elsevier: New York and Oxford [www.iesbs.com]. Volume 17, Issue 2, August 2008

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The challenge of pleasure: Re-imagining sexuality and sexual health Rubin, E. (2005) Sex, politics, and morality William and Mary Law Review 47(1):1-48. Rubin, G. (1994) Sexual traffic (interview with Judith Butler) Differences: A Journal of Feminist Cultural Studies 6(2-3): 62-100. Sabo, D. (2005) The study of masculinities and mens health in Kimmel, M.; Hearn, J. and Connell, R. (eds) Handbook of Studies on Men and Masculinities Sage: Thousand Oaks and London, pp. 326-52. Schubotz, D.; Rolston, B. and Simpson, A. (2004) Sexual behaviour of young people in Northern Ireland: First sexual experience Critical Public Health 14(2):177-190. Scott, S. and Jackson, S. (2007) Theorising Sexuality Open University Press: Milton Keynes. Seidman, S. (1991) Romantic Longings: Love in America, 1830-1980 Routledge: NY. Sullivan, N. (1997) Fleshing out pleasure: Canonization or crucifixion? Australian Feminist Studies 12: 26. SHine SA (2003) Report on the first year of the SHARE Project SHine SA: Adelaide. SHine SA (Sexual Health Information Networking and Education) Sexual Health statistics February 2008 sexual_health_statistics_2008. pdf]. Tickner, A. (2001) Gendering World Politics Columbia University Press: New York. Tickner, A. (1992) Gender in International Relations: Feminist Perspectives on Achieving Global Security Columbia University Press: New York. White, M. (2000) Reflections on Narrative Practice. Dulwich Centre Publications: Adelaide. WHO (World Health Organisation) (2002) Sexuality available at www.who.int/ reproductive-health/gender/sexual_health.html WHO (2002) Sexual Health available at www. who. int/reproductive-health/gender/sexualhealth. html#2. Womens Worlds Congress 2008, 10th International Interdisciplinary Congress on Women, Comp lutense University, Madrid (Spain), 3-9 July available at www.mmww08. org/ index.cfm?nav_id=41.

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The politics of research management: Reflections on the gap ABSTRACT between what we know (about SDH) and what we do
ABSTRACT
KEY WORDS Social determinants of health, research utilisation, health services research, governance, knowledge production, priority setting, sociology

Health researchers in a number of settings are expressing concern about the gap between what we know about the social determinants of health and of health inequalities, and the lack of action based upon this knowledge. Indeed, the know-do gap has become almost a mantra echoed across international and some national institutional sites. This paper examines how the problem of the gap is understood and represented in dominant and sub-dominant conceptualisations. It highlights what is missing from these representations: adequate reflection on changing modes of governance of research management. Where once there was a degree of separation between research production and government policy, increasingly there is congruence between these governmental functions. This congruence means that the problem we face today is not a gap but rather a fit between what we know and what we (dont) do regarding SDH.
Received 27 August 2007 Accepted 5 March 2008

Carol Bacchi
School of History and Politics University of Adelaide Australia

Introduction
The scientist is called upon to contribute information useful to implement a given policy, but the policy itself is given, not open to question So long as the social scientist continues to accept a role in which he (sic) does not question policies, state problems, and formulate alternatives, the more does he (sic) become routinised in the role of bureaucratic technician (Merton and Lerner 1951:306).

oncern about the gap between what we know and what we do about the social determinants of health (SDH) and of health inequalities is widespread and growing. Importantly, this concern is being expressed in two quite different conversations. One is a conversation of some longevity and with
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significant institutional endorsement, which I refer to as the dominant conversation (see WHO 2005). The aim in this conversation about what is called the know-do gap is to determine how knowledge can more effectively be transformed into action, how to increase the uptake of evidence in public policy (ARACY 1995). The second conversation, positioned somewhat at the margins of the first, wants to tackle the perceived lack of government responsiveness to SDH. The concern in this subdominant conversation is the apparent lack of will (Harvey 2006) of those with institutional authority to implement SDH insights and their possible ideological aversion to those insights (Raphael 2005; see also Bambra et al 2005). This paper examines how the problem of the gap is understood and represented in these two conversations, with a predominant focus on the dominant, institutionally endorsed conversation. It highlights a key silence in both conversations: inadequate reflection on changing modes of gover nance of research (knowledge) management. Where once there was a degree of
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separation between research production and government policy, it argues, increasingly there is congruence between these governmental functions, reflected in the recent endorsement of user-driven research both overseas and in South Australia, with users identified as policy-makers and administrators. This congruence means that the challenge faced by those committed to addressing SDH is not a gap but rather a fit between what we know and what we do. That is, increasingly researchers are rewarded (funded and promoted) for producing research that supports the priorities of governing bodies intent on preserving social cohesion and stability. Hence, it is unsurprising that the deep, structural changes required to address SDH and the reproduction of health inequalities do not occur. In terms of the theme of this special issue of HSR therefore, my concern is not the preventive paradigm per se. I am not asking how prevention could be thought about differently or better, nor indeed am I putting into question the understanding of health within the preventive paradigm. Rather, my target is the larger paradigm within which preventive approaches are located: that is, implied models of the researchpolicy nexus and relatedly implied models of policymaking. I suggest that researchers who proceed as if all they need to do is make suggestions to government about necessary policy changes and then wait for these to be enacted need to think again about how policy questions and proposals frame problems in ways that delimit the policy agenda. Hence a key site of intervention is the need to put into question user-driven research and to insist on the inclusion of researchers and the lay public (Popay et al 2003) in shaping research agendas. The paper proceeds as follows. First, it lays out and briefly examines the kinds of explanations put forward to explain the gap between what we know and what we do about SDH (the two conversations). Next, it focuses on the assumptions and presuppositions underpinning the dominant, institutionally supported understanding of the know-do gap, using the Canadian Health Services Research Foundation (CHSRF) and its founder and long-time director, Jonathon Lomas,

as exemplars. To elaborate the models of the researchpolicy nexus and of policy-making associated with this understanding, it explores the languages used to frame the problem of the know-do gap: evidence-based/influenced policy, knowledge translation, knowledge brokers, research synthesis, priority setting and user-driven research. This analysis necessitates a brief excursion into the history of the research utilisation problematic and some reflections on Mode 2 propositions about the new mode of knowledge production (Gibbons et al 1994). The final section of the paper points to tensions and inconsistencies in this dominant understanding of the problem of the know-do gap. It also reflects on the implications that follow from identifying the limitations of this dominant conceptualisation of the problem for those engaged in the second, marginalised conversation, those who wish to promote deep-seated social structural change to improve health and reduce health inequalities.

The two conversations


My journey into this complex territory began with a paper by Dennis Raphael entitled Exploring the Gap between Knowledge and Action on the Social Determinants of Health, presented in 2005 at a conference entitled Dahlgren and Whitehead and Beyond: The Social Determinants of Health in Research, Policy and Service Delivery. In this paper Raphael states clearly his concern that there is a gap between what we know about broad social and economic patterns of causation in population health (his specific example is SDH) and what is being done. He offers several explanations for this gap: first, that SDH seldom gets into media; second, that public sector workers infrequently have the opportunity to defend a SDH approach, even when they endorse it; and third, that governments are disinclined to accept SDH insights when they contravene ideological commitments to small government and the social status quo. More recently, and in the Australian context, Peter Harvey (2006) asks similar questions and offers similar explanations. Harvey wants to know why we have abandoned preventive and early intervention at the social and economic levels of
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The politics of research management: The gap between what we know (about SDH) and what we do

health care in a preference for micro interventions at the end point of chronic illness? He offers two interrelated explanations: first, that our predominant controlling and social ideology has become one of profit and market driven growth; and second, that Australia is dominated by a political agenda, whether conservative or socialist, which represents retrograde values and holds a reactionary position on social and political economy (Harvey 2006:419). In both Harvey and Raphael, politics is central to the uptake (or not) of social preventive interventions (see also Bambra et al 2005). The problem, as they explain it, is the current neoliberal ideology of Canadian (Raphael) and Australian (Harvey) governments, and the capitalist interest groups that sustain them. While I have some sympathy with this explanation, I argue that a central reason for the lack of responsiveness to SDH insights (the concern in this sub-dominant conversation) is the institutional privileging of the voices in the dominant conversation about the know-do gap and the way in which this dominant conversation represents the issues. In the dominant conversation the problem of the know-do gap involves inadequate uptake by governments of research evidence, due largely to poorly developed relationships between researchers and users (policy-makers and administrators). Significantly, this conversation has generated a sub-field in health research, Health Services Research, with a focus on discovering what works in health service delivery. Considerable funds now pour into foundations set up to offer ways to encourage uptake of evidence. The next two sections offer a close analysis of the recommendations for change put forward by one such foundation, the Canadian Health Services Research Foundation (CHSRF), associated with Jonathon Lomas. Lomas is the inaugural Chief Executive Officer of CHSRF, a nationally endowed organisation founded in 1997 to improve the relevance and use of health services research in health system decision-making (ARACY 1995). This Foundation and Lomas are offered as exemplary of the dominant approach to the problem of the gap. There is no
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suggestion of deliberate malfeasance on the part of either Lomas or the CHSRF. Rather, I suggest, we need to understand how the understanding of the problem of the know-do gap in the dominant conversation, with Lomas and CHSRF the exemplars, fits current modes of governance as a first step to thinking about ways forward.

The research utilisation problematic Lomas, and the Foundation with which he is associated, became the focus of my attention because of the significant role their work plays in the current South Australian Governments Strategic Health Research Program. The program endorses Lomass listening model (Lomas et al 2003), stresses the importance of evidenceinformed decision making (Government of South Australia 2007a:2), and uses many CHSRF key terms and strategies, including research/ knowledge translation, linkage and exchange, an emphasis on research synthesis, the 1:3:25 model for research reports (elaboration follows below), the training of knowledge brokers, and user-driven research (Government of South Australia 2007b). Lomas is also a central figure in international health services research, sitting on a number of boards in the US and the UK, and involved in consultancies to the WHO, World Bank and the Rockefeller Foundation. Lomas argues the main reason for a gap between research knowledge and uptake by users is that researchers misunderstand the nature of the policy-making process. He challenges what he describes as the linear model of the research policy nexus where researchers make their research available, much in the way in which storekeepers stock shelves, and policy-makers come along and take what they need to solve a policy problem (Lomas 2000a:140-141). According to Lomas (see also Black 2001), researchers need to recognise that policy-making is a process, not an event, and a complex process at that, where policymakers have to deal with a wide range of political circumstances, including budget constraints, the demands of lobby groups, and their own values and biases. If researchers want increased uptake of their evidence, according to Lomas, they need to become sensitive to the world of policy-makers.
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Indeed, given that policy-makers are the ones who in the end have to make the decisions, it is best for them to communicate their research needs to researchers. With such a user-driven approach to research, uptake will very likely be increased. Says Lomas et al (2003:370), the best predictor of research use is the early and continued involvement of relevant decision makers. It is important to note that in this conversation the issue of SDH is muted. Rather the suggestion is that we are dealing with a larger problem, the lack of uptake of research generally. In addition, it is important to note that this issue of research utilisation (or the lack thereof) has a long genesis. Indeed, we have here a manifestation of longstanding concerns about the relationship between theory and practice, expressed as the relationship between knowledge and policy (see Lynn 1978a). There is no space here to trace the fine details of the genealogy of the research utilisation problematic. However, it is significant to note that the full range of concepts and strategies identified by Lomas appeared over thirty years ago, when the problem of research utilisation grabbed the attention of governing bodies in the United States. (Emphasis has been added in the quotes to follow in order to highlight the shared terminology). In 1978 Laurence Lynn (1978b:17) declared that Policy is not an event. It is a process that moves through time-consuming stages, beginning with public recognition that a problem exists The way to increase research utilisation involved Improving Linkage Between Social Research and Public Policy (Weiss 1978), learning to translate the knowledge needs into research questions and translating research results back into policy (Weiss 1978b:40), synthesising material to make research findings more user-friendly (Davis and Salasin 1978:120), and developing research brokerage as a new discipline (Sundquist 1978:144). Given the close parallels in both the description of the problem and in the range of proposed solutions, it is useful to reflect briefly on the 1970s debate. According to Laurence Lynn (1978c:4) executive concern about the usefulness of social R & D was due to the

chronic budgetary shortages of the early 1970s and post-Great Society disillusionment with social programs. Social scientists feared that administrative remedies involving tighter control by federal staff (Lynn 1978c) might be imposed. Carol Weiss, a leading contributor to the debate, noted that a democratic system does not want technocratic solutions imposed on decision makers. To ward off this possibility she followed the lead of policy theorist, Charles Lindblom (1965), who insisted that policymaking involved reconciliation of interests, based upon recognition that policy-makers operate with political rather than scientific rationality (Weiss 1978:61; see also Bacchi 1999:18, 24-31; Elliot 2006). Researchers were advised to lower their expectations of research utilisation and to recognise that research needed to fit realistic political contexts: The passage of social science knowledge through the filter of political judgment may often be a preferable route to action (Weiss 1978:35). Theorists like Lindblom spoke about usable knowledge (Lindblom and Cohen 1979) and stated that research priorities needed to be generated by a plurality of partisans (Lindblom 1979:64), an interaction among scientists and practical problem solvers such as engineers, government and foundation officials (Lindblom 1979:64). In this context, users were invited to become involved as advisers in the setting of research priorities (Weiss 1978:69). To those researchers who felt dissatisfaction with this somewhat instrumental role, theorists like Janowitz (1970) and Weiss (1977a; 1978) held out the possibility of an enlightenment role. That is, researchers should be content to realise that the concepts they developed had an indirect and gradual impact on the policy community. According to Weiss (1977b:15, in Lindblom 1979:77), Social research can be used in reconceptualising the character of policy issues [and] may sensitise policy makers to new issues. Lomas et al (2003:370) also endorses an enlightenment role for research, although the notion attracts only passing mention. In his view (2000a:143), researchers may influence the beliefs of decision-makers but the window of
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opportunity to make major change, however compelling the research, opens only rarely and briefly when the constellation of values may happen to coincide with the researchs implications. In the meantime, to increase uptake, researchers need to acknowledge the realities of political decision-making and defer to policy-makers in the setting of research priorities. Despite the parallels between 1970s political rationalism and Lomas, an important shift occurs in the latters endorsement of user-driven research. In 1978, policy-makers were invited to become involved as advisers in the setting of research priorities (Weiss 1978:68), to become one among a plurality of partisans (Lindblom et al 1979:64). Weiss (1978:47-48) was quite clear that, in her view, the input of researchers remained crucial since Government officials, partly because of their time perspective, see many aspects of the world as fixed. In Lomas, by contrast, users are to drive the research agenda. To understand this shift it is necessary to examine the changes to research management regimes that have occurred over this period. In 1978 Weiss outlined three mechanisms for obtaining research, each giving a particular set of actors more influence in the formulation of research: (1) procurement where government staff specifies the product to be bought; (2) solicitation, under which government staff set the frame within which researchers define their study; and (3) assistance, described as support for investigator-initiated research where it is the researchers formulation of the research that prevails (Weiss 1978:48-49).The space for enlightenment research is to be found among those basic researchers funded through assistance. In the 1970s, therefore, as in the earlier period (1950s) when researchers tried actively to develop a policy orientation in order to increase status and wealth (Lasswell 1951), researchers faced a choice of affiliations with the academic, business, or government communities (Merton and Lerner 1951, in Janowitz 1970:249; emphasis added). Because it was a choice, Merton and Lerner (1951:306; introductory quote at beginning of paper) felt able to warn researchers of possible compromise of principles should they
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accept a role in which they do not question policies but simply contribute information useful to implement a given policy. By the time Lomas is writing (late 1980s and following) the parameters for research funding have changed dramatically. The role of assistance is sharply reduced, squeezing the place available for those described as enlightened to produce ideas and concepts that might have a gradual impact on the beliefs of policy-makers. Moreover, researchers increasingly have no choice of affiliation; rather affiliation to government and/or business is determined for them by funding constraints (e.g. Collyer 2007:255). Perhaps these changes in funding arrangements explain the diminished attention in Lomas to the role of enlightenment. In the event it is clear that in Lomas the main game is not enlightenment but uptake, and ways to make this happen. The strategies that he and the CHRSF put forward help us understand how the problem of uptake is understood and represented.

The two communities: Strangers in the night


According to Lomas, and here he is in good company (Hanney et al 2003:24; Birnbaum 2000), the main reason for the low impact of research findings (the know-do gap) is that researchers and policy-makers inhabit different worlds, with different priorities, different contingencies and often different value structures. Hence, the two communities are like strangers in the night (Feldman 1999, in Lomas 2000b:236) who have great difficulty talking to each other and understanding each other. The way to fix this problem, says Lomas, is to increase contact and improve communication between the two communities. Hence the goals become listening (Lomas et al 2003), linkage and exchange (Lomas 2000b), knowledge translation and the training of research brokers who are skilled in a liaison role. To improve communication, researchers need to concentrate on the form in which they transfer knowledge. They are instructed to use plain English and to avoid jargon; they are to lay out their research using a 1:3:25 format, with one page of main
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messages, three pages of executive summary and twenty-five pages for the main report (CHSRF 2001); and they are to commit particular attention to producing research syntheses of other secondary research. Brendan Gibson alerts us to limitations in this understanding of the problem, arguing that the dichotomous construction of the research-policy problem as two worlds leads to solutions based only on communication. This understanding downplays more fundamental problems related to beliefs and values, institutional accountability, and power relationships (Lin and Gibson 2003:xxi). Lomass concern, however, is broader than communication. He argues that policy-makers are more likely to draw upon research findings when they have had a direct involvement in the formulation and design of the research project. Here there is talk about the need to generate ownership among research users (Lomas et al 2003:370). Beyond this, says Lomas, policy-makers are best placed to formulate research questions since they are aware of the full range of political contingencies that will place constraints on what can be done. Hence they are to play a key role in priority-setting exercises. Researchers in their turn need to learn to recognise the difference between a sensible decision and a rational decision. For example Lomas notes that, despite research demonstrating that for-profit private hospitals are less efficient than public hospitals, the decision to ignore these findings is sensible from the perspective of a decision maker trying to minimise conflict and perhaps embedded in a pro-business organisation or government (Lomas 2000a:144). As this example illustrates, Lomas is acutely aware of the role of values and ideology in research uptake. He produces a chart laying out his model of policy-making in which ideologies, beliefs and interests are listed as in-puts to the policymaking process (Lomas 2000a:143). Given this understanding of the policy-making process, the issue, I suggest, becomes how researchers are to respond to these ideologies, beliefs and interests. The message is that they must learn to accommodate them (see Black 2001:277), and

perhaps to try to alter them over time through a bit of enlightenment, remembering the diminished space for independent thought given the increasing dependence of researchers on government funding. Significantly, social problems are located at the top of Lomass chart of the policy-making process, exogenous to the process. Hence, in his model, governments are portrayed as responding to problems that sit outside them. Despite the awareness of the role of values and beliefs in the policy-making process, therefore, Lomass model stops short of recognising the ways in which these values and beliefs shape particular understandings of problems, with all sorts of implications for what is done and not done (Bacchi 1999). This point becomes highly relevant given the recommendation that users should drive the research agenda (set priorities), a theme pursed later in the paper. Lomas also endorses evidence-based or evidence-influenced policy. Some might perceive a tension here between, on the one hand, wanting users (policy-makers and administrators) to drive policy and, on the other, requiring policy to reflect evidence, implying a position of some considerable influence for researchers. The following section explains how this apparent tension is managed.

The ambivalence of evidencebased policy


The drivers behind evidence-based policy are several and overlapping. According to Lin (2003:7; see also Hanney et al 2003:2) the evidence-based approach has tended to be researcher-led. Black (2001:275) agrees, noting how researchers in other settings took their cue from evidence-based medicine to demand that policy-makers base their decisions on sound evidence. According to Anna Donald (2001:279) evidence-based medicine was introduced in public health in order to improve not only policy outcomes but also the accountability mechanisms by which decisions were made. In her view, People were fed up with the extent to which politicians whims could change their lives not obviously for the better, based as they were on ideological opinion.
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As an example, Michael Marmot (2004) complains that alcohol policy in the UK has been formulated with little attention to evidence. According to Marmot, to achieve overall reduction in population-level alcohol consumption, research evidence solidly supports a policy of higher prices and limits on availability, while policies continue to stress strategies such as education, more policing, improved treatment, and voluntary agreements with the alcohol industry. Evidence, it seems, can pose a useful, if not always successful, challenge to ideologically and interestdriven policy. However, Neil Black (2001:275) makes an appropriate caution. He points out that, when researchers start to insist that their work should have influence (i.e. that evidence should drive policy), governments can parry with the claim that only research that has an impact should be funded. And indeed that is what has happened in the UK, with the Research Assessment Exercise (Ball 2001:267), and what was happening in Australia with the Research Quality Framework proposed by the Howard-led Coalition Government in 2007 (Australian Government 2006). Both these initiatives explicitly tie university funding to research impact, scholarly and social. Hence, policy-makers are empowered to decide which evidence counts. In this way evidencebased policy comes to fit neoliberal governmental rationality with its emphasis on counting, efficiency and effectiveness, and becomes a technology for disciplining researchers. Still, there remains ambivalence around the concept evidence. As with the example of Marmot above, there is room for researchers to argue that evidence is sometimes ignored, that evidence is malleable (see Solesbury 2001; Marston and Watts 2003). Marmot (2004:907; emphasis added) throws out the challenge to policy-makers that what we have currently is policy-based evidence rather than evidencebased policy. He calls upon the British government to have another look at the evidence linking harm with average alcohol consumption. Because of this lingering potential for evidencebased policy to empower researchers, Lomas and others committed to user-driven policy have
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developed strategies and technologies for managing this ambivalence, in addition to the research impact assessment technology (RAE, RQF) we have just discussed. First, there is a growing tendency in the dominant, institutionalised conversation (CHSRF 2006; Government of South Australia 2007a:2) to talk about evidence-influenced rather than evidence-based decision-making. While at first glance this shift in language seems to imply a willingness to de-privilege evidence (and hence a challenge to technocratic models), the shift also allows users to appeal to evidence when it suits them and to place it to one side when it does not do this. Second, the complexity of the meaning of evidence is now emphasised (CHSRF 2006). Usefully, a distinction is drawn between contextfree and context-sensitive evidence, making a place for social science input. Alongside this development the category of colloquial evidence has been created (Government of South Australia 2007b:3). Decision makers, we are told, prefer to use the broadly inclusive, colloquial definition of evidence as anything that establishes a fact or gives reasons for believing in something, whereas researchers tend to be more restrictive, confining the term evidence to information generated through a prescribed set of processes and procedures recognised as scientific (Lomas et al 2005:3). Whereas scientific evidence is determined by methodology, colloquial evidence is constituted by relevance, highlighting its utilitarian character. (This instrumental turn in policy-making is discussed later in the paper.) The types of colloquial evidence that need to be recognised, we are told, include the same list of factors that Lomas identified as important in-puts into the policy-making process: values, practical contingencies, and pressures from lobbyists and interest groups. The effect, as before, is to suggest that researchers need to accommodate these political realities. Indeed here the pragmatic nature of decision-making is constituted a form of evidence. The third and final strategy to ensure that research evidence is controlled by decisionmakers rather than controlling of them is the
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endorsement of user-driven research. The rationale for this proposal was offered in the previous section. Here I wish to stress how a userdriven research agenda reduces the possibility that researchers could insist that their research findings challenge some government policy directions. The point here is that with user-driven research the opportunity to make this kind of intervention is seriously reduced because users get to set the questions that researchers will then address. Von Lengerke et al (2004:195) make this point clearly:
A crucial issue for the future of public health research itself is that it is not only utilised, but to a large part commissioned and funded by one and the same community of policymakers. Put differently, which research results are available for utilisation is (at least partly) subject to decisions of policymakers, and thus their political will.

The implications of this insight are pursed in the next section.

Knowledge production: The limits of Mode 2


To appreciate what is at stake in these developments it is useful to consider the issue of who gets to set the research agenda (priorities) in terms of Gibbons et als (1994:vii) provocative proposal that currently we are experiencing dramatic shifts from the traditional disciplinecentred mode of knowledge production that they characterise as Mode 1, towards a broader conception of knowledge production described as Mode 2 (Hanney et al 2003:6). The shift, driven by the massification of higher education (the production of numbers of graduates too large for them all to be absorbed within the disciplinary structure), involves an increase in the number of potential sites where knowledge can be created, extending beyond universities and colleges (Gibbons et al 1994:10, 6), and a proliferation of knowledge users. As a result, individuals and groups that have been seen as traditionally outside of the scientific and technological system can now become active agents in the definition and solution of problems as well as in the evaluation of performance (Gibbons et al 1994:7). This new socially distributed knowledge

production system blurs the old distinction between pure and applied science, between what is curiosity-oriented and what is mission-oriented. Emphasis moves away from free enquiry to problem solving and more generally in the direction of problem-oriented research, knowledge in the context of application, with quality assessed in terms of usefulness (Gibbons et al 1994:14, 23, 33): Such knowledge is intended to be useful to someone whether in industry or government, or society more generally, and this imperative is present from the beginning (Gibbons et al 1994:4). Because Mode 2 involves the close interaction of many actors throughout the process of knowledge production, knowledge production is becoming more socially accountable. Moreover, the focus on practical, societal, policy-related concerns means that academic scientists are no longer key policy players. Rather the research priorities will be generated within hybrid fora composed of many different actors (Gibbons et al 1994:vii, 162-3). While there is a useful insight here into the changing shape of what counts as knowledge, the Mode 2 argument has two significant lacunae: first, the focus on knowledge in the context of application means that only certain kinds of knowledge, knowledge about what works, become interesting; and second, there is insufficient reflection on the crucial issue of the mechanisms that define what problems are to be pursued (Gibbons et al 1994:33). I proceed to elaborate each of these limitations and the implications that follow for reflections on the gap between what we know [about SDH] and what we do. The approach to knowledge production in Mode 2 reflects the current utilitarian focus on what works in public policy, with an emphasis on demonstrating the efficacy of particular practices (Solesbury 2001: abstract; Davies 2003; What Works Clearinghouse 2005). As Solesbury (2001:4) explains, the turn to useful research has been driven, to a large extent, by the funders of social science and the demands of government science policy that views academic research as a means to economic and social development much more than as a cultural end in itself . This
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instrumental approach to research produces a very narrow understanding of relevance, bypassing a range of important and often prior questions What is going on? Whats the problem? Is it better or worse than ? What causes it? What might be done about it? At what cost? By whose agency? (Solesbury 2001:8). Crucially, the focus on problem solving (what works) forecloses consideration of how the problem is framed, what the problem is represented to be (Bacchi 1999), and with this foreclosure severely limits the space available to researchers to challenge specific policy directions. As an example, Davey Smith et al (2001) point out that the evaluation group for the Acheson Report (1997) on health inequalities put in question the recommendations of the Report by using randomised control trials (RCTs) that focused on risk factors. With such studies into the effectiveness of a range of interventions on individuals, the evaluation group was able to bypass the Reports concern with broad social factors shaping health inequalities. Considering what works at the individual level while ignoring more important macro-level determinants is, as Davey Smith et al (2001:185) state, tantamount to obtaining the right answer to the wrong question. The larger point here is that the kind of problem-oriented research considered by Gibbons et al (1994) as characteristic of Mode 2 inquiries encourages exactly this kind of instrumental, individual-level research project. By commissioning research on what works, governments set boundaries on the kinds of issues that will be considered. Here, Solesburys (2001) insight into the means-end character of government science (research) policy and von Lengerke et als (2004; see above) concern that the only research that will be available for utilisation is research commissioned and funded by policy-makers, are particularly pertinent. Hence, the suggestion that users should drive research and policy carries significant implications for reflections on the know-do gap. As an example, given the endorsement of user-driven research, researchers in South Australia get to produce research about what works against pre-set questions and/or targets.
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They are required to address the specific questions provided under the research themes (Government of South Australia 2007a:1). At the federal level researchers have to shape research proposals to the Australian Research Council in terms of declared national priorities. Those who do not do so often pay the price of not being funded. The space to scrutinise and critique the models of explanation built into these questions and priorities is severely constrained. It follows that, if the current South Australian State Government and the Australian Federal Government (Howard-led or Rudd-led) conceptualise the problems of preventive health and of health inequalities in limited ways for example, as problems of inappropriate lifestyles or lack of social capital, etc. researchers seeking funding are constrained to shape their projects to fit these paradigms. Researchers as a result tend to tell governments what they want to hear: producing not a gap between what we know and what we do, but a fit between what the government tells us to research and their particular policy agendas. When Dennis Raphael (2005:18) conducted a study of research on SDH and health inequalities, he found that sixty percent of these studies did not mention social and economic issues. This result, I suggest, is unsurprising. Solesbury (2001:4) pinpoints the explanation: Researchers have perforce responded to these changed funding priorities. Stephen Ball (2001:266) is also acutely aware of the way in which funding-driven research makes researchers think about ourselves as individuals who calculate about ourselves, add value to ourselves, improve our productivity, live an existence of calculation, make ourselves relevant (see also Davies 2003:92). Although Gibbons et al (1994:162) refer to the need for hybrid fora for generating research agendas, there is an emphasis in Mode 2, as in Lomas, on the answerability of researchers to decision-makers: scientific specialists now have a double responsibility. They have to be responsive not only to the scientific community but also to public decision makers (Gibbons et al 1994:148). However, if research questions determine the range of issues considered, much
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more attention than this needs to be paid to the nature of this relationship. Given that the values and ideologies of policy-makers shape research agendas in ways that may well be limited, Lomass suggestion that researchers simply accommodate these values and beliefs needs to be reconsidered and debated. Of course at this level Lomas is correct: if researchers accommodate the values and ideologies of particular governments and let those governments set research agendas, this probably will result in an increased uptake of some research. However, it is unlikely, in my view, to result in an increased commitment to the insights generated by SDH research into the social causes of ill-health and health inequalities.

Conclusion
Beyond the argument that ideological governments deliberately set out to restrict the kinds of research produced and deliberately ignore research that suggests the need for significant social change (Raphaels argument), we need to pay more attention to structures of governance, in this case institutional relationships between researchers and governments, including funding arrangements, because of the ways these relationships shape social relations, subjectivities and policy outcomes. While there are possible dangers that a focus on modes of governance can stay at the level of thick description (Dean 2006:38) such a focus is useful because it encourages reflection on why we do what we do and what follows from those decisions. In the instance of research management the kind of analysis offered here helps to make sense of the intransigence of biomedical and behavioural approaches to ill-health. The main message that emerges from this form of analysis is the need to take into account dominant regimes of governance, in particular in this instance funding regimes, when reflecting on the gap between knowledge production and policy outcomes. It makes little sense to talk about a distinction between those who do by thinking and those who think by doing (Birnbaum 2000:130-131) when researchers and policymakers are intermeshed in both purpose and motivation through par ticular institutional

arrangements. Given this situation, researchers committed to social structural preventive health agendas need to put in question institutional arrangements that foreclose the possibility of advancing these agendas. One such space is identified in this paper: the need to challenge the idea of user-driven research. As suggested above, this challenge can be mounted on the grounds that, because research questions frame problems in particular ways, the wrong questions may well produce poor outcomes. Hence, it becomes possible to argue that a wide range of participants, including the lay public (Popay et al 2003; Bolam 2005) and civil society groups (Sanders et al 2004), needs to be involved in framing research questions. The best possible outcomes in terms of SDH, it can be argued, are unlikely to eventuate unless groups other than users have input into priority setting.

Acknowledgment
I wish to thank my research assistant, Anne Wilson, for all her help gathering material for this paper.

References
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Government of South Australia (2007b) Strategic Health Research Program: Guidelines 20062007 Government of South Australia: Adelaide. Hanney, S.R.; Gonzalez-Block, M.A.; Buxton, M.J. and Kogan, M. (2003) The utilisation of health research in policy-making: Concepts, examples and methods of assessment Health Research Policy and Systems 1(2):1-28. Harvey, P (2006) Social determinants of .W. health: Why we continue to ignore them in the search of improved population health outcomes! Australian Health Review 30(4):419-423. Janowitz, M. (1970) Sociological Models and Social Policy in Janowitz, M. (ed) Political Conflict: Essays in Political Sociology Quadrangle Books: Chicago IL, pp.243-259. Lasswell, H.D. (1951) The policy orientation in Lerner, D. and Lasswell, H.D. (eds) The Policy Sciences: Recent Developments in Scope and Method Stanford University Press: Stanford, CA pp.1-15. Lin, V. (2003) Competing rationalities: Evidencebased health policy? in Lin, V. and Gibson, B.J. (eds) Evidence-based Health Policy: Problems and Possibilities Oxford University Press: Melbourne, pp.3-17. Lin, V. and Gibson, B.J. (eds) (2003) Evidencebased Health Policy: Problems and Possibilities Oxford University Press: Melbourne. Lindblom, C.E. (1965) The Intelligence of Democracy Free Press: New York. Lindblom, C.E. and Cohen, D.K. (1979) Usable Knowledge: Social Science and Social Problem Solving Yale University Press: New Haven CT. Lomas, J. (1997) Research and evidence-based decision making Australian and New Zealand Journal of Public Health 21(5):439-440. Lomas, J. (2000a) Connecting Research and Policy Isuma Spring:140-144. Lomas, J. (2000b) Using linkage and exchange to move research into policy at a Canadian Foundation Health Affairs 19(3):236-240. Lomas, J.; Fulop, N.; Gagnon, D. and Allen, P . (2003) On Being a Good Listener: Setting Priorities for Applied Health Services Research The Milbank Quarterly 8(3):363-388. Lomas, J.; Culyer, T.; McCutcheon, C.; McAuley, L. and Law, S. (2005) Conceptualizing and Combining Evidence for Health System Guidance Final Report, produced for the Canadian Health Services Research Foundation Volume 17, Issue 2, August 2008

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Carol Bacchi available at: http://www.chsrf.ca [Date of access: 16.09.06]. Lynn, L.E. (1978a) Knowledge and Policy: The Uncertain Connection Study Project on Social Research and Development Volume 5 National Academy of Sciences: Washington, DC. Lynn, L. E. (1978b) The question of relevance in Lynn, L.E. (ed) Knowledge and Policy: The Uncertain Connection National Academy of Sciences: Washington, DC, pp.12-22. Lynn, L. (1978c) Introduction in Lynn, L.E. (ed) Knowledge and Policy: The Uncertain Connection National Academy of Sciences: Washington, DC, pp.1-11. Marmot, M. (2004) Evidence based policy or policy based evidence? British Medical Journal 328:906-907. Marston, G. and Watts, R. (2003) Tampering with the evidence: A critical appraisal of evidencebased policy-making The Drawing Board: An Australian Review of Public Affairs 3(3):143-163. Merton, R.K. and Lerner, D. (1951) Social scientists and research policy in Lerner, D. and Lasswell, H.D. (eds) The Policy Sciences: Recent Developments in Scope and Method Stanford University Press: Stanford, California, pp.282-363, Popay, J.; Bennett, S.; Thomas, C.; Williams, G.; Gatrell, A. and Bostock, L. (2003) Beyond beer, fags, eggs and chips? Exploring lay understandings of social inequalities in health Sociology of Health and Illness 25(1):1-23. Raphael, D. (2005) Exploring the gap between knowledge and action on the social determinants of health, presentation at Dahlgren and Whitehead and Beyond: The Social Determinants of Health in Research, Policy and Service Delivery Cardiff University, 21 April available at: http:// www.cardiff. uk/socsi [Date of access: 16.09.06]. Sanders, D.; Labonte, R.; Baum, F. and Chopra, M. (2004) Making research matter: a civil society perspective on health research Bulletin of the World Health Organization 82:757-63. Solesbury, W. (2001) Evidence based policy: whence it came and where its going ESRC Centre for Evidence Based Policy and Practice: Working Paper 1 available at: www.evidence network.org [Date of access: 10.10.06] Sundquist, J.Q. (1978) Research brokerage: the weak link in Lynn, L.E. (ed) Knowledge and Policy: The Uncertain Connection National Academy of Sciences: Washington, DC, pp.1126-144. Von Lengerke, T.; Rtten, A.; Vinck, J.; Abel, T.; Kannas, L.; Lschen, G.; Rodriguez Dias, J.A. and van der Zee, J. (2004) Research utilization and the impact of health promotion policy Social and Preventive Medicine 49(3):185-197. Weiss, C.H. (1977a) Research for policys sake: The enlightenment function of social research Policy Analysis 3(4):531-545. Weiss, C.H. (1977b) (ed) Using Social Research in Public Policy Making Lexington Books: Lexington, Mass. Weiss, C.H. (1978) Improving the linkage between social research and public policy in Lynn, L.E. (ed) Knowledge and Policy: The Uncertain Connection National Academy of Sciences: Washington, DC, pp.23-80. What Works Clearinghouse (2005) Who we are available at: www.whatworkshelpdesk.ed.gov/ [Date of access: 26.03.07]. WHO (World Health Organisation) (2005) The Know-Do Gap: Knowledge Translation in Global Health WHO Department of Knowledge Management and Sharing, Geneva, October 10-12 available at: www.who.int/kms/ WHO_EIP_KMS_2006_2.pdf [Date of access: 10.10.06]

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Trust in the health system: An analysis and extension of the social theories of Giddens and Luhmann
ABSTRACT
KEY WORDS Sociology, trust, social theory, health system, Giddens, Luhmann

Social theory provides a lens through which we can analyse the role of trust in health systems. However, the majority of theoretically informed trust literature addresses institutional or interpersonal trust individually, failing to investigate trust as determined by a web of mutually interacting relationships between individuals and social systems. Current theoretical assumptions are also problematic as they fail to recognise the role that social factors (such as socio-economic status, class and age) play in an individuals willingness to trust. Through the analysis and critique of existing social theories of trust, this paper demonstrates a need for further empirical research into the multidimensionality of trusting relationships, while suggesting new directions for research in public health.
Received 1 December 2007 Accepted 5 March 2008

Samantha Meyer, Paul Ward, John Coveney and Wendy Rogers


Department of Public Health Flinders University Australia

Introduction

ociology has been, and continues to be, fundamental for understanding the complex role of trust in the relationship between society and its health systems, as well as between patient, physician, health systems, and broader social systems (for example, economic, political, judicial). Through the study of social organisation, institutions, and the development of society, sociology offers a number of theoretical frameworks through which we can view trust in the health setting. Moreover, the application of social theory provides a useful lens through which the role of trust can be explored (Brown 2008). However, it has been argued that the subject of trust theory is disembodied, causing serious limitations to its scope and usefulness (Beasley and Bacchi 2007). This paper specifically addresses the limitations of the trust theories of Anthony Giddens and Niklas Luhmann. Giddens addresses trusting relationships between the
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individual and the system, while Luhmann looks at the relationships and mutual interaction between social systems. While both offer compelling insight into the concept of trust, this paper challenges several of their theoretical assumptions, and offers suggestions for a reconstruction of their theories. These suggestions may assist with finding a more comprehensive way of empirically researching trust in healthcare.

Social theories of trust: Why do we need them?


The concept of trust has become a major topic of interest in the medical and health service literature in the last decade. In the years 1995 2003, there were 1612 articles on the topic of trust in the medical and health literature, compared with 764 in the preceding 15 years (Schlesinger et al 2005). While useful for understanding the impact of trust on health promotion and illness prevention, much of the literature fails to define or explain adequately the theory of trust. A significant amount of the empirical work that has been conducted on trust in health systems has dealt only with the conceptualisation and description of trust rather than using a strong theoretical foundation. For example, social capital has been used in numerous studies investigating the link between socioVolume 17, Issue 2, August 2008

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economic status and inequalities in health (Kawachi et al 1997; Kim et al 2006; Lochner et al 2003; Subramanian et al 2003). The majority of this research looks at trust as a variable but fails to account for the complexity of trust as a process (Khodyakov 2007). Whilst trust is undoubtedly an important domain of social capital (Bourdieu 1984; Carpiano 2006), the application of social theories of trust would question its measurement in the current social capital literature. Luhmann (1988:100) argues that a conceptual distinction is not yet an empirical theory. In other words, while defining and describing trust helps to differentiate it from other concepts, a theoretical framework is necessary to view the foundations of trust and explain how it is (re)produced (Mollering 2001). Applying theory to research affords the opportunity to measure trust as a changing process. Theory provides a broad framework which shapes societys view of the world (Cooper 2001), and in order to analyse trust in health systems, there must first be a theoretical framework. This paper specifically deals with the theories of Giddens and Luhmann because both have been consistently cited in the majority of theoretically informed literature on trust (Andreassen et al 2006; Bordum 2004, 2005; Brownlie and Howson 2005; Gilson 2003; Lupton 1997; Mechanic and Meyer 2000; Salvatore and Sassatelli 2004; Ward and Coates 2006). Giddens and Luhmann specifically recognise two forms of trust; institutional (Luhmann 1990) (or in Giddens (1991) terms, abstract), systems based (Fukuyama 1995) or faceless (Giddens 1994), and interpersonal (Fukuyama 1995) (or in Giddens (1994) terms, facework). Both regard interpersonal trust as being negotiated between individuals (a decision to trust someone or not) and as a learned personal trait. Russells (2005:1397) argument that interpersonal trust in healthcare is built, sustained or damaged through face-to-face encounters with health providers and is more likely to increase with long-term doctor patient relationships, supports both Giddens and Fukuyamas theories that trust in the system is dependent on trust in the systems representative (Fukuyama 1995; Giddens 1990). Institutional trust is the trust placed in the system or institution. In health systems, this is placed in the

medical system (or in Luhmanns case, also the social systems which influence and interact with the medical system). Indeed, Gilson (2005:1382) argues that trust occurs in different types of relationships and is rooted in a combination of interpersonal behaviours and institutions that underpin those behaviours. Both practitioners and medical institutions (for example, hospitals, GP surgeries) must provide a trustworthy environment, as failing to do so has the potential to undermine the publics overall trust in the health system (Rhodes and Strain 2000). As noted earlier, while social theory provides a useful conceptual framework for exploring trust, there are serious limitations to its scope and usefulness in practical, real life situations. Since the theories of Giddens and Luhmann are covered quite extensively in sociological literature, this paper does not aim to provide a detailed summary of their work as a whole. Rather, the first aspect of this paper provides an explanation for aspects of their theories relevant to understanding the critiques and limitations we present; including their analyses of modernity and reflexivity, and the way in which trust functions in (or for) society. The second, more central aspect of the article, is a critical analysis challenging several theoretical assumptions and revealing the limitations of their analyses of trust. Furthermore, our analysis offers suggestions for new directions for which trust can be reformulated using contemporary theoretical perspectives for a more comprehensive practical application in real life situations. The ultimate goal of such an endeavour regarding health systems will be both understanding and responding to distrust, and building on areas of trust; both of which will be necessary for the smooth functioning1 of social systems, and society at large.

Why is trust important to public health?


Mechanic and Meyer (2000:657) state that trust is fundamental to effective interpersonal relationships and community living, and therefore a decline in trust may lead to continuous vigilance and anxiety within society (Crawford 2004). In terms of healthcare, the trustworthiness of individual health professionals, healthcare institutions (for example, hospitals, health centres, GP clinics) and forms of professionalised knowledge, are all essential for
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health systems to function in the interest of society (Rhodes and Strain 2000). Health system representatives (for example, healthcare professionals) have to convince patients to share personal information (including details of their symptoms), submit to tests, and take potentially poisonous chemicals into their bodies. In order for patients to permit these procedures and release personal information, trust obviously plays a major role since trust in health systems and health professionals has been shown to increase a patients willingness to seek care and utilise health services (Russell 2005), encourage patients to submit and adhere to treatment (Hall et al 2001), enhance the quality of interaction between patients and physicians, facilitate disclosure by patients, enable providers to encourage necessary behavioural changes, and may grant patients more autonomy in decision-making about treatments (Gilson 2003). As a fundamental dimension of the effectiveness of a health system, the function of trust warrants serious consideration in public health research. In the past decade, trust has become of major interest due to a decline in the trustworthiness of several democratic systems with a range of health system arrangements (Canada, US, UK, Sweden) (Hardin 2006), and the emergence of so-called high trust and low trust societies (Fukuyama 1995). Empirical literature has highlighted declining levels of trust in health care along with other institutions (Russell 2005; Gilson 2003; Welsh and Pringle 2001; Mechanic and Meyer 2000; Davies 1999; Birungi 1998). This may be linked to broader epistemological challenges about the authenticity of knowledge (Popay et al 2003; Williams 2000; Williams and Popay 2001), decreasing confidence in the power of science (Irwin and Michael 2003; Wynne 1992, 1996, 2001), increasing individual and societal reflexivity (Giddens 1994), and the capacity of experts to deliver to the patient control over their bodies (Crawford 2004; Scambler and Britten 2001). To compound the increasing levels of distrust, Luhmann (1979:16) argues that one should expect trust to be increasingly in demand as a means of enduring the complexities of the future which technology will generate. In other words, in the future, the whole notion of trust will become increasingly important.
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In addition, the lay populace is constantly bombarded with health messages which are often conflicting, contradictory and change over time. These have led many theorists to suggest we are all in a state of liminality or no mans [sic] land (Armstrong 1993; Bauman 1987; Gifford 2002). The consequences of such liminality are that lay people begin to question the validity of medical knowledge and hence, the trustfulness of both medical practitioners and the system on which their knowledge is based. In this way, trust in the health system (or any other social system) can no longer be simply taken for granted or expected; it has to be worked on and won, through a process of negotiation (Giddens 1991). Trust provides an important lens through which we can view significant relationships within health systems because it highlights often unrecognised dimensions of these relationships, while providing new insights into the way health system management might be improved (Gilson 2005). It is also important to understand the impact of trust relationships on the functioning of a health system, so that any changes which need to be made to improve trust can be determined (Hardin 2006).

A theoretical understanding of trust: Giddens and Luhmann


Both Giddens and Luhmann have made significant contributions to the trust literature. The following discussion however, is limited to prominent themes in Giddens and Luhmanns theories which are crucial for a critique of their work: 1) the conceptualisation of trust; 2) trust in modernity; 3) notions of reflexivity; and 4) trust as a function in (or for) society.

How is trust conceptualised? Giddens (1990) states that trust rests on a vague and partial understanding. Some decisions are based on inductive inferences from past experiences believed in some way to be reliable for the present. In order for someone to trust (rather than base a decision on rational choice), their decision must combine good reason (from past experience), with a further element that satisfies their partial understanding (Giddens 1991). This is similar to Simmels notion of a leap of faith (Mollering 2001).
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Trust invested in people or abstract systems made on the basis of a leap of faith, brackets2 out ignorance or lack of information (Giddens 1991). Giddens (1991) suggests this may be linked to a quasi-religious element or ontological security, drawing upon a sense of safety in the continuity and order of the world and its events. He describes it as a commitment to something other than just cognitive understanding (Brownlie and Howson 2005). Trust is only required where there is ignorance; there is no need to trust in a situation of complete knowledge (Giddens 1991). Luhmann (1988) addresses the concept of trust in terms of its function in/for society, for both individuals and social systems, which fits with his overarching structural-functionalist theory. In terms of the function of trust for individuals, he argues that trust is the glue holding everything together in social life because it reduces the complexity of how individuals think about the world, providing them with the capability to act and make decisions (Pearson et al 2005). In this way, the decision to place trust or distrust reduces complexity, because both decisions function as ways of rationally pursuing individual actions (Luhmann 1979). In terms of the function of trust for social systems, they need to reduce complexity in order to function properly, and with increasing complexity, the need for assurances through trusting relations grows accordingly (Borch 2005). Therefore, trust has become a central motif in late modernity for individuals and social systems. Luhmanns communicative theory rests on the relationships or interactions between individuals and social systems, and therefore trust is theorised as a medium of interaction between social systems and individuals. Trust occurs in a framework of interaction which is influenced by both personality and social systems, and cannot be exclusively associated with either (Luhmann 1979:6). In contrast to Giddens, the interactions between social systems and individuals for Luhmann are not conceptualised in a one-way, unidimensional manner, rather, trust is best understood in a multidimensional sense (Brown 2008), with trust in one social system being both highly dependent on trust in other social systems and individuals (Luhmann 1979). The corollary is obviously also

the case, whereby trust in individuals (e.g. a doctor) is highly contingent on trust in a variety of social systems. Both Luhmanns and Giddens conceptualisations of trust are in need of further investigation and research as they do not attempt to address the partial understanding that bridges the gap between knowledge and ignorance in an individuals decision to trust. This gap will be discussed in the second section of this paper.

Modernity A key component to understanding Giddens theory of trust is a process he calls reflexive modernisation (Beck et al 1994). In his book Consequences of Modernity, Giddens (1990) discusses how modern social forces (such as the expansion of electronic communication), have made the interpenetration of self-development and social systems more pronounced. This expansion has played a central role in mediating the organisation of social relations and in turn, created a demand for expert systems. Expert systems of knowledge now penetrate nearly all aspects of social life in conditions of modernity (Giddens 1991; Habermas 1989; Scambler and Britten 2001): for example, the food we eat, medicines we take. Giddens (1991) points out that whilst we are more and more dependent on expert systems over which we have little knowledge and control, we acknowledge that exper t systems cannot themselves adequately anticipate the future. This acknowledgement has resulted in what Giddens (1991:144) calls the sequestration of experience, also described as lay re-skilling (Hibbert et al 2002) or the myriad ways in which lay people seek to take back control over their own lives, either through a rejection of certain aspects of technology (for example, the growth of complementary and alternative medicine), or through re-appropriating different forms of technology for themselves (for example, self care). Giddens (along with Beck) argues that society is constantly forced to anticipate outcomes and assess risk as a result of modernity and increased reflexivity. As modern circumstances of uncertainty increase, the notions of trust and risk come to have particular applications in the functioning of society
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(Giddens 1991). Giddens (1991) says that to live in modernity is to live in an environment of chance and risk, which fits with Becks theory of the risk society (Beck 1992, 2005). Risk is now conceptualised as a fundamental means by which lay people and technical specialists organise the world (Giddens 1991). In modernity, society is continually drawn into the present through reflexive organisation and constantly forced to anticipate outcomes and assess how things are likely to diverge (Giddens 1991). Risk is an important aspect of trust because it adds another aspect to partial understandings. What or how much is at risk has a substantial influence on a decision to trust. Luhmanns (Luhmann 2005) central thesis around the move to modernity is that social and personal systems strive to reduce complexity. He argues that if there is no risk considered, there is confidence or expectation rather than trust. The awareness of risk is what moves an individuals decision from the assumption of confidence, to one where trust is required. Luhmann (1988) then goes on to distinguish trust from confidence, arguing that individual trust takes into account both past experience and the associated risks involved in the decision to trust, whereas confidence occurs when no alternatives are considered and decisions rely solely on expectation. For Luhmann, the notion of time is also a central concern in relation to trust, and he outlines the problematic relationship between trust and time. To show trust is to anticipate the future. It is to behave as though the future were certain (Luhmann 1979:10). Giddens and Simmel deal with this problem by linking trust with leaps of faith or blending ignorance and knowledge (Giddens 1991; Mollering 2001). Whilst Luhmann acknowledges the unavoidable contingencies in the decision to trust, he shows how individuals and social systems limit the horizons of trust by reducing the complexity of their worlds.

the outcome of, and a means for responding to an increasingly complex society. Since we have already covered issues of reflexive modernisation, we turn our attention here to Giddens ideas about the function of trust in the structureagency dialectic. Giddens (1991) argues that trust acts as a medium of interaction between modern societys systems and the representatives of those systems, which fits with his overarching Structuration Theory. The grounds for this interaction are referred to as access points; the meeting ground for what he terms faceless and facework commitments (Giddens 1990). Facework commitment is dependent on the demeanour of the expert (in health systems, the physician, or other health professionals). Their level of professionalism, mannerisms, and other aspects of their personality affect our impressions and expectations. Alternatively, faceless commitment is the perceived legitimacy, technical competence, and the ability of the expert system (for example, the medical system). As noted earlier, Giddens (1990) says that trust is sustained through facework commitments: trust in the physician is required in order to have trust in the medical system. The access point is the meeting ground between the physician and the medical system, whereby the physician is seen to represent the medical system:
Although everyone is aware that the real repository of trust is in the abstract system, rather than the individuals who in specific contexts represent it, access points carry a reminder that it is the fleshand-blood people (who are potentially fallible) who are its operators (Giddens 1990:85).

Trust as a function of (or for) society In this section of the paper, we draw together some of the previous discussion by exploring the ways in which Giddens and Luhmann see trust as a function of (or for) society. In essence, Giddens regards trust as a response to an increasingly reflexive society, whereas for Luhmann it is both
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In other words, Giddens argues that institutional trust presupposes and is determined by interpersonal trust. For Luhmann, trust is seen as both an outcome of, and response to increasing complexity in society. Individuals have come to depend on learning and confirming trusting relationships between the boundaries of internal systems and the external environment (Luhmann 1988). For instance, a patient can learn to trust a surgeon (who is part of an external system, the medical system), that they have never met, and do not know anything about in terms of demeanour or personality. However, they may have learned to trust between the
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boundaries of systems and believe that both the health system and the medical professional (the surgeon) will operate in their best interest (Russell 2005). The differentiation of the approaches to trust/distrust (internal vs. external), is rational from the point of the system because it helps it to preserve the higher level of inner order, in comparison to its external environment. If the patient did not trust the surgeon but instead, asked the neighbour who is a pilot (whom they trusted) to do their surgery, complication and chaos would result and their action would not be rational. The inner order helps stabilise an extremely complex environment by organising a less complex system-order better suited to human capacities for action (Luhmann 1988). While Luhmann has, of course, much more to say on such issues, there is insufficient space to discuss it all in this paper. For instance, Luhmann discusses trust as a major component in the reduction of complexity between and within modern social systems, and the role of familiarity in trusting.3

while Luhmann argues the reverse, that trust in the system is necessary before an individual can have trust in the systems representative. By constructing their theories of trust relationships as linear, both ignore the web of interactive relationships which may influence individual trust. Rather than linear, trusting relationships can be understood as a complex web of interaction. Lewis and Weigert (1985:974) argue that:
... an adequate sociological theory of trust must offer a conceptualisation of trust that bridges the interpersonal and systemic levels of analysis, rather than dividing them into separate domains.

Towards a more comprehensive social theory of trust


Giddens and Luhmann have both been influential in the pursuit of understanding trust, and made significant contributions to understanding the complex trust relationships that exist between and within different social groups, systems, levels, and relationships. However, both are purely theorists and their work has not been tested empirically. The following critiques aim to identify the gaps in Giddens and Luhmanns work in order to provide contemporary theoretical perspectives for future empirical research on trust in the real world. The idea of developing a further social theory of trust is not to refute or dismantle the theories of Giddens and Luhmann, but to move toward a more comprehensive social theory that can be directly applied to understanding and evaluating the function of trust in health systems. As previously outlined, in order to fully understand trust, it is essential to address the role that both interpersonal and institutional forms of trust play in society. Giddens maintains that interpersonal trust is necessary before there is potential for institutional trust; that trust is linear,

This idea has been discussed by Ward and Coates (2006) when their findings suggested the discourse of mistrust is presented at a number of inextricably linked levels and related to multiple social systems. While participants in their study spoke of a lack of trust in local GPs, this could not be separated from the mistrust of both local and national healthcare and wider social systems (Ward and Coates 2006). However, after extensive literary review, no other empirical trust literature addresses trusting relationships as a multidimensional web, presenting a need for further investigation into the relationships (individual and system level) that affect trust. The contradiction between Giddens and Luhmanns views presents an opportunity for empirical investigation. Determining the relationship between interpersonal and institutional trust is essential to understanding the role of trust in health systems. If trust is the result of complex relationships/interactions between the physician, the medical system, and broader social systems that influence the health system, trust on all levels needs to be addressed when determining how to improve trust within health. As stated earlier, Giddens (1991) argues that in modernity, society is continually drawn into the present through reflexive organisation and constantly forced to anticipate outcomes and assess how things are likely to diverge. However, gaps in this theory become obvious when applied to practical real life situations. Giddens (1991) argues that modern individuals have become sceptical
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about modern institutions (such as science), no longer accept the judgements of experts, and hence trust in modernity must be worked on and won. However, in reality, numerous factors including new communication technologies and advances in knowledge transfer have significantly altered the landscape in which individuals question the judgement of experts. There are for example, vast gaps between the information rich and the information poor (Elliot 2002); and the latter group lack the resources for questioning experts, and therefore, are not making a reflexive choice to trust. The information poor cannot utilise all the available resources for decision-making (lack of information or access to information) and may find themselves further disadvantaged and marginalised in a new world order of reflexive modernisation (Elliot 2002). This idea has been termed stratified reflexivity, and it conceptualises the reality of the structural patterning of reflexivity existing in society (Ward 2006). For instance, Giddens fails to pay significant attention to the role played by gender, age, social class, ethnicity, nationality and so on in constructing differing risk experiences (Alexander 1996), and therefore, the decision to trust. Giddens agrees that technology transfer has increased complexity in society, but does not address the interdependence it also creates. Interdependence, in situations where there is a lack of information, implies more dependency and less reflexivity or self-sufficiency. Institutions are necessary and must function effectively in the context of societal interdependence in spite of distrust. The vested interests of the dependent individual are thus vulnerable to the actions of others (Bluhm 1987). Within healthcare, the information rich may have the means to investigate alternative therapies or seek forms of selfhealing when they mistrust their physician. Conversely, the information poor may not have access to similar information, and may have no choice but to depend on their physician for medical advice. However:
... to argue that principles in complex society have no choice but to trust is far too simple. Indeed, there is enormous variability in the extent to which, and the conditions under which, they exercise that choice (Shapiro 1987).
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Further empirical research is required to determine what these variables are, and under what conditions individuals trust. Trust is best conceptualised as a multi-faceted phenomenon with distinct cognitive, emotional and behavioural dimensions; all of which must be comprehended sociologically as having varying levels of importance for individuals (Lewis and Weigert 1985). The cognitive attitude is present in all forms of trust, but the experience and rationality that reinforces the cognitive leap varies considerably (Lewis and Weigert 1985). The strength and importance of the cognitive versus the emotional base of trust depends on the type of social relationship, the situation, the system under consideration (Bonoma 1976, cited in Lewis and Weigert 1985), as well as the personal characteristics of the individual. A number of factors affect our ability to act as reflexive agents; level of dependency, social/ cultural networks, individual weight in variables of trust, as well as numerous other factors beyond the realm of this paper. Further empirical research is necessary and may afford insight into the practicality of reflexivity as a factor in an individuals decision to trust. One final remark on the work of Giddens and Luhmann forms the basis for a research question rather than a critique. Along with other prominent trust theorists (Simmel, Fukuyama) both theorists discuss trust in situations where there is a shortfall of information. As noted earlier, for Giddens the shortfall is compensated for by a leap of faith which can be understood as intuition; an act of knowing or sensing without the use of rational processes. For Luhmann, trust always extrapolates from available evidence. When the available evidence is not sufficient, risks are weighted against the potential positive outcomes. Luhmann (1979:26) argues:
Although the one who trusts is never at a loss for reasons and is quite capable of giving an account of why he [sic] shows trust in this or that case, the point of such reasons is really to uphold his [sic] self-respect and justify him [sic] socially. They prevent him [sic] from appearing to himself [sic] and others as a fool, as an inexperienced man ill-adapted to life, in the event of his [sic] trust being abused. At most, they are brought into account for the placing of trust, but not for trust itself. Trust remains a risky undertaking.

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Samantha Meyer, Paul Ward, John Coveney and Wendy Rogers

While we recognise that a gap between knowledge and ignorance exists, the explanation for this remains fairly abstract and in need of empirical investigation. In understanding why people place trust, whether based upon experience, knowledge, or faith, there is potential to gain insight on how to encourage trust in health systems. However, we may also look at this challenge as one that is out of the realm of sociology; a challenge of epistemological or psychoanalytical nature. Extensive empirical literature poses the argument that trust is quantifiable; but can we ever really measure and bring into view the linkages between knowledge and ignorance? This question remains an important one in need of further investigation. Theoretical expansion and further empirical research may provide insight into whether we can ever really understand why people trust.

conditions or determinants of trust is more useful than attempting a further definition of trust (Butler 1991, cited in Hosmer 1995). Butler (1991:647) argues currently there is no agreement to what these trust conditions are, and there is not instrument for measuring an exhaustive set of them (cited in Hosmer 1995). Until we can determine what the conditions, determinants, and variables of trust are, we cannot anticipate positive changes in, nor act to alter the declining levels of trust in healthcare. This issue warrants serious consideration for public health and should be included in future health research agendas.

Endnotes
1. When arguing that trust is imperative for the smooth functioning of any health system, we recognise the idea of a smooth functioning system is intrinsically impossible. However this paper takes a functionalist approach in presenting agents as having a responsibility to keep the smooth functioning of society. We also acknowledge that functionalism assumes equal power within society, but this is not a central component of the paper. Rather, in recognising this weakness, we put forward the need for further empirical work. 2. Giddens often uses the term brackets. Bracketing, in this sense, means to remove or compensate for what we are lacking. 3. For further information on social systems theory and familiarity, see Luhmann (1979, 1988).

Concluding remarks and areas for further empirical investigation


Social theory is beneficial to public health because it helps us to understand how, where, and why trust functions in society. This paper is an effort towards identifying the gaps that continue to exist in current trust theories, while suggesting future directions for empirical research. Future research may help to identify modes and possibilities for health system transformation, through understanding the variables and conditions under which people trust. Luhmann (1979:46) poses a question which may form a research program within public health:
... it is all too obvious that the social order does not stand and fall by the few people one knows and trusts. There must be other ways of building trust which do not depend on the personal element. But what are they?

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Copyright eContent Management Pty Ltd. Health Sociology Review (2008) 17: 187198

Consuming bodies: Mall walking and the possibilities of consumption


ABSTRACT
In popular, academic and policy discourses it is taken for granted that consumption plays a vital role in the obesity epidemic. Mass consumption, associated changes to lifestyle and the emergence of obesogenic environments are viewed as underpinning the dramatic rise in the prevalence of overweight and obesity. As a result, excess body weight has transitioned from risk factor to disease status, with overconsumption identified as the principal culprit. Using mall walking as a case study, this paper aims to critique the way in which consumption is understood within the obesity literature. Rather than view consumption within a dualist framework of either neoliberal choice or modern evil, we seek to establish a theoretical foundation for consumption in obesity literature. Mall walking provides a unique opportunity to examine the multiple, complex and contradictory facets of consumption, of how bodies and spaces are reappropriated and transformed by people who are located in an environment that is characterised as obesogenic. In addition to the generation of identities and social relations, mall walking highlights the inherent paradoxes of consumption: of how consumption is positioned as the problem, and at the same time, as the solution to excess. It is via the ethnographic examination of bodies engaged in consumer spaces that new possibilities for thinking about the analytical relationship between obesity and consumption are opened up.
Received 31 November 2007 Accepted 5 March 2008

KEY WORDS Consumption, paradox, obesity discourses, mall walking, sociology

Introduction
Megan Warin
Department of Anthropology Durham University United Kingdom

Vivienne Moore
Discipline of Public Health University of Adelaide Australia

Michael Davies
Discipline of Obstetrics and Gynaecology University of Adelaide Australia

Karen Turner
School of Social and Environmental Enquiry (SSEE) University of Melbourne Australia

f one considers, as do Henderson and Petersen (2002:2), that consumerism has become a way of thinking and a way of life, and provides the very basis for our concept of self, or identity, then it is no surprise that the literature on consumption studies has continued to grow. As anything in social life can become an object of consumption (Baudrillard 1988), a number of disciplines are now viewing consumerism and (and its complex interrelationships with the social and economic aspects of commodification and consumption) through many different kind of social processes and relations, including gender, kinship, ethnicity, age, sexuality and locality. Consumption is a thoroughly multi-disciplinary topic, and this has led, as Edwards (2000) notes, to a contested terrain of definitions (2000:13), where differences in theoretical and empirical foundations of perspectives remain fundamental to debates
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concerning questions of consumption and consumer societies. The heterogeneity (and history) of consumption theory is important to the following discussion of obesity, for we are immediately led to multiple and complex meanings of consumption, rather than a singular understanding. At its simplest and takenfor-granted level (as it is currently used in much clinical literature), consumption refers to the process of consuming, of using up, devouring or even eating (Edwards 2000:10). But from this semantic representation consumption can then branch out into multiple analyses. In acts of desire to consume, people can be unconstrained rational actors seeking to maximise positive personal outcomes (Edwards 2000:11), or, taking a political economy approach, can be seen to fall victim to the lures of packaging and advertising and the negative consequences of consumption. While it is not our intention in this paper to describe the historical antecedents of consumption (as this has already been well documented by, for example, Miller 1995; Edwards 2000; Clarke et al 2003), we aim to highlight a key feature of consumption: that is, its inherent paradox. Consumers can, on the one hand, construct and display their own sovereignty through what they consume, but at the same time cannot escape the fact that consumption plays an ideological role in actually controlling the character of everyday life (Miles 1998; Edwards 2000). Rather than buy into and reproduce dualist discourses of good or bad consumerism, this paper takes as its starting point contemporary theoretical insights that acknowledge the fulcrum of dialectical contradiction (Miller 1995:33) that surrounds consumption. It is through the case study of mall walking in the northern suburbs of Adelaide, Australia (an area with high prevalence rates of obesity and related diseases) that we problematise the taken-for-granted and causative aspects of consumption. As the name suggests, mall walking is organised exercise in shopping malls, in which people do circuits of the complex before the shops open to trade with the public. This is not Walter Benjamins 19th century solitary flaneur [or Friedbergs flaneuse (1993)], the stroller (usually male) who seeks to bathe in the crowd,

and immerse (himself) in the sensations of the shopping arcades and city. Rather, these are organised (and often fast paced) routes that take place at very specific times of day and with the specific goal of exercising and removing the excess flesh of consumption. In order to examine the differing modalities of consumption, the paper is divided into three sections. The first section briefly examines the ways in which consumption has been used in health discourses, and in particular, centrally implicated in discourses of obesity. Lupton, writing in 1994, suggests that little health promotion theory has been informed by recent socio-cultural theoretical developments in understanding consumerism, commodity culture and everyday life choices (Lupton 1994:111). We argue that within the current obesity literature this is still the case, as consumption remains ideologically wedded to a simplistic discourse of moral economy. The second section describes the study and phenomenon of mall walking, locating this activity in the historical and socio-economic context of the region. The relationship between health and place is vital here, as the obesity literature clearly highlights that in most Western countries, there are inverse gradients between socio-economic positions and adult BMI, with the most disadvantaged groups at greater risk of being obese or overweight (King et al 2006:281). Whilst our study spans different socioeconomic locales, mall walking takes place in the socio-economically disadvantaged areas, in an environment that the obesity literature identifies as obesogenic (Swinburn et al 1999). The ethnographic context provides a platform upon which to critique and extend the theoretical trope of consumption. Mall walking highlights the constraining and enabling capacities of consumption, for consumption is implicated in the causative factors of obesity, but simultaneously positioned as a strategy to promote healthy lifestyles. It is this blurring of consuming bodies, health and spaces that provides a window to critically engage with the dialectical tensions of consumption. In particular, we argue that health promotion and prevention initiatives need to consider the multiple ways in which consumption operates in peoples everyday lives, and not
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simply view consumption as a negative (and moralistic) desire to consume goods.

(Over) consuming bodies and the pathologisation of consumption


Explicitly tied to discourses of consumerism are bodies (Bourdieu 1984; Featherstone 1991; Falk 1994), for they are important forms and foci of capital (both symbolic and economic), in which they can become gifted, fragmented, objectified and exchanged in commercial transactions. As Seale et al (2006) argue, many practices relating to bodies have attracted the charge of unwelcome and exploitative objectification and commodification (such as slavery, transnational trade in children and women, the sports industry, and the military use of bodies) (Seale et al 2006:26). Similarly, the anthropologist ScheperHughes has been a long standing critic of the commercial exchange of organs in a global economy, arguing that commodification of body parts leads to exploitation of vulnerable and marginalised bodies (Scheper-Hughes 2001a, 2001b; Scheper-Hughes and Wacquant 2002). Despite this recent anthropological and sociological literature into health and consumerism, Henderson and Petersen (2002:2) argue that there has been relatively little analysis of consumption and consumerism as applied specifically to health and health care. These authors suggest this is somewhat surprising, considering the encompassing language of consumerism in health care, and the commodification of spaces in which health care is delivered. Indeed, health is no stranger to Marxist analysis, and has historically been a classic consumerist model of buying and selling skills and products. Health reforms in Australia (and in many parts of the world) are based on a market ideology that has resulted in an infusion of competitive practices and greater levels of advertising in health care (Gesler and Kearns 2002:140). An outcome of this process has been the construction of health and health care as a commodity and product as well as quality and service, in which the health care system has become what Sack (1992) describes as the consumers world.
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Such shifts in health can be traced in all sectors of health care, from the changing language of patients to consumers, (both in key UK policy documents in the 1990s and the uptake of this rhetoric by advocacy groups), and the shifts in health care delivery from clinical to consumer spaces (such as breast screening facilities in Australian retail stores, and in the growing market of health tourism in desirable locations). Bunton and Burrows argue that health promotion is itself deeply embedded in the domain of consumer culture (Bunton and Burrows 1995:210), for it relies on marketing campaigns and the individualising of consumption issues to market social change in the name of health (Bunton and Burrows 1995:210). Commodities and activities (such as what we eat, how and where we exercise, the brand of cigarettes we (used to) smoke and how much we drink) are symbolic attributes of consumer culture (see also Bourdieu 1979/84), where, in health promotion discourse, they take on the properties of health giving or sick making. Some people and populations are identified as engaging in too many of these sick making activities or lifestyles (Cockerham 2006), and it is these activities and bodies that are being increasingly surveilled and governed under the banner of health promotion (for example, the UKs Body Mass Index Surveillance Programme 2005-6). The health attributes of a commodity vary in the extent to which they can be viewed as health giving or sick making. In the medical literature, tooth brushing is universally viewed as health giving, and smoking is viewed as sick making. In contrast, eating and activity are intrinsically different due to their essential nature for existence. Debates centre not over whether eating is unhealthy, or often even whether a particular food is unhealthy, but whether the diet is unhealthy given a particular pattern of individual characteristics such as age and activity levels. What is healthful for babies is not necessarily appropriate for athletes or the sedentary elderly. Consumption of food is therefore essential for health, but debates over defining which foods and how much to consume is increasing contentious as the accumulation of consumption is reflected in rising obesity.
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From clinical accounts to sociological analyses, consumption is discursively constructed as the effect of an unlimited supply of convenient, relatively inexpensive, highly palatable, energydense foods (Hill and Peters 1998), or as the result of an obsession with mandatory consumption (Dixon and Broom 2007). Consumerism is taken as a broad brush, and includes, according to Lobstein (2006:74) the usual suspects (or sins):
the pharmaceutical industry with an interest in medicalising the problem, and the weight loss industry with products to sell ... the food and beverage industry (including advertisers and the media) the sedentary entertainment industry (tv, video games, etc.) and the transport industry which needs to resist moves to reduce car use and to make roads pedestrian friendly and cycle friendly.

Swinburn et al (1999) argue that it is precisely these modern environments that are fuelling the obesity pandemic by encouraging an oversupply of energy in the population. These damaging consumption practices take place in obesogenic environments, where unhealthy choices are said to be the default option (Swinburn and Egger 2004); and obesogenic landscapes slip into obesogenic lifestyles. These perceived causes of obesity are widespread, and are easily echoed by primary school children (Hardus et al 2003), in policy documents (Evans 2006), lay perceptions found in the media (Lawrence 2004) and clinical discourses. Consumerism is read as an economic (and moralistic) model in which people consume (and over consume) products that may be viewed as either intrinsically unhealthy (such as a trans fats), or where the pattern of consumption generates a cumulative disease risk that can be defined as pathological consumption practices (Hayward and Yar 2006).1 Consumption itself is thereby moving towards medicalisation (as seen in the desire to pathologize obesity as a disease state) (see also Heshka and Allison 2001). In this range of negative discourses, obesity and consumption are thus implicitly connected through a discourse of excess. Obesity is part and parcel of the postmodern condition or culture of surplus (Rundle 2007); presented as a form of

social anaesthesia or commodity fetishism (see also Miller and Rose 1997). Fat people, as Longhurst argues, are aware of negative social stereotypes of corpulent bodies and live with guilt about taking up too much space (2005:252). Obesity is the direct outcome of overconsumption, and both obesity and consumption are castigated as demonstrating greed, stupidity and insensitivity to want (Douglas and Isherwood 1996:vii). Miller notes the ways in which early studies of consumption fall into a series of both colloquial and academic clichs (Miller 1995:52), and it is these clichs that continue to be drawn upon in obesity discourses. While the commodification of health has raised the positive concept of agency and choice within consumerism, in the obesity literature acts of overconsumption are repeatedly blamed for the excesses of modern life. The following section seeks to move beyond this polarisation and global homogenisation of consumption, by examining the contradictory, inconsistent mess of ordinary mundane worlds [that are] so often absent in writings on consumption (Miller 1995:51). It is in the attention to the layering of consumption practices and forces, at both local and global levels, that the complexities of consumption can be understood.

Mall walking in obesogenic environments


The background to the empirical data cited in this paper comes from a larger study (Warin et al 2008) in which we are investigating how a group of thirty women, who are all in the clinical range of obesity, experience and understand their body shape. This project took us to different socio-economic locations across Adelaide, where we not only conducted interviews and participant observation with the women, but also mapped local shopping centres and neighbourhoods in an attempt to understand the environments in which they lived. It was during our fieldwork in a local shopping centre that we noticed a flyer for mall walking, and were immediately drawn to the differing meanings and spaces associated with consumerism; in particular, the person as an active health consumer and the consumer space of a shopping mall. Opposed values of consumerism
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are thus rolled into one: mall walkers are subjects consuming health, and objects in a consumerist environment. It is in the space of the mall, as Thomas (2003) argues, that we can examine this relationship between subject and object in consumption, and embodied and spatial performances of identity (2003:104). Moreover, the mall provides the perfect site in which to trace the symbolic shift in health care from the world of the service user to the world of the consumer. The ethnographers in this study (Warin and Turner), contacted the instructor who ran the weekly mall walking classes, explained our interest, and were invited to participate. We joined the mall walking at two shopping centres as participant observers, walking the circuits over a period of four months. Participant observation was the most appropriate methodological approach, as being there and actively taking part in the process of mall walking allowed us to come closer to experiencing and understanding peoples motivations to be a part of this activity. As we walked with group members we engaged in informal conversations, which provided important contextual data into their lives. Our main focus was the Elizabeth mall walking group, and we joined another mall walking group at a nearby complex for two morning sessions. With permission, we took photographs and video footage, had informal meetings with management and shop proprietors, and conducted open-ended interviews with key informants (regular walkers and instructors). Fieldnotes were written up after mall walking sessions, and our interpretations checked with participants on subsequent visits. We also took detailed ethnographic observations of the temporospatial dynamics of mall and its changing life over the course of a day, including promotional material that was used in architectural displays to advertise the malls refurbishment. Mall walking is a class related activity. In Adelaide it began in 2001 and now occurs across six different shopping precincts, five of which are located in marginal locations (and predominantly lower class suburbs) and the sixth hosted in what has been touted the largest shopping centre in the southern hemisphere. The Elizabeth City Centre shopping mall (which was undergoing a major renovation during our fieldwork) is 30 kilometres
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north from the CBD of Adelaide, and is single storey, unlike many shopping centres today which attract customers through multi-level architecture and car parking. The mall, as its name suggests, is a central landmark of the area, sign posted by a multi-story tower that dominates the skyline and is visible from a significant distance. With its red rose emblem adorning the top of the tower, its aim is to draw shoppers to a centre of urban constellation which appropriates the mall as a surrogate town square (Shields 1992:4-5). While the mall has had several refurbishments and additions over the years (and was undergoing major redevelopment during our fieldwork), it retains a flavour of its original 1960 structure, particularly its single storey box-like design. The surrounding areas are home to a row of car dealers, and the sick making commodities that Bunton and Burrows (1995) and Cummins et al (2005) identify in their research: a high proportion of fast food and alcohol outlets, and gambling and smoking shops. The city of Elizabeth was settled in the 1950s by white British migrants, lured by cheap passage and promise of home ownership and semi skilled labour, primarily around an emerging automotive manufacturing industry. The 2001 census indicates that by far the largest group of people in this area are those born in the UK (significantly higher than any other region of Adelaide) with a notably lower percentage of the population born in non-English speaking countries (City of Playford Community Profile 2006). While there is now greater diversity of income throughout this region, it continues to be stereotyped as a location of low income households (and described by a criminologist as housing the most socially isolated, culturally deprived and often sexually abused group who lived in Adelaides northern suburbs (The Australian 2003). Unemployment is high (14.1%), and is double that of other locations in Adelaide (city of Adelaide 7.1%). A third of households earn less than $AUD400 per week, and the median weekly income is $AUD580 which is well below the average Australian income. Twenty-two percent of residents reside in public housing and the area has a much higher incidence of single parent families than Adelaide (City of Playford Community Profile 2006).
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Like similar locations in Australia (Brisbanes Inala, Melbournes Broadmeadows and Sydneys Mount Druitt), this is a highly stigmatised area, and residents are well aware of the negative stereotypes that come with the territory. As the social historian Peel (2004) argues (having grown up in this area), poverty is embodied by working class people, and in their own accounts, poor people say their bodies often fail them (2004:83). Aching backs from heavy manual labour, poor teeth and oversized bodies speak loudly about impoverished living conditions and become intriguing barometers for interpretations of inequality and welfare reform (Peel 2004:83). In line with studies that have mapped the inverse relationship between socioeconomic status and obesity (Sobal and Stunkard 1989:261; Stunkard and Sorenson 1993), the prevalence of obesity in this area is high, with 59% of people classified as obese according to standard BMI measures (Appleton et al 2006). In public health discourses of obesity, this region fits with the characterisations of obesogenic environments mentioned above. Swinburn, Egger and Raza (1999) define obesogenic environments as the sum of influences that the surroundings, opportunities or conditions of life have on promoting obesity in individuals or populations (1999:564). Broader than the physical environment, obesogenic environments include such aspects as economic constraints, policy impacts and socio-cultural influences. Although they did not use the term obesogenic, mall walking par ticipants reiterated these attributes, describing their neighbourhoods as unsafe, and lacking appropriate lighting, footpaths and affordable exercise facilities. As in Popay et als (2003:18) study of lay understandings on the relationship between health inequalities and place, participants were able to give graphic and explicit accounts of the way in which adverse material circumstances [such as poor housing and crime] impinged on their health. It is in this context that the shopping mall, community and mall walking must be considered. The mall (which also houses community and welfare services) has been a social and commercial pivot of this community for decades, and the renovation is clearly part of a plan to make over

the cultural identity of the region. Architectural promotions in the shopping mall emphasise the magical transformation of bodies and spaces through the bright displays of caf latte and chardonnay sipping faces. In an economically deprived area, developers are well aware that shopping is one of the most important social and leisure activities and aim to exploit the magic of the mall (Goss 1993) by facilitating consumption through consumers participation in an imagined community. It is in the ongoing refurbishment of space that mall walking takes place twice a week, on a Tuesday and Thursday morning at 7.30 am before the centre opens to the public. Different shopping centres have different numbers of walkers, ranging from 15 regulars at Elizabeth to 120 at the larger multi-level shopping centres. Walkers enter via a side entrance and meet at a popular ice cream chain outlet, paying their two dollar fee to the team leader, Jane, a middle-aged, qualified sports instructor with infatiguable enthusiasm. Jane led the group through five minutes of the warm up exercises before they peeled off into small walking groups. The majority of people who come to the walks are women aged over 50, and have lived in the area all their lives. Some participants have been coming since mall walking began, and others are new recruits. They heard about mall walking via leaflets in the malls, through local newspapers and word of mouth, and like the advertising tag line (walk for fun, fitness and better health), the primary reason why people attend is to stay healthy, lose weight and to keep fit. For some, this included keeping my weight down, and as part of a Weight Watchers program. Walkers were defined by groups of friends, and each set their own pace, some walking quickly and decisively, and those using walking sticks or with hip replacements walking slowly. As shop owners were getting their windows prepared for the days trading, they smiled and waved at the walkers: some even knowing each other by name. While very few people stopped to look in windows or the prices of items, everyone had a working knowledge of where the renovations where up to, and which shops were relocating and where, and
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which shops were brand new to the mall. In many ways, these early morning mall walkers were intimately connected to and involved with the refurbishment, as they had a privileged insight into the workmanship and weekly changes. To be in a shopping mall before trading begins, to mingle with the tradespeople, security guards and shop owners, gave the group a particular sense of ownership through space and time that the everyday shopper would not have. Asked why they walk in an indoor mall rather than in the large green parks that are abundant throughout this geographically flat area, it was unanimous that the mall was a safe place (and participants pointed out the mall security guards who all nodded and smiled as walkers passed). As the main doors opened to the public, Trevor (a widower in his 70s) pointed out a group of school children in the mall, saying that he was scared of young people and by walking in a group he felt a sense of security. In their study of deprived communities in the UK midlands, Parry et al (2007:135) similarly note how fear prevented older adults taking outdoor exercise, limited the use of buses to access shops, and compromised day-today social interaction. The metaphor of safe, family shopping is explicitly used in marketing strategies to emphasise warmth, safety, and convenience of the mall as a place to shop (see also Miller et al 1998:92-93). This is in stark contrast to several other shopping centres in the area which embody a sense of danger through their layout; one small suburban shopping centre is surrounded by 12 foot fences that are locked at night, and others have meshed store windows with shopkeepers serving behind wire screens. Many mall walkers said that the flat surface was easier to walk on and there was no threat of tripping over broken pavements. In addition, the climate was controlled so they could come in rain or hot weather, and there were toilets handy if need be. The constant temperature and filtered air was particularly important for Mary, who suffered from asthma and was unable to exercise outdoors at this time of year. These rationales echo Shcnact and Unnithans (1991) findings, who suggest that people are drawn to mall walking because they can do low impact exercise in a
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climate controlled and safe environment, and in doing so, interact with fellow walkers. It was after the walking at the regular caf (where most walkers stopped after each session) that we learnt how intimately these walkers knew each other. As Angela left the table and said goodbye to the man she was sitting next to, Andrew told her how he wouldnt see her next week as hed be in hospital (and proceeded to tell her why). Angela put her hand on his shoulder and said: well be thinking of you, and then others at the table who had overheard similarly conveyed their support. Perhaps the most striking evidence of support was displayed by Jane the instructor, who took on a mothering role by constantly offering hugs, especially to those walkers who didnt have partners or family close by. She explained: It might be the only hug they get that week. Again and again walkers emphasised that mall walking is not just about walking, in fact they said, the walking is incidental. As Lupton (1994) argues, when cultural meanings are examined, health is often a minor component of peoples reasons for engaging in exercise regimens, and in the case of mall walking, it is the network of relationships that sustain the event. These positive effects of mall walking accord with an interpretation of consumptions social, as opposed to economic, importance. The importance of these different levels of social interaction and kinds of social relationships in public consumption spaces are emphasised by Miller et al (1998) in his comparative analysis of Brent Cross shopping centre and Wood Green Shopping City in North London. Miller similarly found that malls are places that perennially constitute and reconstitute social relationships through various practices of shopping and identity (1998:26-27). In focusing on the literature that emphasises consumption spaces as investments in social (rather than economic) relationships (Warde 1996; Miller et al 1998; Erkip 2003), one could easily argue that it was the friendships and social interaction that drew people back week after week. This is what Schnact and Unnithan (1991) argue in their analysis of mall walking and urban sociability. Mall walking does not promote hyperVolume 17, Issue 2, August 2008

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individualism, but creates its own forms of social connectedness and social practice. The shift in social interaction is away from the common interest of public consumption during normal shopping hours to the sharing of a private desire to reduce the impact of overconsumption. By operating during hours when the shops are closed, mall walking constrains consumption, but uses many of the features that make consumption both easy and pleasurable to counteract the effects of consumption. Moreover, from a public health perspective, and with the knowledge of this demographic, there is every reason that affordable and accessible exercise programs should be run in a community which has fewer exercise facilities than other regions of Adelaide and a higher prevalence of weight related disorders (such as diabetes and obesity). So on the one hand, these consumption spaces promote health and are important sites for the creation and maintenance of social relations and communities. Consumption spaces are sites for human creativity and action, in which people negotiate and play with space. Trentmann (2004:384) suggests that groups suffering from social exclusion and low income may very well be left out of a consumerist dream world. Mall walking points to how people in lower socio-economic geographies adapt to, and use, consumerism for their own means. Taking ownership of the community centrepiece re-engages and re-enforces them as participating consumers (even though they are not in the mall to purchase goods, they are purchasing symbolic power by taking ownership of a privately owned, public space). A similar argument concerning the tactical use of space by health consumers is demonstrated in Knowles (2000) work. Her research into the community mental health care system in Montreal reveals how psychiatric clients transit around the city, spending a large part of their days in nearby shopping malls when the shelters are closed. Shopping malls are open long hours, provide warmth, light and company, and clients play at being consumers by filling their plastic coffee cups with water as they sit for hours in the food halls, contemplating consumption as a way of being in the world. As well as providing a haven, shopping

malls provide clients with the idea of consumption, as a legitimate avenue of human gratification and way of spending time (Knowles 2000:221).2 Mall walking creates an additional social context for the mall as depot, where consumption is being balanced by constraint, and where engaging in social relations and shared activities take precedence overconsumption. These are the same features evident in the advertising and architecture of refurbishment that emphasise the socially friendly spaces and sharing of pleasurable moments associated with breaks from shopping to enjoy coffee or wine with friends and family. However, the shift in time to allow occupation when the centre is closed, quiet and private, allows engagement with both active and passive constraint on consumption. The shops become an audience to the activity of the walkers. Both passive and active constraint undergoes decompression once the centre opens to the public, as the motive for walking shifts from working off excess pounds to purchasing more, and the centre of attention is the purchasing activity within shops.

The consumption paradox


To leave this analysis evaluating the positive social attributes of mall walking however, only speaks to one side of the consumption paradox. The role of consumption in mall walking and obesity is much more complex and ambiguous than authors like Schnact and Unnithan (1991) suggest. The concept of health propels an entirely new set of meanings into the equation for it brings with it a different understanding of consumer. Within neoliberal politics of health care, consumerism is often presented in terms of personal empowerment and freedom of choice in which citizen based consumers buy into appropriate participation, advocacy and the improvement of health care for larger numbers of people (Gesler and Kearns 2002:141). Although not explicitly stated, this is the positive consumer model which Schnact and Unnithan (1991) ascribe to, keenly aware that the early morning walks afford mall walkers a sense of active participation in healthy lifestyles. Behind the rhetoric of freedom of choice is however, an array of masked attempts to either
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reduce the role of the State as a welfare provider, increase surveillance of populations, or offer limited choice with an array of predetermined and limited options for action. The walkers are subject to a number of conditions for walking on private property, and for example, pay a fee, must wear a uniform: a name badge, and a short sleeved, royal blue t-shirt (which they pay for) which has the words Elizabeth City Centre mall walking group clearly marked on the back (with emblems of the shopping mall logo on the front and back). Jane explained to us that the management of the shopping mall were particularly interested in making the exercise mutually beneficial, promoting the central role that the complex has in improving the health of local residents. There is a mutual reinforcement of corporate citizenship as the moving bodies of mall walkers become an advertisement (indeed a walking display window or sandwich board) for the centre as it opens. The use of mall walkers as corporate advertisement reflects a societal shift in the recognised risks and responsibility of those involved in overconsumption, and the controllability of consumption. The obesity epidemic means that the aggregate public health risks are perceived to be great and increasing; that exhortations to consumer choice alone are unable to ensure a stabilisation, much less a reduction of the epidemic. Mall management has an increasing interest in demonstrating that they are responsible corporate citizens while seeking to maximise consumption. The irony occurs through using obese bodies as managed consumption for advertising, and by representing belated awareness of excess consumption as responsible progress. Consumption is thus not synonymous with choice, but, as Miller argues (1995:17), is the lack of choice whereby consumption provides the only arena left to many people through which to forge a relationship with the world. During our fieldwork mall management were centrally involved in the walking program, endorsing the health promoting activities and having an obvious presence at any function that the mall walkers had. All of the mall walking sites
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celebrated birthdays, which involved a longer than usual get together at the end of the walk at the designated mall cafe, the presence of centre management and an invited local politician (attempts were made to secure South Australias State Health Minister). Certificates of achievement were distributed and birthday cake eaten. Digital photographs were taken by management representatives and included in their newsletter, further demonstrating their involvement with community life and public face as a socially responsible, corporate body. In this study, while attempting to exploit the mall walkers as advertising, the mall management are also reinforcing the shift in perceived responsibility for consumption excess. More broadly, interpreting activity as consumption is also likely to increase as privately owned space assumes the social role traditionally held for public spaces. In their hegemonic theory of consumption, Kearns and Barnett argue that is not uncommon to see medical services being advertised or located in shopping malls or hubs, monopolising a visibility on the urban landscape to sell a product. In this malling of medicine, Kearns and Barnett suggest that medical services take advantage of this consumerist landscape, embodying some of the characteristics of their retail and fast food neighbours: fast service, discount process and multiple types of care within the one clinic (Kearns and Barnett 1997, cited in Gesler and Kearns 2002:144). This is a clear explication of Baudrillards views, who, in his earlier essay Consumer Society (1988:33-4) had stated:
We have reached the point where consumption has grasped the whole of life, where all activities are squeezed in the same combinatorial mode; where the schedule of gratification is outlined in advance, one hour at a time and where the environment is complete, completely climatised, finished and culturalised work, leisure, nature, and culture, all previously dispersed, separate, and more or less irreducible entities that produced anxiety and complexity in our real life, and in our anarchic and archaic cities, have finally become mixed, massaged, climate controlled, and domesticated into the single activity of perpetual shopping.

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Leisure activities and health, as we have argued, are highly commodified services (and have been for some time), and should not simply be viewed as examples of cultural erosion or the fall of humanity. For the mall walkers involved in this study, remembering that this is a particular group of people in a particular locale, consumption generates far more diverse meanings than Baudrillard considers, for it creates diverse personhoods, social relations and communities that are discounted through hegemonic accounts. As Miller (1995:290) suggests, by ignoring the inherent tensions of consumption there is an overemphasis on the significance of consumption, rather than an investigation of the social consequences within varied conditions of differential empowerment and resources.

Conclusion
In examining the phenomenon of mall walking we have highlighted the central paradox of consumption in which the negative and positive effects are mutually dependent on each other. In the obesity literature this paradox is absent and consumption is primarily used in two distinct ways. Firstly, it is used as a common sense and simple understanding of high energy intake (that does not match levels of expenditure and leads to obesity). Secondly, consumption is presented as a negative ideological force of exploitation, as a stock of lifestyle choices and structural constraints that have caused an obesity epidemic. In either construction (common sense or analytical), overeating, television advertising, and poor lifestyle choices are held accountable. Our argument does not discount these interpretations, yet seeks to broaden the ways in which the theoretical (and rhetorical) trope of consumption is used in understanding obesity. Analytically, consumption needs to be distinguished from common sense understandings, and the singularity of negative discourses. From a public health perspective on obesity, consumption needs to be critically unpacked and examined so we can be attuned to its diverse and contradictory meanings. That mall walkers have more than one way of interacting socially with the mall is potentially valuable for interpreting reasons for visiting the mall and the range of possible activities while there.

Current health promotion and policy approaches to obesity prevention focus on the allencompassing nature of consumption and attempt to eradicate sick making activities, for example, by banning fast food advertising during childrens television viewing hours, improving school dinners and canteen options to healthy foods, and encouraging people to walk rather than use private transport. Schools, work places and urban spaces (most often open, suburban spaces) are being targeted as environmental sites for obesity intervention. Such measures recognise that contemporary societies are inextricably tied to consumption and that negative attributes of consumer societies are deeply implicated in the rise of obesity. Mall walking, however, demonstrates that consumption sites can also be productive spaces in the transformation of bodies and health promotion programs. Shopping malls are a new spatial form that synthesise health and consumption which have previously been held apart by being located in different sites, performed at different times or accomplished by different people. As a space of consumption, malls do not fit with traditional health promotion theories as they are discursively and negatively constructed as cathedrals of consumption and desire and hence, overconsumption. Overweight, exercising bodies do not belong in these spaces, and are out of place. This blurring of spaces, bodies and boundaries of consumption leads to contradiction and paradox. Edwards (2000:6) argues that it is important to note that this sense of contradiction is not easily resolved, and that attempts to polarise consumption are perhaps attempts to rationalise and weaken a power that is both illusory and real. It is not our aim to provide exit solutions to consumption in the obesity literature, but to highlight the ways in which a critical and theoretical account of consumption must be taken into account in the obesity debate. Our aim, like that of Clarke et al (2003:2) is to demonstrate the wide-ranging, contentious and contested meanings of consumption in health and obesity discourses, in which contradiction is embodied (and enabled) in peoples everyday lives.
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Acknowledgements
The authors would like to thank the participants who so generously shared their time and experiences with us. The original version of this paper was presented to the Anthropology Department, University of Melbourne and the authors thank the audience for constructive feedback and criticisms. This project was funded by a University of Adelaide, Faculty of Health Sciences, Research Establishment Grant.

Endnotes
1. Other consumption pathologies include shoplifting, drug misuse and materialism (Miller 1995:34). 2. Thomas (2003:12), in her analysis of a Parramatta shopping mall in Sydney, draws the readers attention to the ways in which the suburban mall space is being utilised by migrant youths to contest and over turn the many stereotypes and preconceptions of youth cultural behaviours.

References
Appleton, S.; Taylor, A.; Wilson, D.; Ruffin, D. (2006) Obesity in North and West Adelaide. The North-West Adelaide Cohort Study (Working paper series number 9) Unpublished manuscript. Baudrillard, J. (1988) Consumer society in Poster, M. (ed) Jean Baudrillard: Selected Writings Polity Press: Cambridge, pp. 26-43. Bourdieu, P (1979/1984) Distinction: A Social . Critique of the Judgement of Taste (trans. Nice, R.) Routledge and Kegan Paul: London. Bunton, R. and Burrows, R. (1995) Consumption and health in the epidemiological clinic of late modern medicine in Bunton, R.; Nettleton, S. and Burrows, R. (eds) The Sociology of Health Promotion, Critical Analysis of Consumption, Lifestyle and Risk Routledge: London, pp. 206-222. City of Playford Community Profile (2006) (results from the 2001, 1996 and 1991 census of population and housing). Available at http:// www.id.com.au/ playford/commprofile/ Default.asp?bhcp=1 (accessed January 2008). Clarke, D.; Doel, M. and Housiaux, K. (eds) (2003) The Consumption Reader Routledge: London and New York. Cockerham, W.C. (2006) Health lifestyle theory in an Asian context Health Sociology Review 15(1):6-15. Cummins S.; McKay, L. and MacIntyre, S. (2005) McDonalds restaurants and neighborhood

deprivation in Scotland and England American Journal of Preventive Medicine 29(4):308-310. Dixon, J. and Broom, D. (2007) The Seven Deadly Sins of Obesity: How the Modern World is Making us Fat University of New South Wales Press: Sydney. Douglas, M. and Isherwood, B. (1996) The World of Goods: Towards an Anthropology of Consumption Routledge: London and New York. Edwards, T. (2000) Contradictions of Consumption: Concepts, Practices and Politics in Consumer Society Open University Press: Buckingham. Erkip, F. (2003) The shopping mall as an emergent public space in Turkey Environment and Planning A 35(6):1073-93. Evans, B. (2006) Gluttony or sloth?: Critical geographies of morality and bodies in (anti)obesity policy Area 38(3):259-267. Falk, P (1994) The Consuming Body Sage: . London. Featherstone, M. (1991) The body in consumer culture in Featherstone, M.; Hepworth, M. and Turner, B. (eds) The Body: Social Processes and Cultural Theory Sage: London. Friedberg, A. (1993) Window Shopping: Cinema and the Postmodern University of California Press: Berkeley CA. Gesler, W. and Kearns, R. (2002) Culture/Place/ Health Routledge: London and New York. Goss, J. (1993) The magic of the mall: An analysis of form, function and meaning in the contemporary retail built environment Annals of the Association of American Geographers 83:18-47. Hardus P van Vuuren, C.; Crawford, D. and .; Worsley, A. (2003) Public perceptions of the causes and prevention of obesity among primary school children International Journal of Obesity 27(12):1465-1471. Hayward, K. and Yar, M. (2006) The chav phenomenon: Consumption, media and the construction of a new underclass Crime, Media, Culture 2(1):9-28. Henderson, S. and Petersen, A. (ed) (2002) Consuming Health: The Commodification of Health Care Routledge: London and New York. Heshka, S. and Allison, D. (2001) Is obesity a disease? International Journal of Obesity 25(10):1401-1404.

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Megan Warin, Vivienne Moore, Michael Davies and Karen Turner Hill, J. and Peters, J. (1998) Environmental contributions to the obesity epidemic Science 280, 5368:1371-74. Kearns, R. and Barnett, J. (1997) Consumerist ideology and the symbolic landscapes of private medicine Health and Place 3(3):171-180. King, T.; Kavanagh, A.; Jolley, D.; Turrell, G. and Crawford, D. (2006) Weight and place: A multilevel cross-sectional survey of area-level social disadvantage and overweight/obesity in Australia International Journal of Obesity 30:381-287. Knowles, C. (2000) Burger King, Dunkin Donuts and community mental health care Health and Place 6:213-224. Lawrence, R. (2004) Framing obesity: The evolution of news discourse on a public health issue The Harvard International Journal of Press/Politics 9:56-75. Lobstein, T. (2006) Commentary: Obesity public health crisis, moral panic or a human rights issue? International Journal of Epidemiology 35:74-76. Longhurst, R. (2005) Fat bodies: Developing geographical research agendas Progress in Human Geography 29 (3):247-259. Lupton, D. (1994) Consumerism, commodity culture and health promotion Health Promotion International 9(2):111-118. Miles, S. (1998) The consuming paradox: A new research agenda for urban consumption Urban Studies 35(5-6):1001-1008. Miller, D. (1995) (ed) Acknowledging Consumption Routledge: London. Miller, D.; Jackson, P Thrift, N.; Holbrook, B. and .; Rowlands, M. (eds) (1998) Shopping, Place and Identity Routledge: London. Miller, D. and Rose, N. (1997) Mobilising the consumer: Assembling the subject of consumption Theory, Culture and Society 14(1):1-36. Parry, J.; Mathers, J.; Laburn-Peart, C.; Orford, J. and Dalton, S. (2007) Improving health in deprived communities: What can residents teach us? Critical Public Health 17(2):123-136. Peel, M. (2004) Imperfect bodies of the poor Griffith Review 4(11):83-93. Popay, J.; Bennett, J.; Thomas, C.; Williams, G.; Gatrell, A. and Bostock, L. (2003) Beyond beer, fags, egg and chips? Exploring lay understandings of social inequalities in health Sociology of Health and Illness 25(1):1-23. Rundle, G. (2007) Gagging on the stale smell of excess: Why were richer, fatter and unhappier than ever before The Australian April 4th. Sack, R. (1992) Place, Modernity and the Consumers World John Hopkins Press: Baltimore MD. Scheper-Hughes, N. (2001a) Bodies for sale: Whole or in parts Body and Society 7(2-3):1-8. Scheper-Hughes, N. (2001b) Commodity fetishism in organs trafficking Body and Society 7(23):31-62. Scheper-Hughes, N. and Wacquant, L. (2002) (eds) Commodifying Bodies Sage: London. Schnact, S. and Unnithan, N. (1991) Mall walking and urban sociability Sociological Spectrum 11(4):351-367. Seale, C.; Cavers, D.; and Dixon-Woods, M. (2006) Commodification of body parts: By medicine or by media? Body and Society 12(1):25-42. Shields, R. (1992) Lifestyle Shopping: The Subject of Consumption Routledge: London. Sobal, J. and Stunkard, A. (1989) Socioeconomic status and obesity: A review of the literature Psychological Bulletin 105(2):260-75. Stunkard, A. and Sorenson, T. (1993) Obesity and socio-economic status A complex relation New England Journal of Medicine 329(14):1036-37. Swinburn, B. and Egger, G. (2004) The runaway weight gain train: Too many accelerators, not enough brakes British Medical Journal 329:736739. Swinburn, B.; Egger, G. and Raza, F. (1999) Dissecting obesogenic environments: The development and application of a framework for identifying and prioritizing environmental interventions for obesity Preventive Medicine 29:563570. Thomas, M. (2003) Hanging out in Westfield Parramatta in Butcher, M. and Thomas, M. (ed) Ingenious: Emerging Youth Cultures in Urban Australia Pluto Press: Melbourne, pp.102-123. Trentmann, F. (2004) Beyond consumerism: New historical perspectives on consumption Journal of Contemporary History 39(3):373-401. Warde, A. (1996) Afterword: The future of the sociology of consumption in Edgell, S.; Hetherington, K. and Warde, A. (eds) Consumption Matters: The Production and Experience of Consumption Blackwell: Oxford, pp. 302-312. Warin, M.; Turner, K.; Moore, V. and Davies, M. (2008) Bodies, mothers and identities: Rethinking obesity and the BMI Sociology of Health and Illness 30(1):97-111. Volume 17, Issue 2, August 2008

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Copyright eContent Management Pty Ltd. Health Sociology Review (2008) 17: 199213

The government of girth


ABSTRACT
The current preoccupation with body weight in western cultures is arguably unprecedented. The obesity crisis has engaged not only health communities, but numerous other public and private organisations, and, in so doing, has created moral alarm as well as a medical crisis. This paper examines the development of obesity and will discuss the ways in which fatness has been rationalised within health discourses. It will explore the way that the corpulent body, once historically considered as a physiological state, is now regarded as a state of moral pathology representing an epidemic. The prospect of this disease sweeping through populations, reaching into virtually every social group, is presented as all the more frightening when no known effective prevention or cure is at hand. The paper will look at the ways in which new forms of government have developed with the panoptic capacity to gaze across populations and objectify the everyday activities of individuals. This government of girth reaches an apogee in the problematisation of children and body weight. Three subject positions in childhood provide a number of opportunities to problematise children: the sick child, the anti-social child, and the innocent child. Each of these amplifies concern about the state of health of children, the permissive nature of parenting and potential moral social decay.
Received 9 October 2007 Accepted 5 March 2008

KEY WORDS Obesity, epidemic, sociology, Foucault, children

John Coveney
Department of Public Health Flinders University Australia

Introduction
besity is regarded as a major global problem and is linked to a variety of physical and psychosocial health problems (World Health Organisation 1997). The issue of population fatness has engaged numerous groups, organisations and institutes whose raison detre become its prevention and management (International Society for the Study of Obesity 2006). Research into the causes of obesity, as well as interventions to address and arrest its spread, have arguably never been greater, with several international journals dedicated to the topic. Moreover, governments in many jurisdictions in many countries have debated the obesity problem (for example, United Kingdom, Australia, New
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Zealand, USA), not least because of the costs involved in managing the diseases that arise as a consequence of fatness at the individual and the population level (House of Commons Health Committee 2004; National Health and Medical Research Council 1997; New Zealand Ministry of Health 2004; US Department of Health and Human Service 2001). A fixation on obesity is not merely a medical and public health matter, however. Fatness has historically invited comment from a variety of social and moral perspectives, and, in the modern context, obesity is widely discussed as part of medical, social and popular discourse (Sobal 1999). This paper aims to examine the growing concern and interest in individual and population girth, or body weight. It will look at how the problem of obesity has become a major issue in medicine and public health. It will also look at the way in which obesity has engendered social anxiety fuelled by moral panic. The term moral panic was originally used to describe social unease arising from an exaggerated media representation of youth
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culture in the 1960s (Cohen 2003). The use of the term moral panic in this paper does not subscribe to this definition. It is instead used to attempt to capture the way in which obesity has fuelled social concerns and public commentary that have raised questions about our individual and collective moral character and social responsibilities. It is precisely because concerns about obesity arise from its growing prevalence across the population, rather than confined to specific so-called vulnerable groups, that the amplification of alarm has been so loud. And unlike other examinations of obesity (see for example, Campos et al 2005; Gard and Wright 2005), this paper will not portray it as a scientific fabrication or an ideological invention. It will instead attempt to explain how, in the face of many health and welfare problems of immediate importance (for example poverty, hunger and mental health), obesity has risen as a national and an international concern. Indeed, one commentator goes as far as to catastrophise obesity as the terror within, capable of wreaking havoc that is likely to even dwarf September 11th or terrorist attempts (Saguy and Almeling 2008). The theoretical starting point for this paper derives from the notion of government, which has been developed from Foucaults examination of governmentality (Burchell et al 1991; Dean and Hindess 1998). Work in the field of governmentality is interested in so-called mentalities of rule which lead to activities or systems of thinking about what is governable and how government takes place (Colebatch 2002). Some critics of governmentality as a theoretical lens point to a selective choice of abstract rules of rationality to support governmental processes. Petersen (2003), for example, suggests that scholars of governmentality leave themselves open to accusations of reinforcing a top-down, state-centred approach to government. If true, this would seriously limit the explanatory possibilities of governmentality. But such a view is not the case. Governmentality is less concerned with hierarchical relationships with state-centred government, and more about the horizontal networks of governing. In fact, governmentality recognises that the state plays only a limited role in managing the conduct of individuals and

populations, and that within contemporary politics, political power is exercised well beyond the state (Rose and Miller 1992). The obesity issue is a good example of the way in which governmentality works by positioning or representing a problem in particular ways (Bacchi 1999). The consequences of these representations, in particular the engagement of so-called stakeholder organisations and groups who have legitimised their role in the field, have intensified professional and public concerns. The increasing traction of the obesity problem has happened largely without the exercise of state political authority. Indeed, in many jurisdictions, the state has been remarkably slow in bringing its powers to bear to intervene in the problem of obesity. In Australia, for example, the federal government has refused to consider legislation and regulation to address the causes of obesity in the food supply or the wider environment (Dugdale and Dixon 2007). Almost all government activity has been concerned with the recruitment of stakeholders inside and outside the health system who are then authorised to engage individuals and groups in the selfregulation of personal habits that promote healthy food choices and physical activity. An important armature of governmentality is the imperative of self-government or selfsurveillance, whereby individuals problematise their own choices, habits, and daily practices. The right choices or habits are promoted as those that are not only rationally sound but also engender moral superiority (Nettleton 1991). There is nothing new in this form of government. As Rose and Miller (1992) have pointed out:
... in Europe for many centuries economic activity was regulated, order was maintained, laws promulgated and enforced, assistance provided for the sick and needy, morality inculcated, if at all, through practices that had little to do with the state.

This form of government is effective not merely by engaging with the health problem itself: its distribution, cause and cure. It operates by recruiting the hearts, minds and conscience of individuals resulting in the forging of alignments
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between the personal projects of citizens and images of the social order (Miller and Rose 1988). The paper begins by examining the recent rise of medical and popular interest in obesity. Particular attention is paid to the spread of obesity across and within populations, and, in relation to the latter, the appearance of obesity in childhood. It then examines new subject positions opened up by discourses on obesity which engage not just health concerns but also social and moral considerations. Finally, the paper situates obesity within a field of governmentality by demonstrating how, after Rose (1996), new relationships between expertise and politics are formed; new partnerships with similar interests are brought together; and new horizons for individual perfection are demarcated. The analysis presented here is not designed to downplay the importance of obesity as a health problem or to say that a focus on fatness is exaggerated and unwarranted. The substantive thesis developed in this paper attempts to show how the problem of obesity opens up medical, public health and moral positions that are inevitably intertwined, gaining momentum, energising and amplifying each other. While the paper will principally draw on examples from Australia, the analysis of growing concerns about obesity are relevant to other settings.

strategic plan for the prevention of overweight and obesity. Noting the widespread nature of the problem, the report says:
During the 1980s there was a steady increase in the proportion of adults who were overweight or obese. Women were, on average, 0.3kg heavier in 1989 than 1980, and men were 1.7kg heavier This trend of increasing levels of overweight and obesity in the population is likely to be the result of small decreases in physical activity and small changes in food intake by many, rather than extreme inactivity and excessive food intake among the few (National Health and Medical Research Council 1997, emphases added).

The obesity epidemic


While increased body weight has been a feature of health commentary in western post-war years (Whyte 1959; Yudkin 1967; Walden 1985), in the mid-1990s a number of developments launched obesity into the headlines. One was the vivid portrayal of obesity as a modern epidemic spinning out of control (Koop 1994). Establishing overweight as a spreading epidemic effectively moves it from being a mere state of health, albeit at one end of a physiological spectrum, to a serious state of pathology. In other words, fatness and body size are no longer risk factors for other diseases; they are now, in fact, disease states in themselves. The notion of obesity as a population epidemic was captured in a number of key reports. In Australia for example, Acting on Australias Weight was developed in 1997 as a
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In other words, according to the report, obesity is spreading throughout the whole community in an epidemic-like fashion, and is not confined to specific population pockets or vulnerable groups. We can see how the facts and figures of the growing girth of the population as an epidemic resonated with more popular forms of news and views which echoed the opinions of medical and health experts. Thus while self-help books and magazines (especially those marketed towards women) have traditionally been a major source of information on overweight (Tebbel 2000), other forms of media increasingly began taking an interest in reporting obesity and overweight (Dugdale and Dixon 2007). Lupton notes that over a recent 14-month period articles on overweight and obesity comprised nearly 50% of stories on food and health hazards in a leading Australian newspaper (Lupton 2004). In part, this reflects increased reporting of scientific announcements and developments on the topic. But it is also probably indicative of the way in which the scale of the problem of fatness as epidemic registered in the publics consciousness as something to be alarmed about. Part of the concern is the recognition that while prevention of fatness is itself a difficult enough proposition, the successful management and treatment of obesity is notoriously difficult (National Health and Medical Research Council 2004). In terms of prognosis, the likelihood of a solution to the obesity problem is poor.
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The epidemic-like phenomenon of obesity also arose from new ways of calibrating population fatness. Calculations of fatness in the form of Body Mass Index (BMI) were commonly featured in public discussions. And the resulting quantification of fatness as either overweight = BMI over 25, obese = BMI over 30 or very obese = BMI over 40 effectively and efficiently segregated populations into categories of fatness. The ramifications of these calculative rationalities are interesting. In Australia, for example, most men (63%) are too fat (Cameron et al 2003) on the basis of BMI categorisation. If the majority position demarcates that which is normal (De Swann 1990), we can say that, after the obesity epidemic, it has now become normal to be abnormal, even diseased. Unease about population fatness was also amplified by increased recognition that fattening foods are more likely to be those that are cheap, palatable and more readily available (Drewnowski and Specter 2004). In other words, diets high in fat, sugar, and salt, and with low levels of fruit and vegetables, have been shown to be much cheaper (Drewnowski and Darmon 2005) and increasingly more popular (Kant 2000) than socalled healthful alternatives. Indeed, it has been argued that healthy diets are simply unaffordable, especially for disadvantaged groups who bear the greatest burden of obesity (Drewnowski and Barrett-Fornell 2003). The ar rival of the term obesogenic environment (Swinburn et al 1999) was another declaration that engaged professional and public consciousness. The obesogenic environment described those conditions where there was ready access to fattening food and little opportunity or encouragement for adequate physical activity. And far from being par t of disordered living, obesogenic environments are, in fact, the ordinary, everyday environments in which most people now inhabit (Broom and Dixon 2007). Thus the ordinary daily living and working conditions of most people in the home, the school and the workplace can now, with all candour, be described as toxic and injurious to health (Savige et al 2004), adding a new dimension to the fatness epidemic.

Spreading across the globe


The second factor that fuelled interest in fatness has been its transmission across populations (Chopra et al 2002). This can be seen for example in the ways in which fatness is not confined to affluent countries, but is being increasingly seen in so called developing countries. The idea of the nutrition transition (Popkin 1994) has been used to represent the ways in which the eating habits of more affluent groups in poorer countries (such as Thailand, Brazil and China) now more closely represent those found in western cultures. In terms of population health this has meant that the degenerative diseases of affluence, for example diabetes, heart disease and some forms of cancer, now accompany the nutritional deficiencies, which have been a continuing feature of many poorer countries. A World Health Organisation report notes that obesity now exists in parts of the world where previously it had virtually not existed (World Health Organisation 1997).

Spreading across the population


The third factor that has increased the concern about fatness has been its transmission within populations. And like most other risk factors for chronic disease, obesity is more common in lower socio-economic groups (Friel and Broom 2007). The higher prevalence in less advantaged populations has given rise to media disquiet, even moralising, that poor people are less able to control eating and lifestyle (Saguy and Almeling 2008). Moreover, parents in disadvantaged groups may not be exercising enough responsibility to prevent children from becoming fat. The spotlight on children is a particular driver of moral panic over the obesity epidemic. Once regarded mainly as a problem of adulthood (especially during later years when more sedentary behaviour sets in) fatness is now increasingly seen in childhood (Tuttle and Truswell 2001). Moreover, the degenerative diseases normally associated with increasing body size, such as type II diabetes and respiratory problems, are now evident in children (Fullerton 2005). The term Generation O (O for Obesity) has been used to indicate the way in which todays children may overall have less healthy outcomes than their parents (Cole 2006).
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Thus we can see fatness opening up in new territories fuelling concerns. The truth claims, or discourse of expertise, play a vital role in establishing the norms of not only health and medical, but also social rules (Armstrong 1983). Truth claims do not force or coerce individual subjects to play their part in the fatness problem, or indeed, the solution. As authoritative, credible criteria, truth claims engage more productively through their ability to problematise the choices individuals are able to make. Making the right choice that is the rational choice results from the process of selfproblematisation and the recognition of ones self as a morally responsible subject, or, in this case, a morally responsible eater (Coveney 2006). We should not expect an engagement with fatness within the field of expertise itself to be evenly spread across the problem. As always in health matters, there is debate about priorities and avenues of least cost-most benefit (National Institutes of Health 1998). Poor results of management regimes in obese adults have helped focus efforts on the prevention of fatness in children. And since childhood is considered to be the point in the lifecourse at which good habits can be inculcated, much of the effort in the fight on fatness is directed to children. This is starkly clear in the most recent Australian strategy on health. Healthy Weight 2008: Australias Future is explicit in its attempts to address children as preventable agents in the national fight against fatness. Subtitled The National Action Agenda for Children and Young People and their Families, the plan frames children as the central targets. In justifying its position the report says:
Obesity develops over time and once it has developed it is difficult to treat. The prevention of weight gain, beginning in childhood, offers the most effective means of achieving healthy weight in the population. This is where action to combat Australias weight problem needs to start and is the focus for the national agenda (Department of Health and Ageing 2003).

Childhood has therefore become a major point of engagement in the war on fat, and the focus for the rest of this paper will be to examine the ways
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fatness in children has allowed for the availability of different subjectivities or subject positions. Subject positions may be thought of as categories or norms for personal and public deportment. Essentially they are points of enunciation (Barratt 1991) constructed within particular forms of knowledge and practice, i.e. discourses that delineate (in)appropriate conduct. For example, using the mundane activities of family life, Grieshaber (1997) demonstrates how subject positions for parents and children are opened up by discourses on appropriate bedtime and sleep regimes for children. Advice by experts, informed by discourses on child psychology and physiology, normalises bedtime and sleep for young children to allow for adequate rest and optimal performance at school. Some parents in Grieshabers study positioned themselves in relation to set bedtimes and enforced the 7.30pm rule recommended by child care and parenting manuals. Other parents, while acknowledging the 7.30pm rule, excused themselves from it by referring to the overall adequate amount of sleep their children were getting, which they felt was normal. Thus children are positioned as normal in relation to sufficient sleep, and parents negotiate this normality by invoking rules of bedtime, or by ensuring overall adequacy of sleep. It is in the attainment of normality that parents are judged by others and indeed by themselves in terms of doing the right thing. And it is the quest for the normal, in this case in relation to proper child-rearing, which requires parents to be aware of what are regarded to be rational parenting practices. Thus subject positions open up possibilities for the ethical evaluation of conduct by which individuals, and indeed societies, make judgements about moral adequacy. Since discourses are socially and historically specific, so too subject positions can become available in relation to the development of particular discursive fields. We will look at three subject positions that are opened up by the discourses in childhood overweight and obesity. The first is sick children, where children are regarded as harbouring greater real and potential levels of disease and illness than what has been considered to be the case. The second is antiVolume 17, Issue 2, August 2008

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social children, where children are considered to be problematic, both in an individual and a social sense. These considerations have a major implication for food and health especially when children are positioned as a problem in relation to food choice and eating. Last is the subject position of innocent children, where we will examine the discourses where children are regarded as highly vulnerable, especially to the pressures of the free market and the consequences of the failure of measures designed to protect childrens innocence. As we shall see, the issue of overweight and obesity in childhood is not confined to children; it is seen as a problem for adults, especially parents, and indeed the whole population.

Sick children
During the late 19 th and early 20 th Century childrens health became a national priority in many countries and the assessment of child growth and development, under the pur view of surveillance medicine, became frequent points of entry into parent professional relationships. The growth chart provided an opportunity to see if children were growing normally, that is in a field delineated not by absolute categories of physiology and pathology but by the characteristics of the normal population (Armstrong 1995). Children that fell outside the normal trajectory of growth predicted by the chart were regarded as requiring investigation. The assessment of childrens healthy weight on a growth chart is usually accomplished by plotting current weight against age. However, this is made difficult by the fact that longer, taller children are likely to be heavier, though not necessarily too fat. Thus a need to account for length or height in the assessment of fatness is required. The definition of a universally recognised cut-off point for children that is regarded as constituting unhealthy fatness has not generally been available. Recently, however, cut-off points for overweight and obesity in children, based on BMI, were made available (Cole et al 2000). The cut-offs were considered appropriate for global use by the World Health Organisation (World Health Organisation 2000) even though there are caveats

about cross-cultural applicability of the measures. This new tool for surveillance of children differs from growth charts in that it is designed to identify abnormal rather than normal growth in children. Moreover, while growth charts are generally used over a period of time to track childrens growth trajectory, BMI cut-offs are strictly categorical: children either do or do not fit into the spaces delineated for fatness. Armed with a new tool for surveillance, child growth surveys in many countries took on new meanings. In Australia for example, researchers analysed data from two surveys, one in 1985 and the other in 1995, of the weight and height of children. They found that over the 10 year period, the number of children who could be classified as fat had doubled from 10% to 20% (Magarey et al 2000). The findings sparked national concerns and in their wake a number of summits and symposia were held where the problem was debated, discussed and widely reported (see for example, NSW Department of Health 2002). The impact of the new cut-off points for assessing fatness in children can not be overestimated; they provided for the first time agreed and expertly derived universal categories of fatness against which children can be measured. And while caution was recommended in using BMI fatness to predict childrens current or future morbidity, the simplicity of a numerical representation of fatness became both fascinating and frightening. Indeed, the force of numbers, what Rose calls the power of the single figure (Rose 1999), annuls the complexity of any background judgements and uncertainties thereby, in effect, making the number itself an incontestable fact. This is not to suggest that fatness in children is a myth or that the BMI standards are false, although there have been a number of critiques of the criteria, especially where there is conflation of the categories of overweight and obesity (Gard and Wright 2005). It is instead to remind us that fatness is constructed within regimes of expert truth that determines the conduct of individuals and submits them to particular courses of action through a process of objectivisation (Foucault 1988). In terms of the fate of children,
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and not just those who were classified as too fat, we can see a number of consequences. The lives of children in Australia have been opened up for examination and mapped against a number of lifestyle measures: for example, close assessments of childrens physical activity and recreational habits (Commonwealth Department of Health and Ageing 2005). These assessments have, of course, been made before (Tomkinson et al 2003). But now armed with a new imperative arising out of childhood fatness rates, these examinations take on new focus and importance. The findings demonstrate that children are not partaking of enough of those activities normally associated with childhood, especially outside play at school or outside school hours (Phillips 2005). Inspection of childrens eating habits has also increased. While meals eaten by children at home have long been of interest to nutrition experts, now new meaning is given to food provided in various institutions, such as day care and schools (Pollard et al 2001; Drummond and Sheppard 2004). In the UK for example, celebrity chef, Jamie Oliver, launched an expose of school dinners on national television. By highlighting the questionable nature of the foods provided to children in schools, and examining ingredients in some detail, the program created a national storm resulting in a petition of over 270,000 signatures for better food in schools (Editorial 2005). In New South Wales in Australia, school food has also been targeted as source of poor nutrition leading to strict criteria about what can and cannot be sold (Bell and Swinburn 2005). While the scientific link between physical activity and health is one that has a long heritage in western medicine (Smith and Horrocks 1999), the importance of physical activity within health discourse now becomes crucial. Indeed, the nexus between what we eat and how active we are has never been made so obvious, and the endeavour to discover what children do be it sport, exercise, or leisure past-times has received high scrutiny. The school setting, as one in which children spend a large part of their time and one which has traditionally been used to regulate childrens bodies, has been a prime target for the collection of data and the implementation of interventions to address increasing weight in children (Olds et
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al 2004). Like body weight where the development of an index of girth was developed as a way of calibrating children on a continuum of fatness, similar indices exist for physical activity. Children are assessed according to time spent on daily pursuits sport, leisure, sleeping etc. from which overall estimates of physical activity are made (Booth et al 2002). Fixing children in a grid of expertise either normalises or abnormalises them in relation to physical activity. For the Australian culture, low rates of physical activity are arguable even more problematic because sport and fitness have been principal cultural goals, and the image of the bronze Aussie, ready to compete on the field or in the pool, is very much a national icon (Lupton 2004). The portrayal of children as slothful or sick, raises major moral questions about the extent to which children are protected from the corrupting social influences which induce laziness and gluttony. And the reaction to fatness in children both in public and political discourse is an indicator of the ways in which in countries like Australia the problem of childhood has been framed. Naturally parents do not escape expert scrutiny or personal responsibility for the behaviour of their children. Dr Kerryn Phelps, president of the Australian Medical Association spoke for many when she told the NSW Child Obesity Summit Parents must lead by example. If children see the only exercise their parents get is picking up the TV remote to change channels, then they will get the message that that is how to be (Phelps 2002). But while identifying obesity as a problem is one thing, dealing with it is, of course, very different. In the modern era of democratic management of children, cooperation rather than coercion has become the key (Fallding 1957). Indeed, the art of good management of children rest on success in instilling into them a rational, autonomous, responsible attitude in order for them to make good choices (Banwell et al 2007). However, as we shall shortly see, the freedom to choose, which is embedded in the modern free market ethos, renders children as problematic, especially in relation to food choice.
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The anti-social child


The idea of children and young people as socially disruptive has a long history in western culture. Pearson (Pearson 1983), for example, discusses the history of children as social misfits: threatening public (that is, social) order and private (that is, family) harmony. This view of children prevails in current public understanding. For example, media and public perceptions of young people pre-teens and teenagers indicate a strong belief that children are regarded as socially deviant, selfish, and likely to cause trouble (Bolzan 2005). The position of children as dangerous, even creatures about which to harbour feelings of dread, extends even to the early years. As Hays (1996) puts it:
It seems to me that parents have always feared their infants and young children somewhat. After all, small children are strange and fragile beings. They look and act not at all like adults, they cry for unknown reasons, they suck at and even bite their mothers breasts, they are uncoordinated, they get sick easily, their demands are incessant, their appetites appear endless, and their excretions seem inhuman.

and are entirely consistent with the principles of neoliberalism which inculcates responsibility, autonomy and freedom. In place of the protectionism of welfare, the free market becomes the site where citizens become what Rose calls responsibilised through their competence as free, knowledgeable and choosing agents (Rose 1996). The idea of children choosing food, especially nutritious food, is however highly problematic. Children are exposed to a range of ideas about food choice and taste not only from inside the home, but importantly outside too. Television advertising to children, for example, has been shown to influence childrens food choices (Donkin et al 1993; Taras et al 1989), and peer-pressure has been demonstrated to alter childrens food selection (Ludvigsen and Sharma 2004). Children are therefore able to bring into the family a range of food preferences directed by outside influences. The notion of the child as agent for outside food influences brings with it problems of childhood which requires parents to be ever vigilant. Indeed, in describing the places where children can be influenced by food promotion, the UK Food Standards Agency (2005) states that:
today, food promotion is multifaceted, including print and radio, SMS text messages, celebrity endorsement, sponsorship materials, point of sale promotion, vending machines, voucher schemes, often supported by powerful branding.

The child as problem has had profound effects on the ways in which children are fed in families. Indeed, the problem eater is now a common phenomenon. Dixon and Banwell (2004) note that in modern families children have taken the place of men at the head of the table. By this they mean that childrens food choices are given household priority over that of parents. The arrival of the child as anti-social and a problem eater to some extent developed out of a new form of parenting, one that gives children substantial choice and voice in family life (Coveney 2004). The importance of child-centredness creating in children independence, freedom and self-expression is paramount in modern parenting styles, replacing the more strict and disciplined forms of parenting of an earlier era. The granting of rights to children in effect extends to them a form of citizenship, not in the sense that they can participate in the execution of political power, but in the sense that they have the right to liberty and they have social rights (Rose 1990). These rights provide for the exercising of choice by children,

While protecting children is hardly a new role for parents, the kinds and types of influences which parents must be alert to have multiplied. Moreover, parents need to resist pressure from within the family, especially from children themselves. The notion of pester power where children make constant requests to parents for specific goods or services, often ones that have been marketed and advertised has become a term in common use. As pests, children are regarded as highly problematic even anti-social because of the constant hassling of parents who are often not able to resist. In one survey only a minority of parents (11%) said they would definitely say no in the face of pester power (Gelperowic and Beharrell 1994). In the area of food and health, the idea of pester power has been invoked during discussions
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on the influence of food advertising to children, especially in relation to advertising unhealthy products. Exposure to advertising opens up a number of situations where children are regarded as problematic, especially when, as agents of change within families, children constantly exert high demands for unhealthy foods. As one commentator for the food industry put it Kids are a brand managers best friend (Arnott 1993). The consumerist nature of children, and the threat they pose to family life and social order has not gone unnoticed in other areas of public life. In a recent UK article on violence perpetrated by youth, one author asks Why are we so scared of children? (Craig 2002). The authority with which children speak and act, their impact on social life generally, and on family life in particular, and the protection afforded to them creates for many adults a feeling of anxiety. Anxiety is no doubt amplified by the belief that even in todays child-centred discourse, the needs of children are not always prioritised (Leach 1994). Left unprotected by parents, and indeed the state which sees the liberty of parents as a given, children can be at the mercy of a free market which seeks to encourage in them rampant consumerism. Thus, as victims of the relentless promotion of unhealthy foods, overweight children signify a failure of not only proper parenting but also of state protection. The idea that children are indeed, innocent victims in the obesity epidemic is the subject to which we now turn.

The innocent child


As Hays (1996) points out, current advice on child rearing valorises childrens innate goodness, derived from childrens purity and innocence. The private sanctuary of the home is the sacred space of the child, as opposed to corruption that exists in the outside world, especially in the market place. The importance of protecting children from that market place, and its inherent competitive, coercive and corrupting influence, becomes a hallmark of good parenting. But as we have seen the market place is able to easily invade the home. Indeed, the electronic pied piper (the television) is positioned as the magnet of questionable morals, or even physical
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danger to which children are invariably attracted (Kapur 1999). Television, through its ability to directed clever marketing and advertising into the home, often literally behind the backs of parents, has become a driving influence in turning children into rapacious consumers. Indeed, the child as consumer which has found a special place in discourse in Australia (Kenway and Bullen 2001), Canada (Kline 1993) and USA (Lindstrom 2003) is often discussed as a product of television and other forms of mass communication. Concurrent with this has been a concern that real childhood, characterised by goodness and innocence, has been replaced by moder n childhood, where children are precocious, outspoken and cynical: indeed, a childhood out of order (Kenway and Bullen 2001). Much of the blame for this is laid at the feet of advertising that promotes a marketing maelstrom (Linn 2004). A focus on the ability of television to lure innocent children in to unhealthy habits has found a natural home in current public health research which has looked at the effects of television in creating children as consumers who feast on the forms of edible merchandise marketed to them. Given that almost 80% of food advertised to children is for unhealthy products (Zuppa et al 2003) exploring the links between obesity, children and television viewing has become a popular form of nutrition research (see for example, Lobstein and Dibbs 2005). Within this research, children are positioned as credulous, innocent, and easily fooled and manipulated by television advertising promoting unhealthy products. Moreover, the failure of the regulatory mechanisms designed to protect children from exploitation by advertisers, has itself become a rich source of debate in public health. Australian researchers found that industry self-regulation of standards had failed to protect childrens gullibility and naivety in the face of food advertising (Morton et al 2005). Closer to home, parents are believed to have failed in their duty to protect children from overweight or obesity. This, in the eyes of some, is no less than child neglect. Arguing that fatness in children is as much a moral problem as a health
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problem, Lotz (2004) is clear where the responsibility lies:


I have argued that it is morally wrong for parents to allow their children to become or remain obese, since it constitutes the causing of indirect harm to the child, through a form of parental neglect.

The basis of this argument lies in the belief that far from being agents of free choice, children are not-as-yet-fully-rational agents and that children do not and should not enjoy the same level of autonomy as adults (Lotz 2004). Within this belief of childhood children are required to be sheltered and protected from the forces of fatness. The innocence of children is also addressed in another way. Acknowledging that as players in obesitys regime of truth, children themselves are now recognised as credible sources of important and compelling information to help fight the problem. Researchers have developed new forms of research practice designed to be child-friendly. Giving power and voice to child participants allows children to be active research subjects, even collaborators, in research activities (Grover 2004). In doing so, the childs world and their subjective experience are, it is believed, more authentically rendered, rather then merely filtered through or authorised by parents, teachers, and carers. For example, research on childrens views about physical activity revealed that children distinguished between spor t (as activity organised by adults) and play (as informal unstructured activities devised by children) (MacDougall et al 2004). As the childs world of innocence becomes more knowable and therefore more known, opportunities increase to introduce strategies and technologies designed to stem the epidemic of obesity that plagues children. In summing up so far, we are now in a good position to better understand why the war on fatness and large body size and the government of girth has developed into a movement, even a crusade. The sheer physicality of fatness, unlike many other hidden health problems like high blood pressure, heart disease or diabetes, presents a body grotesque in size and shape, often arousing feelings of repulsion and disgust (Lupton 1996). But more than that, the

overweight body strikes a discord at a number of other levels. The scientific principles of economy and efficiency, embedded in public health, are framed by what is right and what is proper. This rightness not only speaks to what is correct for health but importantly what is morally correct. The neglect of ones duty to ones self through the visible display of body fat provides endless opportunities for public scrutiny and private guilt. And while neglecting ones self is one matter, neglecting children is something of another magnitude. Fatness in childhood is not only about the parlous state of childrens health, or even the ticking time bomb of later disease. It is also a reminder that parents and the larger society have not protected children from outside forces that seek to strip them of innocence, replacing it with consumerist greed. We can also see new subject positions open up by discourses which fix children, adults, industries and organisations in a variety of roles within the obesity epidemic. Parents are positioned as protective or neglectful; children are framed as sick, slothful and dangerous, or innocent helpless victims; the food industry and advertisers are seen to be shrewd and exploitative, or sometimes concerned, and even contrite. We can usefully examine the government of girth within Roses characterisations of new forms of government (Rose 1996). 1. Relationship between expertise and politics: The recruitment of a panoply of players who have banded together to address obesity has been impressive. A variety of coalitions within the human sciences, from bioscience to philosophy, have helped shape debates and discussions that inform the ongoing construction of the problem of fatness. Importantly, state regulation while playing a role has relied very much on government at a distance. Also important is the role of expert auditing which, as a tool of regulation through numbers, has been crucial to revelations of the extent of the obesity problem. Measuring fatness and demonstrating its movement across and within populations has made obesity the epidemic it has now become. 2. A new pluralisation of social technologies: Neoliberal governance is marked by a shrinking of centralised forms of regulation, and the growth
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of decentralised agencies and organisations often with quasi-governmental status. Coalitions of expertise on obesity have proliferated taking the place of central governments in providing expert opinion on the changing rates, new problem definitions and new solutions. For example, the International Association for the Study of Obesity has brought together a range of policy makers, researchers and practitioners with the aim to improve global health by promoting the understanding of obesity through research and dialogue, while encouraging the development of effective policies for prevention and management. Member organisations and networks in nearly 55 countries provide an authoritative role in guiding research and debate on the problem through membership on key committees and advisory panels (International Society for the Study of Obesity 2006). Marketing opportunities are opened up through collection of data when, for example, the food industry in Australia collaborates with government to fund surveys on childrens eating habits (CSIRO 2006). In governing girth we could wish for no better example of what Dixon and Banwell call the Diet-Making-Complex or DMC (Dixon and Banwell 2004). The DMC represents an amalgamation of compatible interests such as scientists, policy makers, food companies, and communication specialists. The resulting activities, often as publicprivate partnerships, set the agenda for what is regarded as appropriate business in nutrition. 3. A new specification of the subject: The fatness problem has opened up new opportunities to problematise everyday life. Mass information distributed through a multiplicity of media sources provides the constant reminder that for adults and children alike, fatness is an everpresent health hazard. Growing mountains of flesh for which no easy or immediate dietary cure or curtailment is available is of course, never only a health problem. Food and eating are always moral problems (Belasco 1997). The problematisation of body size has required even greater levels of self or ethical evaluation. Now that the lives of individuals invariably take place within obesogenic environments (and that it is normal to be overweight) the opportunities

for self-appraisal are considerable and the duty to be well more difficult. The government of the self by oneself (a relationship Foucault (1986) calls rapports a soi), provides a field of self-surveillance for both obese and non-obese subjects within the new fields of non-infectious diseases, like obesity. Given that the causes are believed to be integral to modern lifestyles normal eating, living and playing the opportunities for self-appraisal in the midst of just doing ordinary life becomes overwhelming. And we should note that while the problem of overweight is mostly taken seriously, growing pockets of cynicism and resistance are evident in a number of areas. For example, the size acceptance movement constructs the problem of overweight as itself a problem: one where there is a pre-occupation with thinness (Sobal 1999). Whether this will see the development of another subject position one in which body weight and shape are not of concern and not subjected to moral judgement and evaluation remains to be seen. Given Western history and the enduring legacy of puritanical systems of thought (Leichter 2003), a social acceptance of the personal choice to stay fat might be a long way off. For the ancient Greeks the dietetics was a concern for the conduct of everyday life in order to live in happiness and harmony (Foucault 1992). The quest to balance pleasure through moderation and self-control was brought about through following a style of life (Petersen 1997). For modern subjects we can see a new dietetics emerging. It is one where constant self-scrutiny is required of food intake through an endless supply of new diet books that have arrived have taken advantage of the obesity epidemic. It is one where physical activity is commodified through home gyms and treadmills, and where pedometers measure the distance individuals covered in a day. And it is one where body weight is monitored by bathroom scales that speak your weight or even calculate individual body fat. Indeed, the obesity epidemic has not weighed down the market place which has seen an explosion of imaginative entrepreneurial products designed to address the problem. And we must not believe that the public
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does not welcome these new opportunities for salvation from fatness. Eager to do the right thing, and reminded constantly what that might be, individuals collaborate actively with science, industry and policy makers to assuage their collective concerns about the obesity problem. And while the fight against fat may appear to represent a heightened awareness of our human failings in the midst of food plenty, we would be deluding ourselves in thinking that this is some new form of morality. Obesity maps onto moral concerns about food and the body that have a long tradition in Western culture.

Acknowledgment
This paper was developed from ideas that appeared in my book, Food, Morals and Meaning: The Pleasure and Anxiety of Eating (2006) (2nd edition) Routledge: London.

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