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Health Sociology Review (2008) 17: 124–128
University of Adelaide and
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, Bacchi’s 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 research–policy 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 Foucault’s account of the operations of power in modernity, Ulrich Beck’s 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 Foucault’s 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 Foucault’s concept of medicalisation in light of the impact of the market (Kickbusch 2006:561), Foucault’s work is nevertheless reexamined in innovative ways in this Special Issue by several contributors. Coveney’s focus on
Foucault’s later work concerning governmentality and Diprose’s 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 Foucault’s biopolitics and Merleau-Ponty’s 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. Beasley’s work initially suggests some qualification of Foucault’s claims concerning the proliferation of sexualising
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have a somewhat different orientation. August 2008 127 . suggesting that commodification of bodies. Importantly. Such governing of the girth is positioned within Rose’s characterisations of new forms of government (Rose 1996). which emphasise networks of governance and pluralisation of ‘social’ technologies. The analysis of this risk orientation has implications for the whole arena of Public Health. and the ways fatness in children has allowed for the availability of different subjectivities or subject positions in which children are framed as sick. While Broom and Diprose refer to the topic of smoking. These perspectives on risk put forward by Broom. HEALTH SOCIOLOGY REVIEW multidimensional webs that activate trust) is required in Public Health research. This ‘fit’ amounts to the curtailment of intellectual diversity and debate. particularly as they relate to contexts of gender and class. the narrowing of complex plural knowledges. We hope that the papers in this collection will continue to Volume 17. and in Gender/Sexuality thinking which informs it. The fourth paper by Bacchi offers another take on the framing of Public Health and is concerned with the structures of governance. Diprose and Beasley enable consideration of what risk problematically prioritises. consumption and governmentality respectively. Coveney’s timely paper illustrates how childhood has become a major point of engagement in the war on fat. this paper also problematises the argument that trust is quantifiable. In short. These writers aim to provide a more rigorous and expansive understanding of widely used terminologies in the critical literature. 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. In consequence preventive sexual health projects are unable to frame hetero-sex beyond the defensive language of risk avoidance. She argues that heterosexuality within Preventive Health. industries. and that both biological and social science perspectives are important to unpacking the complexity of patterns and experiences of health and disease. and unacknowledged institutional regulatory processes. with a focus upon trust. but fundamentally concerned with the paradoxes and possibilities of consumption. she asserts. to recognise that not everything that can be counted counts and that not everything that counts can be counted’ (Sillitoe 2007). involves developing new modes of thinking which do not discount pleasure and its creative potentialities and offer ways of constituting an ‘ethical erotics’. Issue 2. and organisations). An ethnographic approach to a Public Health issue allows us to rethink and redefine key questions of the ‘obesity problem’. questions and expected outcomes. Re-imagining sexuality and sexual health frameworks. slothful and dangerous. The latter three papers by Meyer et al. 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. is largely absent as a potential source of pleasure and over-determined as a source of repressive domination. Meyer et al examine dominant theories of trust in health systems from Giddens and Luhmann. asking: ‘can we ever really measure and bring into view the linkages between knowledge and ignorance’? In many ways.Editorial discourses in modernity. what it may inadvertently privilege and what is absent from its purview. All concentrate upon detailed analysis of existing critical vocabularies in the Preventive Health field. 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. Warin et al and Coveney. this question points to wider positions and arguments raised by the Special Issue as a whole: ‘to value those things that cannot be measured. spaces and health are not simply part and parcel of the negative effects of a ‘consumer society’. This paper attends to funding arrangements. Bacchi critiques the ways in which the knowledge gap between research (what we know) and policy (what we do) is articulated. and suggest that a more comprehensive model (enabling recognition of significant social factors and the complex. Warin et al and Coveney offer careful assessments of the issue of obesity. or innocent helpless victims (and extending to new subject positions for parents. We recognise that no single discipline has a monopoly.
. 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. Issue 2. Osborne. cases and commentary on issues that connect water and gender from international. J. and Woolcock. (eds) Foucault and Political Reason University College Press: London.farm income in depressed rural communities. This issue argues that gender should be explicit in developing policy and aid programs. Bilodeau A. +61-7-5435-2900 Fax.. (1996) ‘Theory in health promotion: Introduction’ Health Promotion International 11(1):7-9. (2006) ‘The health society: The need for theory’ Journal of Epidemiology and Community Health 60:561. Dunn. (1992) Method in Social Science: A Realist Approach (2nd edition) Routledge: London. A. M. Sillitoe. L. and Chabot. (2006) ‘The anthropology of public health’ Journal of Biosocial Science 38(1):1-5. M. Anne Hayes deserves special mention for her instrumental role in organising the original forum from which the idea for this Special Issue arose. (1997) ‘The role of theory in public health’ in Scally.. August 2008 . D. S. and are more often responsible for selection of food and water saving appliances. 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) . Kickbusch. and Vivienne Moore. A. Sayer. M. corporate governance and regional decision making. P (2007) (ed) Local Science vs Global . yet are less represented in politics. The on-going members of this sub-grouping were Carol Bacchi.. J. P (2005) ‘Integrating social theory into public . Jones. J. Acknowledgments The editors would like to thank the anonymous reviewers who generously assisted in reviewing manuscripts for this Special Issue. and Cummins. (2000) ‘The role of theory in evidence based health promotion practice’ Health Education Research 15(2):125-129.. Parker. regional and national perspectives. N. S. . and contribute to new theoretical directions. Annette BraunackMayer. Content Tel. +61-7-5435-2911 PTY LTD eContent Management Pty Ltd PO Box 1027. T. References Bambra. Moore. A. (ed) Progress in Public Health Royal Society of Medicine Press: London. operationalise and measure them’ Social Science Medicine 55:125-129. A. and the hard work of the HSR editorial team. (2006) ‘Speaking theoretically about population health’ Journal of Epidemiology and Community Health 60:572-3. Potvin. New York. S. This special issue includes research. C. Langton. I. S. S. (2007) ‘Trapped in the Aboriginal reality television show’ Griffith Review Edition 19 Re-imagining Australia Griffith University: Sydney. Science: Approaches to Indigenous Knowledge in International Development Berhahn Books: Oxford. G. and Rose. Endnote 1. Szreter. and McQueen. and in designing communication and education programmes. health practice’ American Journal of Public Health 95(4):591-5. Ellaway. (2006) ‘Lost in translation: A genealogy of the “social capital” concept in public health’ Journal of Epidemiology and Community Health 60:729-34. (2005) ‘Towards a politics of health’ Health Promotion International 20(2):187-93. ANNOUNCING DECEMBER 2008–WATER POLICY AND GENDER Edited by Kathleen Bowmer. D. Dean. Green. (2002) ‘Place effects on health: how can we conceptualise. D. Anne Hayes (administrative coordinator). Rose. Teresa Burgess. Chris Beasley. Maleny QLD 4552 128 HEALTH SOCIOLOGY REVIEW Volume 17. Fox.volume 18/3 In most cultures men and women are affected differently by challenges of water scarcity or excess.. Haines V. bear the brunt of generating off. and Scott-Samuel. I. (2004) ‘Rejoinder: Crafting rigorous and relevant social theory for public health policy’ International Journal of Epidemiology 33:700-704. and Harper.Editorial challenge and extend our existing stock of social and political theories of health and prevention. K. Macintyre. policy making.. N. Women are often more sensitive to environmental conservation. (1996) ‘Governing in “advanced” liberal democracies’ in Barry. I. Gendron S. (2006) ‘Whose theory is it anyway?’ Journal of Epidemiology and Community Health 60:571-2. Hawe P and Shiell. and Walker. Popay.
latent functions Preventing disease is by definition a valuable objective. have long been recognised as preferable to therapeutic intervention.Copyright © eContent Management Pty Ltd. and it is therefore important to instigate a rich exchange between innovative theory and rigorous research to minimise such effects. The proliferation of meanings complicates the task of re-imagining. In the paper. show some of the limitations of the conventional theoretical approaches to prevention. I touch on the other forms. I explore the latent functions – the unintended consequences – of what I call the ‘project of prevention’. I sketch the challenges to mobilising that awareness. and note here that the distinctions between them presume boundaries that are empirically and experientially more blurry than the definitions might suggest. ‘prevention’ is typically subdivided into primary. Then. Particularly when clinical care is being discussed. and point to directions for developing more fruitful perspectives. touching on illustrations of the unintended consequences. gender. and the maintenance of good health. is not limited to stopping health problems before they start. The term ‘prevention’. August 2008 129 . Although my interest is mainly in primary prevention (particularly community-based rather than clinical). and is generally believed to be more cost-effective than medical care. Although many latent functions are welcome. and has therefore subverted its explicit agenda and paradoxically contributed to the Volume 17. but it is indicative of the contemporary discursive and socio-political context within which health care and prevention occur. secondary and tertiary types. class. Preventative Services Task Force 1996). This context. 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. 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. contribute collectively to the unintended effects which form the subject of this paper. some have undesirable effects. The prevention of disease and injury. and most debates have revolved around improving the effectiveness of prevention.S. Issue 2. I begin by over viewing several key characteristics of the contemporary context. while tertiary prevention has become another name for medical care that strives to restore an optimal level of health and functioning HEALTH SOCIOLOGY REVIEW T in a person with established disease (U. The term secondary prevention is used to refer to early detection of asymptomatic people. sociology. 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. and the way the definitions and implementation of prevention have developed. Only primary prevention involves avoiding ill-health before onset. Prevention averts pain and suffering. In this discussion. Health Sociology Review (2008) 17: 129–140 Hazardous good intentions? Unintended consequences of the project of prevention ABSTRACT KEY WORDS Health promotion. however.
But even when it is partly successful (or perhaps especially then). I discuss four of its key characteristics: 1. Its focus on the individual. those whose health is poor (Blaxter 1990). in Australia’s 2005 National Research Priorities. Pitts 1996). These characteristics are closely interrelated. 2. and medications to manage hypertension) are believed to contribute to improved health. 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. emphasises ‘enabling people to make choices’ (DEST undated). An emphasis on individuals is hardly surprising. an ambiguous case: spanning both individuals and populations. in some ways. but it is often delivered to groups or whole populations. Issue 2. occluding structure. 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. prohibitions on drink-driving and cigarette advertising. by extension. 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. Health promotion through education continues to be the most popular intervention for improving health-related behaviour. and the accompanying decline in cardiovascular disease. 3. but lay people – including those with impaired health – can also attribute difficulties to the failure to exert sufficient willpower (Blaxter 1993). Similarly. Here. noting that ‘all Australians stand to benefit from preventive health care through the adoption of healthier attitudes. the priority of Promoting and Maintaining Good Health is quickly glossed as ‘enabling individuals and families to make choices that lead to healthy. The location of prevention in a distinctive neo-liberal political economy and a cultural economy of modernity. and increasing surveillance (of self and others). Medicalisation and the expansion of the field of health. and 4. as are the development and marketing of food products with lower saturated fat content.Dorothy Broom reproduction of health inequalities in the process of advancing prevention. individual behaviour change is still typically the axis on which these interventions turn. and especially on individual behavioural risk factors (Lin and Fawkes 2007. lipid lowering drugs. Even the priority goal Strengthening Australia’s social and economic fabric which might be expected to have a strong structural dimension. Health education is. productive and fulfilling lives’. although a systematic deconstruction of their relationships is beyond the scope of this paper. For example. since it is designed to influence the behaviour of individual persons. 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. 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 Volume 17. However. in light of contemporary ideology and political culture. although clinical interventions (such as nicotine replacement therapy. August 2008 130 HEALTH SOCIOLOGY REVIEW . Characterising prevention Contemporary prevention could be described in many ways. the emphasis on the individual as the target of prevention entails at least three undesirable unintended consequences: stigmatising the sick. Some health professionals have explicitly attributed illness to personal sins such as greed and sloth (Knowles 1977) . Apart from the distress of being unwell and being blamed for causing (or failing to prevent) one’s own suffering. Individualised health The focus of contemporary prevention is fixed largely on the individual. regulation and legislation designed to improve health (such as laws requiring the use of seat belts. For example. The increasing emphasis on an evidence base. habits and lifestyles’.
many of the ‘technologies of the self’ that involve working on one’s body (including diets. we can ill afford to ignore elements of structure if the health (particularly of vulnerable populations) is to be improved (Crawford 1980). we foreground. colon and cervix. People who wish to establish themselves as independent. individualised prevention can inadvertently create new subject positions defined by resistance to health promotion. For example. friendly. class. Furthermore. culture. prostate. 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. people are being incited to pay compulsive attention to various kinds of behaviour. urban design. ‘choice’ and ‘lifestyle’ are readily applied to people who are apparently solitary individuals. even though the most cursory sociological analysis identifies environmental (GilesCorti 2006). amplified by what has been called the project of the body. Indeed much health related surveillance has been strongly gendered. As new tests become available. At least one US state (Wisconsin) has a statute defining certain forms of prenatal maternal behaviour as prenatal child abuse. or cultural and socioeconomic inequality (and indeed it can be intellectually and politically challenging) (Lin and Fawkes 2007). sociable and not up tight may be attracted to hazardous behaviour as a way of establishing and displaying such identities. Commercial weight loss programs such as Weight Watchers incorporate such attentiveness through the meticulous balancing of physical activity and calorie intake. as socioeconomic gradients. they reestablished their adult agency by consciously flouting medical advice. That is. Words such as ‘personal habits’. the very balance between the individual and the social (agency and structure) is itself heavily shaped by structural considerations (Williams 2003). However. Another example of perverse unintended consequences is the pattern of explicitly disparaging people who conform to health promotion advice as being killjoys or ‘goodygoodies’. As long as problems can be avoided and health promoted by solitary individuals. because it is often asserted that health service providers and policy makers cannot intervene in such elements as the economy. the default option of the individual as author of their own destiny is constantly reinstated. responsible people are urged to subject themselves to medical surveillance through tests for bone density. Consequently. blood sugars and fats. or are disposed of in a sentence or two. This kind of self surveillance also fosters the surveillance of others. That is. since the exercise of such freedom is denied to children. ethnicity. In addition to medical testing. gym memberships and exercise machines and food supplements) are justified partly in terms of their alleged health benefits. particularly what they eat and drink. 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. such patterns HEALTH SOCIOLOGY REVIEW Intensified surveillance Surveillance is a virtually inevitable consequence of contemporary prevention. August 2008 131 . Elements of politics. ignoring structure does no harm. culture and social structure that are believed to be beyond the scope of public policy either disappear altogether. Invisible structure Theories of health and disease prevention are redolent with terms that appear to signify the centrality of individual behaviour. gender. and cancers such as breast. and geography as elements of social identity and social relations that are significantly correlated with the distribution of health and illness (Cockerham 2006. However. gender and ethnic differentials in health (Cockerham 2007) are rarely explained by the composition of the relevant groups alone. the economy. particularly as far Volume 17. the factors that are already defined as modifiable. and ultimately only investigate and act on.Hazardous good intentions? Unintended consequences of the project of prevention (Broom and Whittaker 2004). 2005). Issue 2. that is by the characteristics of the individuals who comprise socioeconomic or ethnic categories (Wilkinson and Marmot 1998). Consequently. sometimes literally. An understandable policy interest in practical interventions and ‘modifiable’ factors becomes a self-fulfilling prophecy.
In the first few decades of the 20th century. the results of RCTs can probably be applied only to pharmacological (plus a very few surgical) interventions administered in hospitals. Additionally. this borrowing from evidencebased medicine is far from straightforward. and cannot be generalised for use of medicines or other therapies in the community. while the vices of middle-aged professional white men go unremarked. eroding its effectiveness. Paradoxically. despite their substantial impact on individual or environmental health. thus reinforcing women’s potentially obsessive concern with appearance. The unproblematic reliance on professional medical and public health reasoning to define rational choice. The discrepancy poses important questions about the ethics of persisting with weight loss propaganda. Neither the content of health education nor the nature of what constitutes a rational response appear to yield to simple definition (Broom 1984. it was widely believed to be caused by a germ. especially among the poor and among inmates in institutions such as mental hospitals. despite the fact that ‘the evidence supporting the link between promoting weight loss and improving health is. particularly ‘masculine’ diets such as those entailing high meat intake (Bentley 2004) because of concerns about appearance as well as health. Policymakers are keen to identify interventions that have been subject to evaluation. that such changes do not constitute instances of ‘de-gendering’. Unfortunately. the difficulty assembling rigorous evidence of the effectiveness of certain preventive interventions has not discouraged their use (Rogers 2004a). as well as raising the issue of public expenditure on this agenda. Kavanagh and Broom 1998). but rather signal the mobile and adaptable character of gender and its value in consumer culture (Broom 2008). 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. The history of medicine is replete with examples of rigorous evidence that has been ignored or even actively suppressed. rational people will take the appropriate action. in the current climate of moral panic about the rising prevalence of obesity. and the related fragmentation and fetishisation of body parts (Broom and Dixon 2008). It affected about three million people of whom 100. The quality of evidence for preventive interventions has been undermined by the individualistic focus (discussed above). women’s bodies have been more intensely subject to ‘the gaze’. contentious’ (Aphramor 2005:315). at best.Dorothy Broom as their own body shape and weight are concerned. admirable intentions. pellagra was widespread in the American South. Health risks taken by ethnic minorities. is a weakness of the model.000 died of the disease. 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). however. and that when individuals know which personal behaviours lead to illness. but the young doctor sent by Volume 17. what constitutes gold standard evidence in medical care (the randomised controlled trial. For example. Issue 2. Note however. people in rich countries are being exhorted to control their weight. prisons and orphanages. Gay male interests in gym culture and bodily appearance seem to have been taken up in the heterosexual male population. These gender dynamics may be shifting somewhat as the male body is mobilised as an object to be deployed in advertising and consumed visually. Furthermore. The assumption (often implicit) is that health education is a straightforward means to inform people about behavioural risk factors. At the time. For one thing. and becomes virtually impossible to conduct where questions of population health are concerned (Rogers 2004b). August 2008 132 HEALTH SOCIOLOGY REVIEW . RTC) is of limited practical value even in clinical settings. Such limitations are compounded in the case of prevention where both problems and solutions are usually multifactorial. Once again. Furthermore. more men are apparently becoming engaged in diets. working-class people and women are often construed as irrational.
calcium deficiency can cause rickets. a rare and difficult combination. And with increasing numbers of conditions now defined as questions of health and Volume 17. he assembled ever more detailed evidence. Conrad and Schneider 1980). cultural and political obstructions to achieving the shift proved more difficult than the empirical research. Woodward et al 1995). 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. 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. He tried the simple intervention of improved diet. Lest we imagine that such errors are a product of a bygone era.html). 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. August 2008 133 . classism and regionalism to overcome science. HEALTH SOCIOLOGY REVIEW The germ theory of disease has fostered a belief in single causes. with elaborate alternative diagnoses and explanations persisting despite abundant evidence. Metcalfe referred to doctors and health promoters as ‘secular missionaries’ (Metcalfe 1993). 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.gov/exhibits/goldberger/index. because it obstructs access to effective interventions as well as imposing ineffective or even counterproductive ones (West 2005. but he had not reckoned on the power of racism. his findings were discounted and his competence disparaged.Hazardous good intentions? Unintended consequences of the project of prevention the predecessor of the National Institutes of Health to investigate the epidemic could find no evidence to substantiate that belief. Prevention of pellagra is simple once the focus shifts from disreputable filth to dietary deprivation. and on which health professionals are presumed to be appropriate authorities (Zola 1972). And indeed. 2006). The result was decades of delay accepting his hypothesis and diminishing the burden of this disease (http:// history. occupational overuse syndrome (RSI) and chronic fatigue syndrome are examples of this change to an extent (Broom and Woodward 1996. but because this view contravened the prevailing theory.nih. even as others (such as aspects of male ageing) are being added to the list of health problems requiring medical treatment (Conrad 2007). Some conditions that had been de-medicalised are now being re-medicalised. but the social. The determination to base prevention on evidence thus may require the cultivation of a subtle blend of empirical rigour and humble agnosticism. a belief that can be hazardous even when germs are implicated. hyperactivity. Furthermore. However. since – as epidemiologists tell us – exposure. host and environment are all elements of the puzzle of health and disease. It seems that even in the presence of plenty of sunshine. Issue 2. some conditions do appear to have become less stigmatised as a result of being redefined as diseases. Indeed. Alcoholism. which suggests that medicine is becoming a kind of lay religion. 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. he antagonised both the New England establishment and Southern pride with his health heresy. an attitude that appears to pose a considerable challenge to evidence-based prevention (Gard and Wright 2001). and many children in poor countries have suffered because of the unwillingness of medical authorities to acknowledge that their paradigms were incomplete. and documented dramatic results. Thinking that more rigorous proof would persuade the sceptics. As the New York Jewish son of poor Hungarian migrants. 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. some of the most significant public health questions require a capacity to tolerate high levels of uncertainty.
the definition of what constitutes healthy weight or blood pressure and the threshold for classification as disease continues to shift downwards (Rose 1985). Consequently. generate an ever louder cacophony of supposedly authoritative voices telling people what to do to be healthy (Dixon and Winter 2007). placing the persons so labelled in a liminal space between health and disease. and amplified medical authority. more and more bodily states become objects of preventive interventions. and we have already glimpsed some of the undesirable effects of this focus. Thus. but rarely the only or even the primary one. The redefinition of citizens as ‘consumers’. Most people are not keen on ‘living in a clinic’ (Metcalfe 1993). and physical activity. Medicalisation entails not only a lengthening list of problems that come to be defined as diseases. high blood pressure or ‘excess’ weight are now often defined as diseases in their own right. August 2008 134 HEALTH SOCIOLOGY REVIEW . all enacted in specific social and physical environments. Posner 1993). And all of these are deeply embedded in identities. That is. diet. and are often reluctant to accede to the imperatives of ‘healthism’. The valorisation of the individual is a key element of neoliberal ideology. intricate. and in the process. particularly in the environment where 1000 flowers (and many more weeds) bloom on the internet. Far from being singular ‘risk factors’. prompting the fat acceptance movement to assert that ‘obesity is not a disease’. medical authority continues to proliferate. medicalisation now incorporates the manifestation of certain health risk factors. Patients are encouraged to hope Volume 17. we have seen selfhelp organisations mobilised by international drug companies to assist with lobbying to add new prescription products to the Pharmaceutical Benefits Scheme. social relations. Together with discourses of prevention. However. However. New labels are devised for new conditions (such as pre-diabetes or 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. The medical management of hypertension or serum cholesterol. commodification and modernity Preventive care is subject to particular constraints in the context of the currently dominant neoliberal political economy. Neoliberalism. through a kind of verbal slippage. the rise of consumerism and the culture of modernity. In combination with a kind of ‘risk factor bracket creep’. most of what is required for disease prevention entails repeated. In Australia. symptoms. we should not be too surprised that so many people have so much difficulty conforming to the numerous (sometimes conflicting) injunctions of health promotion. is justified on the basis that doing so prevents disease in the future. Perhaps none of these trends entail obviously undesirable consequences. gender. Being diagnosed with pre-cancer. for example.Dorothy Broom illness. ethnicity and culture: indeed everything that contributes to the formation and enactment of what Bourdieu calls ‘habitus’.g. Collyer 2007). the worthy objective of improving health can bring with it medical dominance and the erosion of people’s confidence in their ability to manage problems of life without professional supervision. Issue 2. even in the absence of impaired function or any other symptom. 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. subtle and often quite sophisticated management of testing. therapies and supplements. 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). an apparently factual test result in the medical sphere may carry personally and socially ominous connotations to the person whose body is thus redefined. This proliferation of experts further complicates the already difficult task of health promotion. As health and its protection have become commodified. Paradoxically. but also an expansion in the scope of time that may be subject to surveillance and judgment. but instead aim to balance health with an array of competing priorities where health is one objective. commercial firms advertise what they claim are ‘health promoting’ products. class.
trade disputes tribunals have typically required a very high level of evidence of health harm to justify restraint of trade. and authorised by international finance and trade agreements. but nearly equal proportions of women smoke now. and that ‘no less commercially restrictive alternative measure was possible’ (Zeigler 2006). As knowledge of its health hazards became more widespread. and in Volume 17. even in the case of such demonstrably dangerous products as asbestos and tobacco. 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’. Additionally. gradually transforming it into a marker of workingclass status or poverty (Barbeau et al 2004. cigarette smoking was democratised. its popularity among elites declined. Despite rhetoric to the contrary. but the gaps persist. HEALTH SOCIOLOGY REVIEW 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. 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. especially for women. Initially a signifier of discretionary income. 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. even reversed in Southern Europe) (Mackenbach 2006). However. August 2008 135 . higher status people. the gradient shifted during the 20th century. a view endorsed by many governments. but did nothing to shrink the socioeconomic differentials in health (Black 1980). Globally it is still true that the majority of smokers are men. In an equally striking shift. particularly by war. These cases are not so much of unintended consequences of prevention. but the gender differential is shrinking in many nations. Issue 2. lower incomes. Privatising health care and water supplies are also being driven by commercial interests in the first world. neoliberalism includes the ideology that unfettered commerce is the best route to improved health. 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. clients or the population more broadly. but collateral health damage of neoliberalism. In these circumstances. The famous Black report in the UK showed that better living conditions and the advent of the NHS diminished premature mortality overall. Turrell and Mathers 2000). The neoliberal regime can also directly thwart efforts at disease prevention. less education. People lower down the socioeconomic scale are more likely to smoke than wealthier. only men smoked at the beginning of the 20th century (Berridge 2001). The health of the whole population improved. 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. these gradients were believed to be products of poverty that would be alleviated by better material conditions and improved access to health care. 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. Cigarette smoking follows the inverse socioeconomic gradient in the Anglo-American democracies and in Northern Europe (the gradients are much less marked and. and living in poor neighbourhoods are more likely than their counterparts to manifest health risks and impaired health status (Murray et al 2005). worse jobs. Return to shareholders can take precedence over the health of workers. health education and health promotion. In the first half of the 20th century. How might prevention have contributed to that persistence? Smoking provides an informative case in point.Hazardous good intentions? Unintended consequences of the project of prevention that the drugs will prevent symptoms and complications of their disease. Most health risk factors are distributed according to socioeconomic position: people with less wealth. at least in the Anglo-American democracies (there is more variation in nations of the EU (Graham 1996). Just as health is not the sole aim of individual citizens.
it reappeared with its new masculine profile. Patton et al 1998). (Castrucci et al 2002). For example. and tobacco control has been one of Australia’s health promotion success stories. Greaves 1993). the development and promotion of explicitly feminine brands (such as perfumed. some young women smoke in order to resist the ‘good girl’ stereotype and render themselves socially approachable (Banwell and Young 1993. Issue 2. and the gender dynamics remain largely unaddressed. the UK and Australia. may be particularly motivated to abstain from smoking by their participation in sporting activities and a desire for physical fitness (Rodriguez and AudrainMcGovern 2004. cigarette manufacturers were eager to enlarge their exclusively masculine market. It sells large highfat steaks and hamburgers (such as ‘The Doublebypass Burger’). while the general failure of health promotion to generate research informed by appropriately sophisticated theory (Dunn 2006. At the time when virtually no women smoked. Another example is evident in the case of a new commercial venture in the USA that proudly labels itself ‘The Heart Attack Grill’. Dichter 1947. Jeffery et al 2000. Bialous 2005. when it was originally released in 1924. August 2008 136 HEALTH SOCIOLOGY REVIEW . The implicit assumptions of individualism. the political. identities and segments of the female market (Anderson et al 2005). Throughout the 20th century. Thiri Aung et al 2001). factors which may contribute to women’s generally lower rates of cessation (Abrams et al 1995. This initiative would appear to be targeted particularly at working-class males (Mosher 2001) who have been disempowered and disenfranchised by globalism. and that it does so without unacceptable inadvertent social and health costs. In the 1950s. elements that are also likely to be gendered and have implications for health promotion. there is no longer any consistent sex difference (McDermott et al 2002). Furthermore. some of the factors driving smoking and obstructing quitting may differ subtly between the sexes. followed by a campaign to attract female consumers who were encouraged to ‘try the cigarette for men that women like’. especially young men.Dorothy Broom North America. In the second half of the 20th century. Cigarettes are often given or shared rather than purchased. and cigarettes. Marlboro (later associated with the independent cowboy ‘Marlboro Man’) was intended to be a women’s brand with the catchphrase ‘mild as May’. Vagero 2006) has left it ill-equipped to address classed or gendered ‘targets’. including the development of brands intended to appeal to women. Camp et al 1993. Conclusions Good intentions are not enough to ensure that the project of prevention achieves its promise of better health. corporatism and feminised professions. menthol and pastel-coloured cigarettes. and giving and receiving cigarettes may contain strongly gendered elements. For example. or ad campaigns quoting feminist slogans) was supplemented by more subtle forms of gendered marketing designed to appeal to particular images. Men. That is. beer. cigarette advertising and promotions were targeted specifically to each sex. economic and cultural setting of both health risks and health promotion continue to serve the interests of the commercial sector. That campaign signals the way a supposedly unisex brand (smoked by both women and men) can nevertheless be imbued with genderspecific signification. perfectibility and the superiority of what passes for expert and scientific knowledge can authorise prevention interventions with ineffective Volume 17. legitimised. Nevertheless. Sociologically oriented studies show that smoking and sharing cigarettes operate to support sociability and to build solidarity (Barbeau et al 2004. rational choice. like smoking itself. Kaplan 2004. all served by nubile waitresses in the scanty costumes of ‘naughty’ nurses (www. the last 50 years of which have become increasingly medicalised.heartattackgrill. Because of the associations between smoking and disreputable female sexuality. Honjo and Siegel 2003). Smoking appears to be more strongly linked to emotional distress and concern about weight among women (Berlin et al 2003. the class gradient persists.com). Australia has experienced a century of antitobacco activism. new antihealthist subject positions relating to smoking appear to be particularly gendered (Broom 2008). Lennon et al 2005). and supported by legal regulation (Walker 1984).
S. Banwell. and left the door open for systematic unintended consequences to arise from health promotion efforts... Aubin. social class. Thus. S.. Barker. I suggest that the purview of prevention should be broadened to include diminishing health inequalities. continuing to devise and implement prevention as it has traditionally been practiced is likely to continue to reproduce or even exacerbate health inequalities. not more of the same decontextualised individualism and relegation of structure and culture to the too-hard basket. 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. (1998) Independent Inquiry into Inequalities in Health: Report The Stationery Office: London. S. and List. References Abrams. (1993) ‘Rites of passage: Smoking and the construction of social identity’ Drug and Alcohol Review 12:377-385. E. and Young. Phillips. Berridge.. I. Finally..A. (2004) ‘Smoking. Lancrenon. L.M.H. P (2005) . Graham. Issue 2. et al (2003) ‘Modified reasons for smoking scale: Factorial structure. and Health in the 21st Century Palgrave Macmillan: London. An inadequately theorised approach to preventing smoking-related harm has fostered the persistence of health inequalities.D. (eds) Globalization.A. (2006) ‘Developing an evidence base for policies and interventions to address health inequalities: The analysis of “public health regimes”’ The Milbank Quarterly 84(3):577-603.. J. Aphramor.. Women.M. as well as the improvement of health overall. Barbeau. Bialous. Leavy-Sperounis. August 2008 137 .219-225.. Singleton. (2005) ‘Is a weight-centred health framework salutogenic? Some thoughts on unhinging certain dietary ideologies’ Social Theory and Health 3(4):315-350. Chambers. HEALTH SOCIOLOGY REVIEW Volume 17. H. 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.Hazardous good intentions? Unintended consequences of the project of prevention or occasionally perverse consequences. M. Graham and Kelly 2004. Pedarriosse.. (1980) Inequalities in Health: Report of a Research Working Group DHSS: London.J.J. P and Friedman. Acheson. Prevention has yet to become a consistently effective and equitable resource for improving public health. Graham 2002. and to Carol Bacchi and the editors of this special issue for stimulating discussions and their encouragement to develop these ideas. . but to date it has been difficult to develop and advance politically in Australia (Lin and Fawkes 2007).. pp. J. Anderson. (2005) ‘Women’s health under fire: Does it need to go up in smoke?’ in Kickbusch. A. and Halliday. S. 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. Asthana.G. ‘Emotions for sale: Cigarette advertising and women’s psychosocial needs’ Tobacco Control 14(2):127-135. D. D. H. Berlin. A.A. Rames.L.S. M. Black. S. K. Acknowledgments I am grateful to two anonymous reviewers for constructive suggestions. Hartwig. J. 2006. gender effects and relationship with nicotine dependence and smoking cessation in French smokers’ Addiction 98 (November):1575-1583. A. E. it will need detailed research grounded in innovative theory. and gender: What can public health learn from the tobacco industry about disparities in smoking?’ Tobacco Control 13(2):115-120. E. V.. and Balbach. A. That is.M. C. To fulfil its potential. (2001) ‘Constructing women and smoking as a public health problem in Britain 1950-1990s’ Gender and History 13(2):328-348. such as when refusing health promotion becomes a form of resistance and a means to reclaim spoilt identity. I. D. This priority has been forcefully articulated as an objective for health and social policy in the UK (Acheson et al 1998. and Marmot. Marmot 1999). (2004) ‘The other Atkins revolution: Atkins and the shifting culture of dieting’ Gastronomica 4(3):34-45. political economy and culture which form the context of contemporary prevention. J. Glantz. D. and Ling. Bentley. (1995) ‘Commentary: A reappraisal of research results for the local treatment of early stage breast cancer’ Journal of the National Cancer Institute 87(24):1837-1845..
D. N. Graham. D.C. H.K. E. (2007) Social Causes of Health and Disease Polity Press: Cambridge. Greaves.C. Dichter.P (2004) Health Inequalities: .C. (2003) ‘Perceived importance of being thin and smoking initiation among young girls’ Tobacco Control 12(3):289295.nhs. (1993) ‘Why do the victims blame themselves?’ in Radley. Australia. B. R. M. C.H. M.124-142.uk Graham. On the Transformation of Human Conditions into Treatable Disorders Johns Hopkins Press: Baltimore. Graham. Gard. Broom. Cockerham. Monash University Department of Anthropology and Sociology. H. M. R. Broom. (2001) ‘Managing uncertainty: Obesity discourses and physical education in a risk society’ Studies in Philosophy and Education 20(6):535-549. E. Klesges. Conrad. Kaufman. (2008) ‘Gender in/and/of health inequalities’ Australian Journal of Social Issues 34(1):11-28. Crawford. Frameworks and Policy Retrieved 23 August 2006.E. Gerlach. Dunn. and Broom. (ed) The Psychology of Everyday Live Barnes and Noble: New York. A. C. Conrad. W. (2008) ‘The sex of slimming: Mobilising gender in weight-loss programs and fat acceptance’ Social Theory and Health 8(2):148-166. Camp. J. P (2007) The Medicalization of Society: . (ed) Perspectives in Health Policy Australian National University: Canberra.C. and Whittaker. pp. and Medicalization: From Badness to Sickness C. (ed) Worlds of Illness Tavistock: London. W. (1990) Health and Lifestyles Routledge: London. Evidence Base for Tackling Health Inequalities and Differential Effects Economic and Social Research Council: London. H..C.J.dest. M.H. D. Dixon.P (2006) Developing the .hda. (eds) Seven Deadly Sins of Obesity: How the Modern World Is Making Us Fat University of NSW Press: Sydney. (1993) The Meaning of Smoking to Women: Women. Giles-Corti. controlling diabetics: Moral language in the management of diabetes type 2’ Social Science and Medicine 58(11):2371-2382. D. and Siegel. (2004) ‘Controlling diabetes. (2002) Adolescents’ acquisition of cigarettes through noncommercial sources Journal of Adolescent Health 31(4): 322-326.M. Louis. Broom. and Winter.R. pp. Blaxter. J. Graham. L. F (2007) ‘A sociological approach to . (2006) ‘Health lifestyle theory in an Asian context’ Health Sociology Review 15(1):6-15. Issue 2. Cockerham. org. from www. Conrad. (2002) ‘What do we mean by “social determinants of health”?’ in NSDR Program (ed) NCEPH: Canberra. Broom. and Wright. H. Smoking and Identity Unpublished PhD.gov. pp. R.H. M. B. (DEST: undated) (www. Broom. (1980) Deviance . and Kelly. Annual Review of Sociology 18:209-232. J.. P (1992) ‘Medicalization and social control’ . Collyer.au/sectors/ research _sector/policies_issues_reviews/ key_issues/national_research_priorities/ priority_goals/promoting_and_maintaining_ good_health. (1984) ‘The medical gamble: Toward a model of health risk-taking’ in Tatchell. J. D. G.H. A. Honjo. D. (2006) ‘Speaking theoretically about population health’ Journal of Epidemiology and Community Health 60(7):572-573.T.H.69-80.V. M. J. (1947) ‘Why do we smoke cigarettes?’ in Dichter. K. J. Mosby Company: St. pp. and Dixon. P and Schneider. (1996) ‘Medicalisation reconsidered: Toward a collaborative model of care’ Sociology of Health and Illness 18(3):357-378.86-99. Volume 17. and Relyea. and Woodward. Castrucci.V.W. August 2008 138 HEALTH SOCIOLOGY REVIEW .H. Concepts. (1996) Smoking prevalence among women in the European Community 1950-1990 Social Science and Medicine 43(2):243-254. (2005) ‘Health lifestyle theory and the convergence of agency and structure’ Journal of Health and Social Behavior 46(March):51-67. and Kelly. (1993) ‘The relationship between body weight concerns and adolescent smoking’ Health Psychology 12(1):24-32.126-147. D.Dorothy Broom Blaxter. (1980) ‘Healthism and the medicalization of everyday life’ International Journal of Health Services 10(3):365-388.. W. workforce shortages: Findings of a qualitative study in Australian hospitals’ Health Sociology Review 16(3-4):248-262. Cockerham. (2006) ‘People or places: What should be the target?’ Journal of Science and Medicine in Sport 9(5):357-366. (2007) ‘The environment of competing authorities’ in Dixon. and Orleans.J.htm). K. M.
Knowles. Lin. A. (2000) ‘Socioeconomic status and health in Australia’ Medical Journal of Australia 172(9):434-438. Volume 17.. (2004) ‘What is wrong with social epidemiology. Europe in Profile Erasmus Medical Center: Rotterdam.. and What Else? International Institute for Food.M. H. Kavanagh. (1993) ‘Ethical issues and the individual woman in cancer screening programs’ Journal of Advances in Health and Nursing Care 2(3):55-69.T.. Owen. A. Kickbusch. (2004) ‘Team sport participation and smoking: Analysis with general growth mixture modeling’ Journal of Pediatric Psychology 29(4):299-308.. Hennrikus. and Dobson.W. Thiri Aung. Mackenbach. and Development (CIIFAD). Mosher. and Broom. Wolfe. Uphoff. J.W. W. N. Cornell University: Cornell. D.105-131. J. J.. Russell. D. Rogers.L. Kulkarni.H. (2001) ‘Health and performance related reasons for wanting to quit: Gender differences among teen smokers’ Substance Use and Misuse 38(8):1095-1107. and Mathers. health disparities’ American Journal of Preventive Medicine 29(5S1):4-10. L. N. Carlin. L.A.B.57-80. and Combs. H. Patton. (eds) Social Determinants of Health Cambridge University Press: Cambridge. and Audrain-McGovern. (1993) ‘Living in a clinic: The power of public health promotions’ Australian Journal of Anthropology 4(1):31-44.. M. Rose. J. (1998) ‘The course of early smoking: A population-based cohort study over three years’ Addiction 93(8):12511260. E. Rodriguez.E. Hickman. T. Preventative Services Task Force (1996) Guide To Clinical Preventative Services (Second edition) Williams and Wilkins: Baltimore. N. and McDermott. Rickets.G. Lennon. U. V. A. Marmot.C.P (2006) Health Inequalities: .Hazardous good intentions? Unintended consequences of the project of prevention Jeffery. Gallois.166-193. August 2008 HEALTH SOCIOLOGY REVIEW 139 ... pp. Leichter. Metcalfe. J. and Fawkes.S. A. Issue 2. (1998) ‘Embodied risk: My body. and how can we make it better?’ Epidemiologic Reviews 26:124-135. and Moolchan. D. (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. D. (2003) ‘“Evil habits” and “personal choices”: Assigning responsibility for health in the 20th century’ The Millbank Quarterly 81(4):603-626. J. J. M. M.. C. D.. G.J. and LeBesco. J. Murray. (2000) ‘Reconciling conflicting findings regarding postcessation weight concerns and success in smoking cessation’ Health Psychology 19(3):242-246. S. Rogers. W. (2001) ‘Setting free the bears: Refiguring fat man on television’ in Braziel. Turrell. I. Posner. myself?’ Social Science and Medicine 46(3):437-444. (2007) ‘Health promotion in Australia: 20 years on from the Ottawa Charter’ Promotion and Education 14(4):203208. A. (1977) ‘The responsibility of the individual’ in Knowles. Pitts. Hibbert. M. G.J. (1997) ‘Understanding abnormal Pap smears: A qualitative interview study’ British Medical Journal 314:1388-1392. (eds) Bodies Out of Bounds: Fatness and Transgression University of California Press: Berkeley. C. M. Kaplan. R.A. J. A. Lando. McDermott.D. (2004a) ‘Evidence-based medicine and women: Do the principles and practice of EBM further women’s health?’ Bioethics 18(1):50-71. (1999) ‘Health and the psychosocial environment at work’ in Marmot. pp.S. pp.J.M. R. A. R. G. and Ezzati. Coffey.A. and Broom. (2005) ‘Eight Americas: New perspectives on U. (ed) Doing Better in Feeling Worse: Health in the United States Norton: Near York. S. C.. K. G. and Wilkinson. (2006) ‘The health society: The need for a theory’ Journal of Epidemiology and Community Health 60(7):561-562. and Liu. (1996) The Psychology of Preventive Health Routledge: London. H. C. G. (2001) Some Things Can’t Be True But Are: Rice. Agriculture.A. Kavanagh. (1985) ‘Sick individuals and sick populations’ International Journal of Epidemiology 14:32-38. (2005) ‘Young women as smokers and nonsmokers: A qualitative social identity approach’ Qualitative Health Research 15(10):1345-1359. Murray. (2002) Cigarette Smoking among Women in Australia Commonwealth Department of Health and Ageing: Canberra. and Bowes..
Issue 2. Authors are invited to contact the Guest Editors to discuss their approach in advance of submitting papers (email: b. and Legge. Walker. Broom. context and agency’ Sociology of Health and Illness 25(3):131-154.com Content PTY LTD www.V.uk AGEING. G.com/page/22/author-guidelines eContent Management Pty Ltd PO Box 1027. (2005) ‘Time for a change: Putting the Transtheoretical (Stages of Change) Model to rest’ Addiction 100(8):1036-1039.H. the impact of global demographic transitions across localities. (1984) Under Fire: A History of Tobacco Smoking in Australia Melbourne University Press: Melbourne. Guidelines for manuscript preparation are available at: http://hsr.Dorothy Broom Vagero.edu. 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. ANTI-AGEING. this issue aims to develop a better understanding of the mechanisms of engaging patients in self-care and the impact this has for patients. Zeigler. GOVERNANCE AND GLOBALIZATION Deadline for Papers: 20th February 2009 GUEST EDITORS – Associate Professor Brett Neilson and Beatriz Cardona Centre for Cultural Research. b. and Marmot.Lindsay@salford.2009 SPECIAL ISSUES EXPERT PATIENT POLICY Deadline for Papers: 30th August 2008 GUEST EDITOR – Sally Lindsay Institute for Social. August 2008 . Further.com 140 HEALTH SOCIOLOGY REVIEW Volume 17. Cultural & Policy Research. R.e-contentmanagement.G. R. Authors are invited to contact the Guest Editor with their Abstract in advance – S.e-contentmanagement. Zola.cardona@uws. Williams. Maleny QLD 4552. (1998) Social Determinants of Health: The Solid Facts World Health Organization: Geneva. (1972) ‘Medicine as an institution of social control’ Sociological Review 20 (November):487-504.au). (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. West.K.. D. R. (2006) ‘Where does new theory come from?’ Journal of Epidemiology and Community Health 60(7):573-574. UK Reducing the incidence of chronic disease and health inequalities is a key priority for governments. D. 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. +61-7-5435-2911 subscriptions@e-contentmanagement. R. (2003) ‘The determinants of health: Structure. Fax. a better quality of life.neilson@uws. I. D. CALLS FOR PAPERS . M. health care providers and larger social structures. (2006) ‘The Transtheoretical Model of behaviour change and the scientific method’ Addiction 101(6):774-778. West.W. +61-7-5435-2900. University of Western Sydney.H. D. 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. (2006) ‘International trade agreements to challenge tobacco and alcohol control policies’ Drug and Alcohol Review 25(6):567-579. 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. 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. University of Salford.au. Australia Tel. 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.ac. self-esteem and a user-driven health system.edu. Abstracts should be submitted via email no later than 8 November 2008. Wilkinson. R. Woodward.
outline Volume 17. and effective approach to the promotion of health and well-being. 1 Alongside the focus on managing calculable risk. Received 10 August 2007 Accepted 5 March 2008 KEY WORDS Pre-emptive paradigm. respectful. With reference to Foucault’s concept of ‘political technologies of bodies’ and Merleau-Ponty’s ideas about the temporality and intercorporeality of bodies. the world. 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. Using the example of ‘quit smoking’ campaigns of 2006-7. intercorporeality. first. sociology Rosalyn Diprose School of History and Philosophy University of New South Wales Australia T here is increasing recognition among risk theorists that we are undergoing a paradigm shift in the way we understand and enact ‘society’s obligations for [ensuring] the physical security of its members’ (Ewald 2002:273). In pursuing admirable aims of preventing 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. particularly the conservative comportment toward the future that it fosters. there has been an intensification of what I will call political technologies of pre-emption in response to incalculable threats to physical security – threats HEALTH SOCIOLOGY REVIEW that have a low probability of occurring but would have potentially catastrophic effect. in pursuing admirable aims of the prevention of ill-health in the population. temporality. The paradigm presents a special challenge for public health programs in Australia that involve ‘life style’ health problems such as obesity. and other people. This provides the basis for a gesture toward a more ‘democratic’. is that. Health Sociology Review (2008) 17: 141–150 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’. which Ulrich Beck argued characterised the organisation of ‘Western’ societies for much of the 20th Century (Beck 1992). and drugs (illegal and legal). 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 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. Issue 2. depression. key features of the preemption paradigm are outlined. well-being. and social relations in general. particularly those dealing with ‘life style’ health problems such as obesity. the paper also explores deleterious effects of this approach to risk and health on human agency. embodied agency.Copyright © eContent Management Pty Ltd. The challenge this presents to public health programs. However. 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. and drug addiction (illegal and legal).2 This focus on preventing low probability but high consequence risks is most obvious in the arenas of biosecurity and anti-terrorism measures. depression. there are also indications that features of the paradigm have infiltrated approaches to the management of public health more generally. August 2008 141 . However.
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. and government agencies charged with managing health and physical security (for example. Hence. although all three share similar features. I consider the impact of the paradigm on human agency. but always imminent (Collier et al 2004. I adopt the latter descriptor. 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. corporations. 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). particularly the attitude about the future that it fosters. I will gesture toward a more ethical and effective approach. harm is said to be caused by our own decisions and actions. While these first two features alone are not a problem. Second. when combined with the third feature. actual medical and industrial accidents and environmental disasters in the 1980s. ‘preparedness’ (Rabinow 2003. and. the health of human bodies. or failure on the part of an individual or health agency to act to ward off future harm to one’s health and physical wellbeing). 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.Rosalyn Diprose the key features of the emerging paradigm. 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. human error in the biomedical lab or clinic. 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. August 2008 142 HEALTH SOCIOLOGY REVIEW . ‘nature’. Collier and Lakoff 2008) or ‘pre-emption’ (Derrida 2003. pre-emption. that of individuals. and indeed signal a move away from either biological or social determinism in understandings of human well-being. Cooper 2006). in the absence of a single cause of harm (such as God. and social relations in general. drugs. but a risk that is characteristically incalculable. to take some more recent examples. The first distinctive feature of the pre-emption paradigm is the assumption that risks and threats to health and physical security are incalculable. terrorism since the 1970s. 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. Issue 2. While the risk to health of such practices and technologies that come under the paradigm may be high. Second. That is. Third. etc. in outlining four features said to differentiate the new paradigm from previous approaches to physical security. 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 Volume 17. Ewald 2002:285. from the previous unbridled use of biotechnologies. 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. For the purposes of this analysis. the nature and extent of actual harm in the future remains incalculable. harm arising from ‘risky’ behaviour of individuals. the threat of tsunamis and avian influenza).) that might be considered to pose a high probability of some risk to health. unpredictable. 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. a moral dimension enters the health agenda with an attendant return to determinism. suppose or fear … [and] to consider the worst hypothesis’ (Ewald 2002:286). Luhmann 1993). adding to this uncertainty is the recognition that. or a single external ‘enemy’) the salient cause of harm is now taken to be unpredictable and fallible human agency.
‘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. The message is neither subtle nor appropriately qualified: ‘if you smoke. 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 smoker’s excuse. Second. this kind of orientation toward the future renders responsibility futural and conservative: against such bleak future-scenarios. in combination with a moralism about particular forms of risk. Each excuse involves a gesture toward possible futures with or without smoking and acknowledges the incalculability of the future per se. In the case of the man who says he ‘could be hit by a bus’. smoke-free) futures. scenarios of a bleak future if the risky practice of smoking continues. and of human ‘agency’ and to thereby predetermine a future of a nation.5 Not only is ensuring ‘continuity of the future with the past’ ‘counterrevolutionary’ by definition (Ewald 2002:284). if I did. First. These features of the pre-emption paradigm. more typically. ‘My pop smoked all his life – lived ’til he was eighty’. I could be hit by a bus. antisedition measures as part of anti-terrorism legislation. Two themes about the future are apparent in these quit-smoking campaigns. juxtaposed with preferred (healthy. the message that health and future security will be assured with a cessation of the risky practice HEALTH SOCIOLOGY REVIEW implies the body would be thus returned to a ‘natural’ order of becoming thus allowing a continuous progression from past to future. are apparent in a series of ‘quit smoking’ television advertising campaigns run throughout Australia in 2006-7. (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.3 It is better to be safe than sorry and preserve what is deemed good about the past that is still present. so what is the point). individuals and relevant organisations) have a responsibility to take measures to pre-empt a future that is continuous with the past (Ewald 2002:284). or practice as specific to context or type. This stifling of the unpredictable elements of human agency and material ‘life’ can be blatantly anti-democratic (Hardt and Negri 2005): for example. Together these themes associate moral prudence.4 This depicts four examples of smokers (probably in their mid to late 30s) expressing typical excuses for not giving up smoking. disease. not: ‘you might get this if a myriad of other determinants of ill-health are also in place’.) When combined with a general politics of fear. For example. biotechnology. But. There are two problematic consequences of the pre-emption approach to physical security of most relevance here. particularly the attitude toward the future it fosters. imply a reductive causal link between risky present practice and a catastrophic future. and maturity with individuals who would live in an ideal world of zero risk. the image that follows is of a man (of about the same age) in a darkened hospital room who says. ‘risk’ theorists point to how the paradigm fosters conservative government in all senses. Issue 2. its occurrence is generalised as prototypical of events threatening to health. group. social agents (governments.Biopolitical technologies of prevention packets carrying photographs of a cancerous mouth and a gangrenous foot is a headline banner ‘What you see is what you get’. but also the proliferation of imagined potential threats justifies ‘totalising’ and paternalistic government characteristic of ‘overmanaged democracy’. First. mouth cancer and gangrene are what you will get in the future’. physical security. 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. this dampening Volume 17. weakly: ‘I feel like I’ve been run over by a truck’. The problem with this paradigm of pre-emption is that instead of viewing a life-threatening event. discourages contestation of the status quo (including gover nment policy). I could give up smoking but. or individual that is continuous with the past. August 2008 143 . or ‘I could be hit by a bus’ (that is. and biological life of a population in all situations. rational intelligence. of bio-material life. The ‘excuses campaign’ illustrates the points well. Finally.
particularly the way it stifles the unpredictable elements of human agency and bio-material life. and the link he makes between political power and technology. the stifling of agency (by prohibiting or discouraging par ticular practices or by circumventing democratic participation in solutions to health problems). the political is technological by analogy. is too complex to posit such a simplistic counter-force to totalising government). As Foucault and others have shown (for example. neurological or molecular level to reorganise corporeal processes. First. 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. I suggest. 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. Just as biotechnologies intervene into bodies at the muscular. Rabinow and Rose 2006). I want to indicate why such pre-emptive campaigns are unlikely to achieve their expressed aims. disciplinary power operates at the Volume 17.6 but also. August 2008 144 HEALTH SOCIOLOGY REVIEW . Political technologies of bodies Foucault’s reformulation of the political in terms of disciplinary and biopower. And. contribute to the proliferation of those illnesses. 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. in the context of the management of life-style illnesses. and go on to argue. but overuse of antibiotics would be a comparable example in the biomedical field. some argue. that. by formulating a model of both embodied agency and resistance to such to government of life. bio-material life. Further. following Foucault and assuming the Aristotelean meaning of techne as skill or knowledge directed toward production. on the other. as well as fostering a bleak and conservative orientation toward the future. 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. security and surveillance measures. 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. 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. The mobilising of the paradigm in some public health campaigns in Australia intensifies the nexus between medicine and science. Issue 2. is helpful to account for the impact of pre-emptive mode of governance on human bodies. 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.Rosalyn Diprose of agency and dissent is subtle. Both are directed toward the ‘production’ of particular sorts of bodies. 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 socio-political regimes of meaning. on the one hand. 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. strategic protection against incalculable threats fosters ‘autoimmunity’ where ‘a living being … works to destroy its own protection’ (Derrida 2003:94). in governance of the health and security of the biological life of populations. and. Nor am I pointing the finger at health agencies and health workers involved in designing these campaigns: there is no telling from the consumer’s perspective how much these campaigns are shaped by government or advertising companies. a wider moral rhetoric about the proper future one should pre-empt for oneself and for the good of the nation (read economy).
it is more likely to disrupt the disciplined compliant body and reopen the body’s ‘forces’ onto the realm of potentiality. or rather which results in us being situated in all these respects (Merleau-Ponty 1962:136). Issue 2. on the other hand. and physical relations involved in the temporalisation of the body as follows: [T]he life of consciousness – cognitive life. biotechnologies rarely aim at ‘obedience’ or compliance. I carry forward to an open future a ‘collective history’ intermingled with experience of my personal history (Merleau-Ponty 1962:433). compliant subjectivities that are compatible with a neo-liberal political economy. on the one hand. ideological and moral situation. it involves political technologies that aim toward political and biological determinism. that is. But disciplinary power that renders bodies docile in this way does not exhaust. productive human bodies can become instruments of government and the economy. metabolic rates. 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). Moreover. the ground of conditioned ‘freedom’ where. orders the world in a par ticular way. disciplinary modes of government operate with the same banality as technology in general. our human setting. August 2008 145 . 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). labouring. pain medication. and turns it into a relation of strict subjection (Foucault 1979:138). productive. biological. HEALTH SOCIOLOGY REVIEW which it seeks to increase. Rather. Instrumental thinking however.Biopolitical technologies of prevention micro-level of the body’s movements. the political dimension of biotechnologies. to mark time. While these can be co-opted or rendered problematic in political paradigms intent on reproducing ‘useful’ bodies with enhanced ‘capacities’ and ‘aptitudes’. This temporality of the body and its ‘intentional arc’ (meaning-giving and receiving activity embedded in a world) is. it reverses the course of the energy. for example. a ‘capacity’. or even best characterise. The pre-emptive paradigm of responding to threats to health and physical security treats human bodies in this instrumental way and. or whatever). In other words. or speeding up neurological events. and human beings and so reorder the world that produces them. and temporal rhythms to realign the body’s forces and powers (Foucault 1979:136-8). unlike exercises in sovereign power. without a single coordinating agent with sinister motives. the life of desire or perceptual life – is subtended by an ‘intentional arc’ which projects round about us our past. Volume 17. The phenomenologist Maurice Merleau-Ponty explains the complex social. discourses surrounding biotechnologies (whether medicinal or recreational) would suggest that they aim at the enhancement of life for its own sake. 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). bio-technologies are political insofar as they are mobilised within these disciplinary regimes and so participate in the reproduction of normalised. in so far as the paradigm is mobilised to discipline a population to aspire to reproduce a future continuous with the past. through encounters with elements of the ‘life world’ within a social horizon. Similarly. it turns it into an ‘aptitude’. our physical. Second. Ways of thinking are paradigms involving a chiasmic relation between socio-political meaning. Whatever else. the power that might result from it. our future. spatiality. technical devices. Smokers use cigarettes instrumentally. a biotechnology does (stopping the course of pain or cell disintegration. scientifically speaking. for Merleau-Ponty. biotechnologies (cigarettes. 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). In short. and conversely. it dissociates power from the body. Pre-emptive approaches to health and physical security are political technologies of the body in this sense. participate in a re-temporalisation of the body with attendant effects and affects.
it is the ‘intentional arc’ that ‘goes limp’ in illness (Merleau-Ponty 1962:136). 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’). 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. While such body rituals can become habit. alongside the government of anatomical bodies through disciplinary power. to coin Helen Keane’s phrase. in so far as biotechnologies are involved in this enhancement and temporalisation of ‘life itself’. Conversely. The ‘stubborn ordinariness of smoking’. not so much individual bodies.Rosalyn Diprose Others from the same philosophical tradition call this complex relation between the human body and its biological. Issue 2. Taking into account the human body’s temporal dimension. other persons etc. It is in this context that practices that are deemed to present ‘internal dangers’ to health. so is the undoing of disciplined forces and the attendant opening of new directions via the body’s temporality. but such measures would also make us sick. August 2008 146 HEALTH SOCIOLOGY REVIEW .7 Rather. sexual activity.) to a undetermined future or potentiality (Arendt 1998:97. And bios is the condition of agency. And the futural paths that human being as bios takes and the impact of its acts are necessarily unpredictable. 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. which. but the ‘biological existence of a population’ (Foucault 1980:137-139). bios – embodied human being that is at once historical but also opened (by encounters with a physical environment. smoking punctuates the passing of time with openings to a different future. consists in ‘interventions and regulatory controls’ that exercise the ‘power to foster life or disallow it’ in the interests of maintaining. as can any means of introducing duration into human existence. they enter the second political register that Foucault claims attends disciplinary power in modern liberal democracies: biopower. 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 Volume 17. Diversity of biological human existence is not the aim of biopower. Such are the pleasures and dangers of an intelligent. Human being as bios is affective (involves pleasure and pain) in excess of habit and utility and it is intercorporeal. directed toward. Smoking is a social practice that temporalises human being as bios in this way (as does eating. and national uniformity. particularly use of biotechnologies like drugs (recreational and illicit). that is. However. rational. biotechnologies. it also goes limp in subjection. and intertwined with. 200-1). ‘Biopower’ refers to the idea that modernity is characterised by a bio-politics of the ‘species body’ (as distinct from the individual body). just as the potentiality of bios (or the ‘intentional arc’ as Merleau-Ponty puts it) ‘goes limp in illness’. or any body ritual). cleaning one’s teeth. On the contrary. an equilibrium that reassures with the promise of protecting ‘the security of the whole from internal dangers’ (Foucault 2003:249). each repetition of the practice is marked by this pre-reflective ‘intentional arc’ or opening of the body to an undetermined future. and ordinary human life. work. 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). become ‘problematised’ under the paradigm of pre-emption. 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’. environmental and meaningful situation. While disciplinary power and compliance are features of the political dimension of biotechnologies. People who do not smoke resort to other biotechnologies and rituals to temporalise the body. That is. things and other people. physical and economic security. suggests that the smoker is not a passive victim of addiction to a substance that will inevitably ruin one’s life (Keane 2006:107).
g. The inevitable disjunction between compliant. socio-political appeals to a future continuous with the past. is that such measures will meet with resistance from the bodies they target. But it is also a problem for the effectiveness of such public health campaigns. risking one’s savings on the stock market. while recognising that human bodies resist disciplinary and biopower and any normalising techniques of government. aside from ethical issues related to democratic pluralism and demonising sections of the population. even when attitudes about the moral status of particular consumption practices change over time. 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. where restraint in consumption gives way to exercises in ‘expressive. the sample claiming to measure objectively the extent to which an individual has complied with medico-moral regimes – making a Volume 17. presents government with the problem of mediating between the two. 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. Once ignited and trained.9 There are two ways to think about how this resistance might arise. which would arguably be a more effective (and certainly a more democratic) way of dealing with the potential risks of consumer agency in general. has also given rise to experimentations in techniques of consumption and of self-formation. this culture of the individual consumer. 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. a kind of ‘excessive conformity’. smoking. Rather than harm minimisation strategies. not surprisingly. 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.Biopolitical technologies of prevention ‘nature’). 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 HEALTH SOCIOLOGY REVIEW at controlling the consumption of drugs (both medicinal and recreational) (Race 2005). On the one hand. 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). On the other hand. August 2008 147 . also participate in the constitution of ‘consumer agency’ and. This is a problem for democracy because ideological-political determinism is its most obvious adversary. erotic. The overriding problem with the way the preemptive paradigm configures human agents. making certain practices of cultural consumption a bad example. or what would be deemed risky and irresponsible practice. that is. ‘disciplined productivity’ that governments would prefer and ‘excessive conformity’. he argues. the self-administration of drugs conforms to the rise of ‘consumer citizenship’ in post WWII consumer cultures. as Race puts it. did not elaborate how and why. it is difficult to control consumer agency and direct it toward one externally designated end rather than others. That is. or consumption of illicit drugs. self-administration of drugs is a practice consistent with disciplined. (in both biological life and the potentiality that is a condition of sociopolitical agency). of a future self] are its favorite tools. 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. Resistance and ethics It is widely acknowledged that Foucault.8 While the human body has a foot in both camps of zoe and bios. and experiential pleasure’ (Race 2005:2). compliant subjectivity. This excessive consumption can take many forms – shopping beyond ‘need’. Any appeals to a ‘natural’ body as the proper determinant of culture (and therefore of the future self). The sample and moral example [e. 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. Issue 2.
consumption of illicit drugs) and ill health. for example. then. The question that some biotechnologies and the corporeal. and with its physical and social environment. however sick or subjected a body is. and. It is impossible to completely suppress this ‘potentiality’. 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 he’s been ‘hit by a truck’). It might be a cigarette. the material world. by emphasising education and by considering health to be a communal and a personal matter. Like Race’s idea of ‘excessive conformity’. harm minimisation programs tend not to treat their subjects like irrational deviants. it never loses its futural orientation toward its material. Further. temporal basis of unpredictable human agency raise. A body subjected to paternalistic. as a consequence. It is haunted by the memory of a discipline at once paternalistic and protective. and other persons are open and indeterminate. In this game of presenting a range of possible futures. August 2008 148 HEALTH SOCIOLOGY REVIEW . social. in concert with the body’s temporality. Rather. a key precondition of both health and agency (personal. It will do this by reaching for material at hand. keep open an undetermined future. and meaningful world and the unpredictability this implies. infantilising. most likely what has worked before to punctuate time. that is. Issue 2. Volume 17. Exemplary power marks the bounds of legitimate consumer citizenship by declaring a stop to (what it designates as) non-medical activity. some causal link between particular practices (smoking. social. The smoker in the ‘excuses’ advertisement could indeed be run over by a bus tomorrow. on this model. It certainly cannot be suppressed by projecting a threatening future or an ideal future that are unrelated to a person’s current or past experience. their habits. Extending Race’s analysis to include consideration of the body’s temporality. and political) is a body open to ‘potentiality’. But they also allow that the causal link between a practice and future (well. 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 else’s image of the biological destiny of a nation. social. 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. 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. encounters that. that the relationships between a person. this account does not appeal to an original freedom or a self uncontaminated by biological. because government by medicomoral example appeals to the same regimes of self-administration and consumer agency that it seeks to dampen. or governmental determinants of health. that it is impractical (if not unethical) to exclude the person from participation in their health solutions. a body inclined toward encounters with others. 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. 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 else’s 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).or unwell) being is dependent on a range of factors. as he claims. Or as Merleau-Ponty (1962) puts it. we can suggest that.Rosalyn Diprose biochemical example of the propriety of individual behaviour. Unless it is dead. 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. Harm minimisation programs may contain some elements of the pre-emptive paradigm: they usually assume. in the context of the spread of biopolitical and totalising government. the ones that would be most convincing are those within the individual’s past and present experience. which it seeks to supplant by installing as its vision of control a medico-moral imagery of the self (Race 2005:10).
following Foucault but with reference to Arendt. 9. Helen Keane has provided a provocative and compelling account of the relation between smoking and time (2006). tend to think that they are immortal. 2. Arendt. Hardt and Negri (2005). M. 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. 7.Biopolitical technologies of prevention There are examples of the more viable alternative approach to public health already available in Australia. 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). and intro by Lash. Research suggests that the increase in the number of HIV-AIDS infections elsewhere may in part be due to the availability of treatments that. See. 5.) Stanford University Press: Stanford CA.gov. They have since been removed from websites of both the NSW Department of Health and the Cancer Institute NSW. 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’. one of Keane’s 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. 3. for example. Heller-Roazen. 10. (intro) University of Chicago Press: Chicago IL. see Cooper (2006). and that any such education and harm minimisation measures treat those men with respect (see Rier 2007. Maurizio Lazzarato has provided a useful account of how a model of resistance to normalisation can be derived from Foucault’s work (Lazzarato 2002). the subjected target of political power (1998:1-14). Endnotes 1. Significantly. Tony Abbot announced (in February 2007) a ten million dollar budget to counter the 40% increase in reporting of new HIVAIDS infections since 2000. For similar arguments see. Volume 17. nevertheless give the impression of relative safety leading to some complacency (Van de Ven et al 2002). Derrida (2003). S. Issue 2. References Agamben. B. 6. like all youth. that it be used in educating a new generation of gay men who. in retrospect. with special regard to biosecurity and biowarfare.10 One remains hopeful that the pre-emption paradigm does not swallow up that budget. and Nowotny (2006:4). incalculable future per se. and Nowotny (2006). Georgio Agamben argues. and Wynne. this paradigm shift. there has been no increase in rates of infection in Sydney since 2002. it was foreshadowed earlier by others such as Luhmann (1993) and Beck (1999). The causes of this increase are complex. while unpleasant and problematic.nsw. and it is in Sydney that harm minimisation strategies have had the highest profile. in the same era. The former Federal Minister for Health. 4. Collier et al (2004:5). Ewald (2002). (1998) Homo Sacer: Sovereign Power and Bare Life (trans. August 2008 HEALTH SOCIOLOGY REVIEW 149 . G. for example.health. For a general analysis along these lines see Foucault (2001) and. Collier and Lakoff (2005). These include harm minimisation approaches to heroin addiction operating in Sydney the 1990s and.) 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. 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). and whose friends have not yet died of the disease. (1992) Risk Society: Towards a New Modernity (trans. While drawing on different conceptual resources to that in this account. (1998) The Human Condition Canovan. 8. H. Beck. The ‘excuses’ adver tisement and similar advertisements could be viewed online at http:// www. D. U.au/cancer_inst/campaigns/ media/ until the end of 2007.) Sage: London. While Ewald is usually credited with first outlining.
(2005) Multitude: War and Democracy in the Age of Empire Penguin: London. A. . (2006) ‘Pre-empting emergence: The biological-turn in the war on terror’ Theory. (ed) Power: Essential Works of Foucault 1954-1984 Volume 3: Power Penguin: London.. K.221-228. Collier. W. (2002) ‘From biopower to biopolitics’ (trans. (2005) ‘Recreational states: Drugs and the sovereignty of consumption’ Culture Machine 7 available at http:// culturemachine. on Modern Equipment Princeton University Press: Princeton NJ. and Lakoff. Keane. S. N. Hurley.) The Question Concerning Technology and Other Essays Harper and Row: New York. (2003) ‘Autoimmunity: Real and symbolic suicides’ in Borradori. (ed) Essential Works of Michel Foucault 1954-1984. Lakoff. Cooper. Heidegger. Volume 17. A. Foucault. N. Ramirez. Rabinow. A. Foucault. I. and Rabinow. (1980) The History of Sexuality: Volume 1 (trans. U. Ewald. A. M. history’ in Faubion.) Routledge and Kegan Paul: London. H. Collier.) Vintage Books: New York. Issue 2. I. (2001) ‘Security and dependence: A diabolical pair’ (1983) in Faubion. (1994) ‘Nietzsche. C. and Epistemology Penguin: London. M.. Foucault.) Bertani. F.94-115. pp. (eds) Picador: New York. Smith. (eds) Embracing Risk: The Changing Culture of Insurance and Responsibility University of Chicago Press: Chicago. Method. (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. G. and Negri. (eds) Global Assemblages: Technology. Van de Ven. A. (2005) ‘On regimes of living’ in Ong. (2006) ‘The quest for innovation and cultures of technology’ in Nowotny. J. and Simon. H. I (ed) Power and Invention: Situating Science University of Minnesota Press: Minneapolis MN and London. H. (2002) ‘The return of Descartes’ malicious demon: An outline of a philosophy of precaution’ (trans.1-23. ‘Biosecurity: Proposal for an anthropology of the contemporary’ Anthropology Today 20(5):3-7. (1977) ‘The question concerning technology’ (trans. IL. D. genealogy. Kippax. and . Lovitt. (ed) Cultures of Technology and the Quest for Innovation Berghahn Books: New York and Oxford. Hardt. Sheridan. and Society 23(4):113-135.365381. S. Foucault. (1997) ‘Drugs: Ethical choice or moral consensus’ (trans.Rosalyn Diprose Beck. S. J. S.) Penguin: Harmondsworth. M. (1979) Discipline and Punish: The Birth of a Prison (trans. pp. M. N. S. P and Rose. M. Merleau-Ponty. R. and Fontana. and Ethics as Anthropological Problems Blackwell: Malden MA and Oxford. (1993) Risk: A Sociological Theory Aldine de Gruyter Press: New York.) Stengers. and Lakoff.. Stengers. Luhmann. Diprose.326-349. M. A. (1999) World Risk Society Polity: Cambridge. J. (2008) ‘Governing the future: Political technologies of risk management’ Security Dialogue 39(2):267-288. and Olubas. Bains. pp. Nowotny. Collier. D.uk/frm_f1. T. Race. P (2004) . Volume 2: Aesthetics. A. (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. August 2008 150 HEALTH SOCIOLOGY REVIEW . K. B.tees.ac. R. M. (eds) Women Making Time: Contemporary Feminist Critique and Cultural Analysis University of Western Australia Press: Perth. P in . (2008) ‘Distributed preparedness: The spatial logic of domestic security in the United States’ Environment and Planning D: Society and Space 26(1):7–28. Utz. P (2003) Anthropos Today: Reflections . and Collier. Macey. M. pp. pp. M.htm Rier. Stephenson. pp.) in Baker. and Race.) Pli: The Warwick Journal of Philosophy 13:100-111. E. Derrida.85-136. Philosophy in a Time of Terror: Dialogues with Jügen Habermas and Jacques Derrida University of Chicago Press: Chicago IL. pp. P Rawstorne. (2006) ‘Biopower today’ . Mills. Biosocieties 1:195-217. J. (2006) ‘Time and the female smoker’ in McMahon. Lazzarato. Politics. G. Foucault. (2003) Society Must be Defended: Lectures at the Collége de France 1975-76 (trans. J. M.. and Gille. O. Culture.. (1962) Phenomenology of Perception (trans. C. S. Rabinow. M. Hawkins. P Crawford.215-232..J.
including sexual violence. Issue 2. August 2008 151 . Thus I consider Volume 17. The critical literatures—which include writings in Gender/Sexuality studies and Preventive Health—aim to offer alternative understandings of heterosexuality which move beyond the imperatives of the popular media. young men have not been engaged by ‘critical’ analyses of sexuality. who insist that men – along with women – have a stake in ending violence. pleasure. including sexual violence (Kaufman 2001. Thus we must think carefully about our future strategic directions. sex education. this stake has not yet been widely and actively embraced by men. produce significant absences with regard to analysis of heterosexuality and heterosexual subjects. Received 1 May 2008 Accepted 23 May 2008 KEY WORDS Sociology. 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. In par ticular I assert a requirement to re-imagine the theoretical framing HEALTH SOCIOLOGY REVIEW of both Gender/Sexuality studies and Preventive Health in the arena of sexuality. In this context. Yet such critical approaches remain undeveloped. a re-thinking which attends to significant existing absences in the scholarly and policy literatures. Taking the case of sexual violence. 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. Tensions in Gender/Sexuality scholarship. gender. but has implications for strategies regarding sexual violence. my intention is to take up the work of Masculinity studies scholars such as Michael Kaufman and Michael Kimmel. Such research is not just relevant to prevention of disease. Attention to the former is associated with its influential input into the latter. masculinity Chris Beasley School of History and Politics University of Adelaide Australia Introduction T 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. While young people are constantly exhorted in popular media to be sexual and to undertake sex. Health Sociology Review (2008) 17: 151–163 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. I suggest that these directions involve re-thinking sexuality and sexual health by considering absences in the scholarly and policy literatures. and Preventive Health sex education materials which draw upon that scholarship. including ending sexual violence. 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. Kimmel. In discussing strategies with regard to sexual violence. While I agree with Kaufman and Kimmel that theoretically men may well have a stake in ending violence. heterosexuality. Interview).Copyright © eContent Management Pty Ltd.
existing research indicates that recognition of pleasure in sexual health education results in increased negotiation of sexual practices. Yet. in Foucault’s terms. come to ‘discipline’ us. 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. Volume 17. I suggest that while young people are constantly exhorted in popular media to be sexual and to undertake sex. 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. Preventive Health agendas attending to sexuality – in particular. We are told we must behave in certain ways. These new sexual norms. activism and public policy. 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’. 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. Such sources say in essence. And yet. 2. The Foucauldian thesis and its potential limits Foucault challenges what he called the ‘repression hypothesis’. Rubin 2005). My aim is to develop this overall analysis by outlining four interconnected arguments: 1. On the one hand.1 It would seem at first sight that Foucault’s approach is self-evident: the modern world does appear to be saturated in (hetero)sex. such that it remains almost exclusively aligned with the second-wave Modernist ‘sex-as-danger’ camp of the sex wars debates. This has ramifications for the theoretical framing of noncommercial voices dealing with sexuality and. This bombardment amounts to provision of sexual education by privatised commercialised sources with sexuality presented in terms of material consumption. 3. The Gender/Sexuality field involves approaches which inform Preventive Health with regard to sexual health. I have a sense of missed opportunity in relation to the possibilities offered by non-commercial voices regarding sexuality. ‘Buy this. On the other hand. August 2008 152 HEALTH SOCIOLOGY REVIEW . the hypothesis which for example Freud outlined in describing social relations as founded upon the repression of sexuality (Foucault 1981). Issue 2. A sexual ‘freedom’ consisting of insistent cultural exhortations to engage in heterosex appears omnipresent in our modern society. young men have not been engaged by ‘critical’ voices (scholarly or policy literatures) attending to sexuality. Yet such critical approaches remain undeveloped. Despite certain elements of the ‘prosex’ approach. for their anti-violence strategies. By contrast. 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. 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. Now we must be sexual. be sexy’. 4. I am not so sure this is the whole picture. These critical voices – which include writings arising from Gender/Sexuality studies. My concern is that existing cultural discourses do not provide much that might encourage men’s theoretical stake in ending sexual violence to be actualised in everyday life. in particular.Chris Beasley we must think carefully about our future strategic directions for scholarship. sex education in schools – draw upon these Gender/Sexuality writings. 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. 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. 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.
However. In this context.123) may underestimate the unevenness of the social in modernity. 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. potentially more reflective perspectives that move beyond the limits of medicalised discourses and genuinely embrace a more holistic treatment of bodies and desires. 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. Non-commercial voices regarding sexuality may not be taking up the challenge of providing alternative. the Foucauldian ‘sexualisation’ thesis (Seidman 1991:67. HEALTH SOCIOLOGY REVIEW 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). 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. by socially ‘critical’ agendas in relation to heterosexuality and masculinity. 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. including resistance to the hegemony of commercialisation. in the way that Gender/Sexuality and Preventive Health writings on sexuality presently are. they do young people a disfavour. Rather heterosex remains unspoken for the most part and. Issue 2. despite these agendas. Yet. 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. mainstream popular cultural discourses are not explicitly shaped. largely do not attend to hetero-pleasure. Gender/ Sexuality writings and Sexual Health literature. This scarcely fits with Foucault’s account of a mode of ‘eroticisation’ and ‘control by stimulation’. In this setting. August 2008 153 .The challenge of pleasure: Re-imagining sexuality and sexual health Commercial and non-commercial representations of sexuality are by no means entirely dichotomous arenas. Noncommercial discursive spaces may well not offer the same sexualising norms and sexualised identities. 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. Nevertheless. which in my view has implications for the way they address and their capacity to address sexual violence.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. there are discernable and important differences between them—at least in relation to sexuality— which can provide opportunities and spaces for enhancing diversity in views and practices. by contrast with the popular media. when meagrely acknowledged. 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. as Kickbusch (2006) notes. is simply cast as a problem. 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. I suggest that insofar as these noncommercial voices offer a limited challenge to the increasingly prevalent discourse of sexuality as consumption. Commercial popular media may provide socially critical perspectives and. the Gender/Sexuality field (which is a crucial source Volume 17. effectively giving them little purchase on the diverse possibilities of fashioning their own sexuality and sexual citizenship. In short.
Sexuality and Masculinity Studies are not simply commensurable bits that fit together neatly like pieces of a jigsaw. On this basis I argue that. Michael Kimmel.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. Masculinity Studies thinkers remain aligned with (second-wave) Modernist views which presume that gender does effectively determine sexuality. since the 1960s/70s. 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. Secondly. Whereas Feminist and Sexuality Studies have taken up Postmodernism with enthusiasm. and that this is particularly evident in relation to sexuality. This differential uptake has particular resonance around sexuality and sexual violence. for example. In contrast. if women would only let them’ (Kimmel 2005:74). Feminist/Sexuality/Masculinity studies and the sex wars Feminist and Masculinity Studies literatures—that is. talking about ‘sex as danger’ in the 1970s/80s. He approves the statement that ‘straight men might have as much sex as gay men. Gender Studies literatures—have been in an ongoing ‘conversation’ with Sexuality Studies writings. this may signal a problem in the context of developing theoretical frameworks and strategies intended to involve men in ending sexual violence. Tensions between heterogeneous trajectories in the Gender/Sexuality field then impact upon analyses of heterosexuality. Whereas Butler’s work has become a cornerstone of both Feminist and Sexuality Studies theoretical frameworks.Chris Beasley for alternative understandings of masculine sexuality and anti-violence agendas) contains disparate sub-fields—importantly. Andrea Dworkin. 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. The point here is that the different trajectories of Feminist. The subfields contain differing knowledge cultures involving (amongst other things) different theoretical underpinnings and emphases (Beasley 2005. Susan Griffen and Mary Daly. Masculinity Studies has increasingly appeared as ‘the odd man out’. supports the claim that heterosexual men and gay men are largely alike in terms of their sexuality (Kimmel 2005:1621. Initially Feminist and Masculinity Studies developed closely linked Modernist theoretical paradigms under the rubric of the term ‘gender’. the three major sub-fields of Feminist. amongst many others. A crucial theme in this conversation may be summarised as the ‘pleasure and danger’ ‘sex wars’. August 2008 154 HEALTH SOCIOLOGY REVIEW . 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. I suggest in other works that the three subfields of Feminist. Beasley forthcoming). In brief I would note two points in support of my claims regarding these developments. and on the other side the growing influence from the late 1980s/ 1990s of Postmodern thinkers associated with Volume 17. The ‘sex wars’ amounted to a debate between on the one side Modernist radical Feminist (Gender studies) thinkers like Catherine Mackinnon. By contrast. Writings in both Feminist and Sexuality Studies for the most part nowadays do not presume that gender produces sexuality. 2000:20-1). Sexuality and Masculinity Studies—with distinguishable trajectories.3 major ‘gate-keeper’ theoreticians in Masculinity Studies such as Connell remain rather resolutely Modernist and highly skeptical concerning Postmodern agendas and Butler’s work (Connell 2005:xix. Sexuality and Masculinity Studies have shifted in relation to their differential uptake of Postmodern perspectives. 2002:71. the subfields have aligned in shifting ways. 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). with the rise of Postmodern approaches Feminism and Sexuality Studies have moved closer to one another in terms of overarching theoretical frameworks. Kimmel and Plante 2004:xiv). It became explicit in the 1980s so-called ‘sex wars’. in Masculinity Studies this is much less evident. Issue 2. However.
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. Epstein and Renold 2005). very few current (post 1998) books on heterosexuality. In such pro-sex theorising.The challenge of pleasure: Re-imagining sexuality and sexual health Sexuality Studies. The emphasis was on gendered power and in this context men’s sexual power over women. At this conference a so-called ‘pro-sex’ position was put forward which rejected that all women were as one. More recently. 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. August 2008 155 . The ‘pro-sex’ position was however primarily. 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 men’s social dominance. and that all women liked gentle ‘vanilla sex’ (Echols 1983. for example. Heterosexual men were still sexual and still nasty. while heterosex continues to be locked into its earlier constitution as problematic. 1984. Lesbians.5 Heterosexuality is largely taken to be of little critical interest. Though they had access to pleasure. Volume 17. it was nasty oppressive sexual fun.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. Evans 1993). and were rather courageously critical of penis-centred conceptions of sexuality. and remains mired in the old ‘sex wars’ divide. 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. These existing accounts of heterosex as either primarily nasty or boring. Heterosexual women largely disappeared from sight (Beasley 2005:122-3. but in this approach queer becomes the site of subversive. transgressive. this ‘sex as danger’ position remains the most common viewpoint in Masculinity Studies today since—along with feminist work on violence—it remains one of the last bastions of support for Modernist radical feminist agendas. that all women had the same HEALTH SOCIOLOGY REVIEW sexuality. such a position increasingly came under fire from the 1980s onwards and reached a head at a conference at Barnard College. appeared predominately as passive victims who had no fun at all (Kanneh 1996:173). but at least they now all had access to sexual pleasure. and the evils of prostitution. In brief. engaged in gentle womanly forms of sexual pleasure. Rubin 1994. Gayle Rubin and Steven Seidman. the ‘sex-as-danger’ stance became aligned with Modernist thinking and the ‘pro-sex’ stance with Postmodern thought. Insofar as heterosex is mentioned at all in such pro-sex theorising. in 1982 titled ‘Pleasure and Danger’. pornography and rape. They were consequently inclined to depict women as a group as vulnerable and men as a group as predatory. NY. However. the combined Feminist/Queer ‘pro-sex’ perspective has become prevalent in analyses of sexuality. even almost exclusively about queer sexualities. focussed on the ‘danger’ of heterosex. The ‘pro-sex’ stance was increasingly critical of Feminism which was cast as ‘mumsy’ and sexually repressive (Beasley 2005:158-170). In these forms of radical feminism men and women were categorically divided. In the related literature on sexual citizenship. queer minorities were discriminated against. In short. Importantly. Sullivan 1997. in this account men were all ‘hegemonically abusive’ (Heise 1997:423). particularly gay men (Bell and Binnie 2000. Heterosexual women. Sex in this approach was precisely about embracing danger. They noted the links between normative heterosexuality and displays of men’s power over women such as rape. power and even consensual violence. The Modernist radical feminist approach was. owing to foolishly consorting with men. Califia 1996. There are. Issue 2. by contrast. in short. as simply to be equated with heteronormativity. the emphasis only shifts somewhat from nasty and normative to its boring and normative features. talking usually from a Foucauldian and Queer Theory perspective about ‘sex as pleasure’: the ‘pro-sex’ position. exciting and pleasurable sex. the focus remained firmly on queer minorities.
relative to other sexualities. dysfunction or infirmity. most of the limited debate on sexuality in a global context has been fashioned by themes of trafficking. but is also defined within a social framework. these voices effectively confine heterosexuality to the abandoned backblocks of theoretical history by leaving it stuck in the predominately negative ‘sex-as-danger’ camp. slavery and rape in war. the sexual rights of all persons must be respected. [s]exual health is a state of physical. August 2008 156 HEALTH SOCIOLOGY REVIEW . To the extent that it is discussed. 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). there are important links here with the pleasure oriented Volume 17. stressing well-being and not just stating the absence of negative qualities. Only gay men’s desire involves permissible pleasure. 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. it is almost impossible to find any account of heterosexual men’s pleasure in Masculinity Studies that does not presume desire=damage. This definition states: . Preventive health asserts its difference from this negative framing of our embodiment by emphasising a more holistic engagement with the body. Heterosexuality is a majority orientation but. mental and social well-being related to sexuality. Issue 2. The problematic analysis of heterosexuality in Gender/Sexuality theorising reoccurs in odd ways in the Preventive Health field and thus in sex education materials. 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 thinking—as at a distance from the now more thoroughly ‘pro-sex’ agendas of Feminist and Sexuality frameworks—comes home to roost. emotional. 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). 2001).. Sexual health is further defined in an affirmative way. Women’s Worlds Congress 2008). In the Preventive Health framework sexual health not only has physical and mental aspects. For sexual health to be attained and maintained. Similarly. protected and fulfilled. it is not merely the absence of disease. In other words. as well as the possibility of having pleasurable and safe sexual experiences. It is a model in which doctors save us from the failings of our bodies. free of coercion. Preventive health. interest and transgression. and over-determined as a source of domination. discrimination and violence. However. Sexual health requires a positive and respectful approach to sexuality and sexual relationships. and the rationalist scientific calculation of the body as in need of fixing or management. I do want to challenge heterosexuality’s comparative absence in contemporary Gender/Sexuality thinking and challenge its continuing restrictive constitution as unremitting cruelty and pain in the service of oppressive normativity. do not provide much room for manoeuvre. This medical model focuses on what is awry and how the mutinous body can be brought to heel. For example.7 Such a stance offers little in the way of strategic directions for positively engaging young men in the development of an egalitarian heterosexuality. critical scholarly voices in the Gender/Sexuality field have almost frozen and remain largely undeveloped regarding heterosexuality. More specifically. Tickner 1992. In essence. is under-theorised as a potential source of pleasure. Such themes are unquestionably crucially significant. themes largely dominated by gendered representations of male victimisers and feminine victims (Sabo 2005. since Masculinity Studies’ general advocacy of a ‘sex-as-danger’ stance has implications for its capacity to re-conceptualise heterosexuality and sexual violence strategies. Re-public: reimagining democracy 2008. 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.Chris Beasley but in any case normatively exclusionary.
Studies in Human Sexuality. beliefs. In many. form serious limitations to the sexual health of women. The list reveals the tendency in Preventive Health to discard its more expansive claims in favour of returning to medical management. Yet while Preventive Health sometimes has a rhetorically expansive ‘pro-sex’ framing. pleasure. if not most. Sexual Paraphilias.2008) amongst others.com/callabstracts. rather than a representation of most people’s current condition. phenomena such as sexual violence and sex-trafficking. Sexually Transmitted Infections. The main topics were as follows: Sexual Health.The challenge of pleasure: Re-imagining sexuality and sexual health ‘pro-sex’ position I outlined in the ‘sex wars’ debate previously. roles and relationships. Pleasure and Respect’. accounts of sexual health the ‘sex-as-danger’ HEALTH SOCIOLOGY REVIEW feminist position I discussed earlier is reborn as populations and individuals being exposed to health ‘risk’. behaviours. 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. Secondly. [s]exuality is a central aspect of being human throughout life and encompasses sex. often falling back into more traditional models of health. Issues in Reproductive Health. However. WHO’s definitions of sexual health and sexuality have a utopian cast. Family Planning Australia. with a classic Preventive Health conference theme of ‘Achieving Health. even when Preventive health models of sexuality do not lapse into miserable medicalisation. sexual orientation. which enable consideration of hetero-pleasure. This association is evident in the WHO definition of sexuality: . reinforcing a focus on sexual ‘problems’ conceived in biomedical terms. induces a predisposition to fall back upon the primarily negative ‘sex-as-danger’ orientation with regard to heterosexuality. most. Sexuality is experienced and expressed in thoughts.sexsydney-2007. and also more generally the construction of women as sexually passive. Ethics. Issue 2. gender identities and roles. fantasies. sexual minorities face discrimination. If both partners want to have sex together and are protected against unwanted pregnancy or catching an STI. Tellingly the clitoris Volume 17. Basic Science on Sexual Function. Sexual Orientation. Orgasm Disorders. when associated with sexual health. 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. Arousal Disorders. More affirmative and expansive accounts of (hetero)sexuality. it is more likely to be enjoyable. such a focus in Preventive Health. Cultural Studies on Sexuality. desires. Desire Disorders. August 2008 157 . have outlined and problematised the crucial focus on prevention/pre-emption of danger and risk within Preventive Health. in answer to the question ‘can sex be fun?’ the answer is: Sex can be lots of fun … it depends on the circumstances.. For example. This rather grim and decidedly medical looking list contains rather a lot of disorders. values.. attitudes. Sexual Violence. ‘avoid pregnancy and don’t get STIs’. if not all.htm]. 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. Gender Dysphoria. A pro-sex agenda quickly becomes. infections and dysfunctions [www. practices. For an example of this. Sexuality Education. intimacy and reproduction. Sexuality in Special Populations. consider the first World Congress for Sexual Health in April 2007. it frequently fails to live up to its promise. Broom (2007. Moreover. 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 people’s (sexual) quality of life and as linked to conceptions of (sexual) justice and full citizenship. become sidelined. The Preventive Health framing of sexual health as defined by the WHO may be seen as offering a worthwhile goal to aim for. more socialised versions of ‘risk’ frequently still dominate. Endocrine Disorders. Sexual Pain Disorders. Given the worldwide prevalence of heteronormative sexual prejudice.9 However. 2008) and Diprose (2007. eroticism.
While sex education almost entirely evades queer sexualities.Chris Beasley gets four lines in this book. most sexual health education programmes remain restrictively focussed upon biomedical information. Specifically. and is de-eroticised. one of the better Australian books for adolescents. In this context. but apparently gave little clue about the interactive including pleasurable aspects of the enterprise (Powell 2007. This is not a problem in Australia alone. SHine SA (Sexual Health Information Networking and Education). I should add. also reports that 80% of young people regard sex education in schools as useless or fairly useless [sexual_health_statistics_2008. Allen 2006). 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. as Janice Irvine (2000) puts it. the SHARE Project (a sexual health program for upper level Volume 17. As the 2003 Australian Study of Health and Relationships—the largest and most comprehensive survey of sexuality undertaken in the country—has revealed. This is. 2008) point out. it also neglects heterosexual female sexual pleasure and characteristically denies heterosexual young men a positive and legitimate sexual subjectivity (Harrison and Hillier 1999. even to hetero-pleasure. for instance. Issue 2. sex education in schools gained ‘top marks’ from young people in terms of learning about technical ‘mechanics’. Sex education of even this meager sort is of course under threat in the USA (Irvine 2000). ARCSHS 2003). As both Broom (2007. 2008) and Diprose (2007. the inadvertent consequence of employing ‘scare’ tactics associated with preventing risky behaviours may well be increasing resistance to Preventive Health approaches. while vaginas get over 20. fuelled by the ‘risk’ of teenage pregnancy rates.pdf]. 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). 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). as Kimmel notes. 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. This is a serious problem for sexual health strategies intending to promote egalitarian sexual practices including ending sexual violence. Furthermore. August 2008 158 HEALTH SOCIOLOGY REVIEW . 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). stated that sex education in schools provides basic factual biological information but beyond that was extremely limited and even confused (Campbell 2005). 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). Relatedly. However. 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’. Sexual health education programs remain dominated by a framing of sex as risk and danger—by assumptions which reflect the Modernist feminist ‘sex-asdanger’ position I outlined earlier—often depicting women/girls as vulnerable and men/ boys as culpable. The latter study showed 13% of secondary students reporting unwanted sex under pressure from their partner. This analysis is also relevant to sex education. Similarly. a sexual health agency in South Australia. Non-consensual heterosexual sex and sexual violence is undoubtedly a world-wide concern. For example. it is evident that rape. the sex education curriculum all too often neglects the complicated process of choices regarding sexual behaviour. is not perpetrated by a lunatic fringe but rather is a crime marked by its ordinariness (2005:189). This Preventive Health focus on fear and danger with regard to heterosex is problematic precisely because it is likely to be counter-productive. a joint report to the British government on sexual health in 2005. 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.
Burke (2007) and Diprose (2007. Holland et al 1992). that Preventive Health in sexuality—even in its more progressive manifestations—is rarely in practice about sexuality. SHARE was highly attentive to teenage pregnancy and STIs. We are faced here in her view either with sex as danger and risk OR with Foucault’s embrace of bodies as pleasure. Debra Lupton (1995. 2008). stressing rational knowledge-based choice. she reiterates in many ways the binary enunciated in the ‘sex wars’ debate. The program did stress being positive about sex. presented itself as having a healthy. This is not a criticism of SHARE. Recognition of hetero-pleasure can in other words inform a shift towards positively reconstructing men’s identities in ways that exclude violence against women (White 2000. 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). 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 risk—with making sex safe—and a concern with pleasurable sex are not mutually exclusive. as I have noted in relation to sex education programs such as SHARE. I am not sure this analysis is sufficient either. It is rarely about doing sex. does not get us very far. which ties it into regulatory governance. Recognition of pleasure paradoxically appears to produce more egalitarian rather than non-consensual sexual relations between men and women. and service usage. As I pointed out at the beginning of this paper. employs Foucault’s work on the modern surveillance of bodies to discuss its risk/danger orientation (Lupton 1994:20-40). in the first instance there is reason to qualify Foucault’s thesis regarding the proliferating sexualisation of the modern public realm at least HEALTH SOCIOLOGY REVIEW when considering the non-commercial arenas of Gender/Sexuality scholarship and Preventive Health. The Foucauldian pro-sex stance may not be the answer. and much more about health as regulatory management of social risk. in increased use of condoms by men and greater involvement of women in negotiation of sexual practices. Yet SHARE was explicitly shaped by concerns about risk and danger. along with many others who offer critical perspectives on Preventive Health. Jenkins 1990). Issue 2. ‘safety’. ‘neutral’. However. (Philpott et al 2006. the program could barely mention pleasure. For instance. existing research indicates that recognition of pleasure in sexual health has resulted in greater safety.The challenge of pleasure: Re-imagining sexuality and sexual health 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. This research information is not just relevant to prevention of disease. which faced vitriolic attack by Christian Right-Wing lobbyists precisely for its ‘pro-sex’ stance (Gibson 2007). at the same time. Debra Lupton. while heterosexuality=heteronormative and heterosexual women simply disappear from view. affirming sex is ‘healthy’. August 2008 159 . but. Ingham 2005. that it is also strongly associated with the present dominance of public discourses throughout the Western world prioritising ‘security’. non-moralistic approach to sexuality and implicitly therefore as not about suppressive regulation of sexuality (SHine SA 2003:8-9). in common with the perspectives of Hage (2003). Lupton’s Foucauldian analysis casts the Preventive Health framework as still mired in the ‘sex-asdanger’ camp. ‘The Power of Pleasure’ undated. Volume 17. Indeed. but has implications for strategies regarding sexual violence. 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. In other words. a ‘pro-sex’ framework. The Foucauldian ‘pro-sex’ camp does at least bring Queer sexualities into view. let alone about experiencing or giving pleasure. Secondly. but simply to point out. I would add. The Foucauldian critique may be a problematic framework for assessing the treatment of heterosex in non-commercial arenas. it is inclined to equate pleasure almost exclusively with Queer sexualities. In this context.
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). but is a deeply political question. Yet it is possible. Talking about pleasure is not necessarily at odds with safety but instead may well produce it. As noted above. I am indebted to Heather Brook for this way of expressing the problem. inequitable and risky. Jackson 1999. including those which aim to promote gender equity. Perhaps we could instead learn from aspects of the HIV/AIDS work and refuse to accept the established binary of pleasure versus danger.Chris Beasley I have attempted here to indicate the limits of a primarily negative (an always already punitive) orientation which emphasises danger and warnings. aggression and violence and toward mutuality and equality—a loving lust that is … equal parts heat and heart’ (2005:xiv). fail to engage young men in particular. Issue 2. relatedly. identification with forms of heterosexual masculinity attuned to egalitarian sexual practices. I have suggested that both Gender/Sexuality scholarly writings and Preventive Health sex education materials remain captured by precisely such a narrow agenda. Volume 17. McNay and Bland. 7. Strategies to encourage egalitarian (hetero)sexuality. that young heterosexual men’s 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. My thanks to Carol Bacchi for discussions which helped clarify my thinking on aspects of the Foucauldian sexualisation thesis. the exception is feminist work on violence. Ingraham 2008. August 2008 Conclusion I suggest we may need to move away from the standard binary thinking of the old sex wars. we need an ‘ethical erotics’. 5. they are unable to provide an enticing alternative to the seductive barrage of consumerist messages about (hetero)sexuality and. My concern here is that. 3. for example. though their particular concern is to indicate the gendered limitations of this account (McNay 1992:38-47. The telling exception here is feminist work on violence. and hence to end sexual violence. Making safe sex hot may well provide a more attractive counter-discourse than the existing emphasis on heterosexuality as monolithically normative. 8. in common with Michael Kimmel I too see the aim as refashioning our sexualities ‘away from control. 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. This problematic equation of heterosexuality with heteronormativity will be the subject of more extensive analysis in a forthcoming co-authored book. to the extent that critical non-commercial voices do not attend to hetero-pleasure and the libidinal body. offer related observations regarding the difficulties attached to an account of disciplinary power as monolithic and uniform. As Moira Carmody (2005) puts it. 2. Indeed they may inadvertently produce a counter-productive resistance amongst young men to sexual health strategies. amongst other commentators. titled Adventures in Heterosexuality. such that ‘safe sex’ can also be hot sex. must move beyond conceptions of heterosexuality simply as a problem and instead generate positive 160 HEALTH SOCIOLOGY REVIEW . Scott and Jackson 2007. Endnotes 1. 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. Hockey et al 2007. even likely. 6. We must face growing evidence that promoting pleasure when discussing sex is likely to encourage forms of sexuality that are safer and more egalitarian. Holland et al 1998. The comment is also relevant to feminist work on violence. Though I have suggested some difficulties with current directions in Masculinity Studies scholarship in this regard. Bland 1981:58-9). See. Johnson 2005. 4. which largely retains a second wave Modernist framing.
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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 men’s 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. Women’s 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.
Please Knock Before You Enter:
Aboriginal regulation of Outsiders and the implications for researchers – By Karen L Martin – 2008 ISBN 978-1-921214-37-0 Pages: ii+168 This research study provides seven rules for research to direct culturally safe and respectful researcher behaviour and ensure that researcher responsibilities and accountabilities to the Burungu, Kuku-Yalanji, the research study and the academy are fulfilled. When research is transformed in this way, it is itself, transformative and works towards achieving Aboriginal sovereignty in research.
Orphaned by the Colour of My Skin:
A Stolen Generation Story – by Mary Terszak – 2007 ISBN 978-1-921348-08-2 Pages: viii+156 In an invasive, paternalistic, federal public policy environment for Indigenous communities, this book provides an in-depth account of one person’s experiences as a ‘Stolen Generation’ Aboriginal Australian. Told from the heart, this auto ethnographic account speaks in the raw voice of a grandmother reflecting on her life. It illuminates her childhood experiences, subsequent perceptions and life stories, following Mary’s removal from her mother, Elizabeth Clare Khan.
In Our Own Right: Black Australian
Nurses’ Stories – Edited by Sally Goold OAM, Kerrynne Liddle – 2005 ISBN 978-09757422-2-8 Pages viii + 120 The intimate, private, and heart wrenching stories told in this book, the first of its kind in Australia, will penetrate the hearts and souls of even the most hardened reader. Told with incredible dignity and humility, each of the individual and deeply personal stories recounted is a powerful testimony to the gross inhumanity and brutal capacity of white people in Australia colonists who selectively destroy and humiliate, without remorse, the lives and souls of their fellow black Australians.
Advances in Indigenous Health Care:
Building Capacity Through Cultural Safety – Edited by Eileen Willis, Vicki Smye and Maria Rameka – 2006 ISBN 978-0-9750436-9-1 Pages: xii + 140 This special issue of Contemporary Nurse focuses on building Indigenous health capacity through examining the roles of current community, traditional, social, rural, remote and clinical nursing practices in Australia, New Zealand and North America, as well as their cultural, colonial and historical constraints and opportunities.
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Copyright © eContent Management Pty Ltd. Health Sociology Review (2008) 17: 165–176
The politics of research management: Reflections on the gap ABSTRACT between what we ‘know’ (about SDH) and what we do
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 (don’t) do regarding SDH.
Received 27 August 2007 Accepted 5 March 2008
School of History and Politics University of Adelaide Australia
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
Volume 17, Issue 2, August 2008
Hence. increasingly there is congruence between these governmental functions. Policy and Service Delivery. The final section of the paper points to tensions and inconsistencies in this dominant understanding of the ‘problem’ of the ‘know-do gap’. 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. it argues. Harvey wants to know why we have ‘abandoned preventive and early intervention at the social and economic levels of Volume 17. First. that public sector workers infrequently have the opportunity to defend a SDH approach. 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. presented in 2005 at a conference entitled Dahlgren and Whitehead and Beyond: The Social Determinants of Health in Research. To elaborate the models of the research–policy nexus and of policy-making associated with this understanding. my concern is not the preventive paradigm per se. 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).Carol Bacchi separation between research production and government policy. my target is the larger paradigm within which preventive approaches are located: that is. it is unsurprising that the deep. nor indeed am I putting into question the understanding of health within the preventive paradigm. I am not asking how ‘prevention’ could be thought about differently or better. those who wish to promote deep-seated social structural change to improve health and reduce health inequalities. 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. ‘priority setting’ and ‘user-driven research’. marginalised conversation. ‘knowledge brokers’. reflected in the recent endorsement of ‘user-driven research’ both overseas and in South Australia. second. and third. Issue 2. The paper proceeds as follows. More recently. even when they endorse it. August 2008 166 HEALTH SOCIOLOGY REVIEW . that governments are disinclined to accept SDH insights when they contravene ideological commitments to small government and the social status quo. Rather. as exemplars. that SDH seldom gets into media. 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’. ‘knowledge translation’. That is. institutionally supported understanding of the ‘know-do gap’. it focuses on the assumptions and presuppositions underpinning the dominant. using the Canadian Health Services Research Foundation (CHSRF) and its founder and long-time director. Peter Harvey (2006) asks similar questions and offers similar explanations. structural changes required to address SDH and the reproduction of health inequalities do not occur. 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. and in the Australian context. 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. it explores the languages used to frame the ‘problem’ of the ‘know-do gap’: ‘evidence-based/influenced policy’. Next. ‘research synthesis’. He offers several explanations for this gap: first. Jonathon Lomas. implied models of the research–policy nexus and relatedly implied models of policymaking. increasingly researchers are ‘rewarded’ (funded and promoted) for producing research that supports the priorities of governing bodies intent on preserving social cohesion and stability. 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). with ‘users’ identified as policy-makers and administrators. In terms of the theme of this special issue of HSR therefore.
the training of ‘knowledge brokers’. associated with Jonathon Lomas. that ‘our predominant controlling and social ideology has become one of profit and market driven growth’. stresses the importance of ‘evidenceinformed decision making’ (Government of South Australia 2007a:2). ‘linkage and exchange’. and involved in consultancies to the WHO. 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. He challenges what he describes as the linear model of the research– policy nexus where researchers make their research available. and the Foundation with which he is associated. If researchers want increased ‘uptake’ of their ‘evidence’. and second. the Canadian Health Services Research Foundation (CHSRF). with a focus on discovering ‘what works’ in health service delivery. the 1:3:25 model for research reports (elaboration follows below). and policy-makers come along and take what they need to ‘solve’ a policy ‘problem’ (Lomas 2000a:140-141). and the capitalist interest groups that sustain them. the demands of lobby groups. Lomas is also a central figure in international health services research. Considerable funds now pour into foundations set up to offer ways to encourage ‘uptake’ of ‘evidence’. I suggest. In both Harvey and Raphael. as they explain it. August 2008 167 . an emphasis on research synthesis. sitting on a number of boards in the US and the UK. There is no HEALTH SOCIOLOGY REVIEW suggestion of deliberate malfeasance on the part of either Lomas or the CHSRF. This Foundation and Lomas are offered as exemplary of the dominant approach to the ‘problem’ of the ‘gap’. Health Services Research. The problem. with Lomas and CHSRF the exemplars. which represents retrograde values and holds a reactionary position on social and political economy’ (Harvey 2006:419). became the focus of my attention because of the significant role their work plays in the current South Australian Government’s Strategic Health Research Program. much in the way in which storekeepers stock shelves. including budget constraints. Volume 17. and their own values and biases. Rather. The ‘research utilisation’ problematic Lomas. and uses many CHSRF key terms and strategies. Significantly. politics is central to the uptake (or not) of social preventive interventions (see also Bambra et al 2005). Issue 2. including research/ knowledge ‘translation’. While I have some sympathy with this explanation. that ‘Australia is dominated by a political agenda. and ‘user-driven research’ (Government of South Australia 2007b). ‘a nationally endowed organisation founded in 1997 to improve the relevance and use of health services research in health system decision-making’ (ARACY 1995).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. Lomas is the inaugural Chief Executive Officer of CHSRF. The program endorses Lomas’s ‘listening model’ (Lomas et al 2003). The next two sections offer a close analysis of the recommendations for change put forward by one such foundation. we need to understand how the understanding of the problem of the ‘know-do gap’ in the dominant conversation. and a complex process at that. this conversation has generated a sub-field in health research. According to Lomas (see also Black 2001). fits current modes of governance as a first step to thinking about ways forward. according to Lomas. whether conservative or socialist. 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. researchers need to recognise that policy-making is a process. they need to become sensitive to the world of policy-makers. World Bank and the Rockefeller Foundation. where policymakers have to deal with a wide range of political circumstances. is the current neoliberal ideology of Canadian (Raphael) and Australian (Harvey) governments. not an event. due largely to poorly developed relationships between researchers and ‘users’ (policy-makers and administrators). In the dominant conversation the ‘problem’ of the ‘know-do gap’ involves inadequate ‘uptake’ by governments of research ‘evidence’.
users were invited to become involved as ‘advisers’ in the setting of research priorities (Weiss 1978:69). Charles Lindblom (1965). it is significant to note that the full range of concepts and strategies identified by Lomas appeared over thirty years ago. an interaction among scientists and ‘practical problem solvers’ such as ‘engineers. To ward off this possibility she followed the lead of policy theorist. Carol Weiss. in Lindblom 1979:77). 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). It is a process that moves through time-consuming stages. It is important to note that in this conversation the issue of SDH is muted. researchers should be content to realise that the concepts they developed had an indirect and gradual impact on the policy community. August 2008 168 HEALTH SOCIOLOGY REVIEW . That is. it is important to note that this issue of ‘research utilisation’ (or the lack thereof) has a long genesis. In this context. 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). Social scientists feared that ‘administrative remedies involving tighter control by federal staff’ (Lynn 1978c) might be imposed. There is no space here to trace the fine details of the genealogy of the ‘research utilisation’ problematic. In his view (2000a:143). it is useful to reflect briefly on the 1970s debate. Indeed. According to Weiss (1977b:15. ‘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). see also Bacchi 1999:18. when the ‘problem’ of ‘research utilisation’ grabbed the attention of governing bodies in the United States. ‘the best predictor of research use is the early and continued involvement of relevant decision makers’. However. noted that ‘a democratic system does not want technocratic solutions imposed on decision makers’. ‘Social research can be “used” in reconceptualising the character of policy issues … [and] may sensitise policy makers to new issues’. Rather the suggestion is that we are dealing with a larger ‘problem’. who insisted that policymaking involved ‘reconciliation of interests’. Elliot 2006). Issue 2. 1978) held out the possibility of an ‘enlightenment role’. Says Lomas et al (2003:370). expressed as the relationship between ‘knowledge’ and ‘policy’ (see Lynn 1978a). 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). based upon recognition that policy-makers operate with ‘political’ rather than ‘scientific’ rationality (Weiss 1978:61. (Emphasis has been added in the quotes to follow in order to highlight the shared terminology). we have here a manifestation of longstanding concerns about the relationship between theory and practice. the lack of ‘uptake’ of research generally. researchers may influence the ‘beliefs’ of decision-makers but ‘the window of Volume 17. theorists like Janowitz (1970) and Weiss (1977a. In addition. learning to ‘translate the knowledge needs into research questions’ and ‘translating’ research results back into policy (Weiss 1978b:40). In 1978 Laurence Lynn (1978b:17) declared that ‘Policy is not an event. although the notion attracts only passing mention. Lomas et al (2003:370) also endorses an enlightenment role for research. given that policy-makers are the ones who in the end have to make the decisions. Given the close parallels in both the description of the ‘problem’ and in the range of proposed ‘solutions’. government and foundation officials’ (Lindblom 1979:64). ‘uptake’ will very likely be increased. 24-31. 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’. it is best for them to communicate their research needs to researchers. a leading contributor to the debate. To those researchers who felt dissatisfaction with this somewhat instrumental role.Carol Bacchi Indeed. With such a ‘user-driven’ approach to research.
an important shift occurs in the latter’s endorsement of ‘user-driven research’. researchers faced a ‘choice of affiliations with the academic. however compelling the research. researchers increasingly have no ‘choice’ of affiliation. Despite the parallels between 1970s political rationalism and Lomas. In 1978 Weiss outlined three mechanisms for obtaining research. with one page of ‘main Volume 17. by contrast.g. 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’. to increase ‘uptake’. In the event it is clear that in Lomas the main game is not ‘enlightenment’ but ‘uptake’. in her view. with different priorities. The strategies that he and the CHRSF put forward help us understand how the ‘problem’ of ‘uptake’ is understood and represented. the input of researchers remained crucial since ‘Government officials. and (3) assistance. Because it was a ‘choice’. and here he is in good company (Hanney et al 2003:24. researchers need to concentrate on the form in which they ‘transfer’ ‘knowledge’. as in the earlier period (1950s) when researchers tried actively to develop a ‘policy orientation’ in order to increase status and wealth (Lasswell 1951). to become one among a ‘plurality of partisans’ (Lindblom et al 1979:64). In Lomas. different contingencies and often different value structures. Hence the goals become ‘listening’ (Lomas et al 2003). (2) solicitation. emphasis added). the main reason for the low impact of research findings (the ‘know-do gap’) is that researchers and policy-makers inhabit different worlds. the ‘two communities’ are like ‘strangers in the night’ (Feldman 1999. ‘linkage and exchange’ (Lomas 2000b). To understand this shift it is necessary to examine the changes to research management regimes that have occurred over this period. partly because of their time perspective. they are to lay out their research using a 1:3:25 format. under which government staff ‘set the frame within which researchers define their study’. By the time Lomas is writing (late 1980s and following) the parameters for research funding have changed dramatically. In the 1970s. They are instructed to use plain English and to avoid jargon. ‘users’ are to drive the research agenda. The role of ‘assistance’ is sharply reduced. Merton and Lerner (1951:306. Birnbaum 2000). is to increase contact and improve communication between the ‘two communities’. researchers need to acknowledge the realities of political decision-making and defer to policy-makers in the setting of research priorities. rather affiliation to government and/or business is determined for them by funding constraints (e. Perhaps these changes in funding arrangements explain the diminished attention in Lomas to the role of ‘enlightenment’.The space for ‘enlightenment’ research is to be found among those ‘basic’ researchers funded through ‘assistance’. therefore. introductory quote at beginning of paper) felt able to warn researchers of possible compromise of principles should they HEALTH SOCIOLOGY REVIEW ‘accept’ a ‘role’ in which they do not question policies but simply ‘contribute information useful to implement a given policy’. business. Collyer 2007:255).The politics of research management: The gap between what we ‘know’ (about SDH) and what we do opportunity to make major change. August 2008 169 . Issue 2. Weiss (1978:47-48) was quite clear that. see many aspects of the world as fixed’. described as ‘support for investigator-initiated research’ where ‘it is the researchers’ formulation of the research that prevails’ (Weiss 1978:48-49). To improve communication. in Janowitz 1970:249. Moreover. opens only rarely and briefly when the constellation of values may happen to coincide with the research’s implications’. The two communities: ‘Strangers in the night’ According to Lomas. or government communities’ (Merton and Lerner 1951. In 1978. 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. The way to fix this ‘problem’. and ways to make this happen. ‘knowledge translation’ and the training of ‘research brokers’ who are skilled in a liaison role. in Lomas 2000b:236) who have great difficulty talking to each other and understanding each other. says Lomas. Hence. In the meantime. policy-makers were invited to become involved as ‘advisers’ in the setting of research priorities (Weiss 1978:68).
arguing that ‘the dichotomous construction of the research-policy problem as “two worlds” leads to solutions based only on communication’. The message is that they must learn to accommodate them (see Black 2001:277). In her view. beliefs and interests. three pages of ‘executive summary’ and twenty-five pages for the main report (CHSRF 2001). remembering the diminished space for independent thought given the increasing dependence of researchers on government funding. based as they were on ‘ideological opinion’. ‘People were fed up with the extent to which politicians’ whims could change their lives – not obviously for the better’. Black (2001:275) agrees. on the one hand. in his model. This understanding downplays ‘more fundamental problems related to beliefs and values. Lomas’s concern. Beyond this. requiring policy to reflect ‘evidence’. The ambivalence of ‘evidencebased policy’ The drivers behind ‘evidence-based policy’ are several and overlapping. noting how researchers in other settings took their cue from ‘evidence-based medicine’ to demand that policy-makers base their decisions on sound evidence. Lomas’s model stops short of recognising the ways in which these values and beliefs shape particular understandings of ‘problems’. and perhaps to try to alter them over time through a bit of ‘enlightenment’.Carol Bacchi messages’. Here there is talk about the need to generate ‘ownership’ among research ‘users’ (Lomas et al 2003:370). and power relationships’ (Lin and Gibson 2003:xxi). 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. 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’. and they are to commit particular attention to producing research syntheses of other secondary research. According to Lin (2003:7. Given this understanding of the policy-making process. August 2008 170 HEALTH SOCIOLOGY REVIEW . Hence they are to play a key role in priority-setting exercises. The following section explains how this apparent tension is managed. however. 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. I suggest. Volume 17. Some might perceive a tension here between. Issue 2. Researchers in their turn need to learn to recognise the difference between a ‘sensible’ decision and a ‘rational’ decision. see also Hanney et al 2003:2) the ‘evidence-based approach has tended to be researcher-led’. For example Lomas notes that. a theme pursed later in the paper. the issue. institutional accountability. exogenous to the process. Significantly. Lomas also endorses ‘evidence-based’ or ‘evidence-influenced’ policy. Brendan Gibson alerts us to limitations in this understanding of the problem. As this example illustrates. with all sorts of implications for what is done and not done (Bacchi 1999). beliefs and interests are listed as in-puts to the policymaking process (Lomas 2000a:143). despite research ‘demonstrating that for-profit private hospitals are less efficient than public hospitals’. is broader than communication. Lomas is acutely aware of the role of values and ‘ideology’ in research ‘uptake’. ‘social problems’ are located at the top of Lomas’s chart of the policy-making process. 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). This point becomes highly relevant given the recommendation that ‘users’ should drive the research agenda (‘set priorities’). says Lomas. therefore. Hence. on the other. 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. becomes how researchers are to respond to these ideologies. implying a position of some considerable influence for researchers. He produces a chart laying out his model of policy-making in which ideologies. wanting ‘users’ (policy-makers and administrators) to drive policy and.
to achieve overall reduction in population-level alcohol consumption. He points out that. As with the example of Marmot above. Marston and Watts 2003). if not always successful. there remains ambivalence around the concept ‘evidence’. The third and final strategy to ensure that research ‘evidence’ is controlled by decisionmakers rather than controlling of them is the Volume 17. the ‘complexity’ of the meaning of ‘evidence’ is now emphasised (CHSRF 2006). governments can parry with the claim that only research that has an ‘impact’ should be funded. scholarly and social. whereas researchers ‘tend to be more restrictive. efficiency and effectiveness. In this way evidencebased policy comes to fit neoliberal governmental rationality with its emphasis on counting. and what was happening in Australia with the Research Quality Framework proposed by the Howard-led Coalition Government in 2007 (Australian Government 2006). emphasis added) throws out the challenge to policy-makers that what we have currently is ‘policy-based evidence’ rather than ‘evidencebased policy’. 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. The effect. He calls upon the British government to have another ‘look at the evidence linking harm with average alcohol consumption’. Evidence. practical contingencies. with the Research Assessment Exercise (Ball 2001:267). Hence.The politics of research management: The gap between what we ‘know’ (about SDH) and what we do As an example. Because of this lingering potential for ‘evidencebased policy’ to empower researchers. research evidence solidly supports a policy of higher prices and limits on availability. Still. Alongside this development the category of ‘colloquial evidence’ has been created (Government of South Australia 2007b:3). However. is to suggest that researchers need to accommodate these political ‘realities’. According to Marmot. Usefully. while policies continue to stress strategies such as education. when researchers start to insist that their work should have influence (i. Lomas and others committed to ‘user-driven policy’ have HEALTH SOCIOLOGY REVIEW developed strategies and technologies for managing this ambivalence. and ‘voluntary agreements’ with the alcohol industry. a distinction is drawn between contextfree and context-sensitive ‘evidence’. challenge to ideologically and interestdriven policy. we are told. August 2008 171 . in addition to the research impact assessment technology (RAE. confining the term evidence to information generated through a prescribed set of processes and procedures recognised as scientific’ (Lomas et al 2005:3). that evidence is malleable (see Solesbury 2001. Neil Black (2001:275) makes an appropriate caution. Indeed here the pragmatic nature of decision-making is constituted a form of ‘evidence’. include the same list of factors that Lomas identified as important in-puts into the policy-making process: values. that evidence should drive policy). institutionalised conversation (CHSRF 2006. there is room for researchers to argue that evidence is sometimes ignored. While at first glance this shift in language seems to imply a willingness to de-privilege ‘evidence’ (and hence a challenge to technocratic models). ‘colloquial evidence’ is constituted by ‘relevance’. Whereas scientific evidence is determined by methodology. highlighting its utilitarian character. (This instrumental turn in policy-making is discussed later in the paper. improved treatment. Decision makers. and becomes a technology for disciplining researchers.e. it seems. Government of South Australia 2007a:2) to talk about evidence-influenced rather than evidence-based decision-making. First. policy-makers are empowered to decide which ‘evidence’ counts. prefer to use the ‘broadly inclusive. making a place for social science input. we are told. Issue 2. more policing. colloquial definition of evidence’ as ‘anything that establishes a fact or gives reasons for believing in something’. can pose a useful. and pressures from lobbyists and interest groups. RQF) we have just discussed. Michael Marmot (2004) complains that alcohol policy in the UK has been formulated with little attention to ‘evidence’. there is a growing tendency in the dominant. And indeed that is what has happened in the UK.) The types of ‘colloquial evidence’ that need to be recognised. Second. Both these initiatives explicitly tie university funding to research ‘impact’. Marmot (2004:907. as before.
Solesbury (2001:4) pinpoints the explanation: ‘Researchers have perforce responded to these changed funding priorities’. is unsurprising. live an existence of calculation. the focus on ‘problem’ solving (‘what works’) forecloses consideration of how the ‘problem’ is framed. etc. there is an emphasis in Mode 2. Issue 2. what the ‘problem’ is represented to be (Bacchi 1999). 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. the evaluation group was able to bypass the Report’s concern with broad social factors shaping health inequalities. 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’. Solesbury’s (2001) insight into the means-end character of government science (research) policy and von Lengerke et al’s (2004. 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. if research questions determine the range of issues considered.The politics of research management: The gap between what we ‘know’ (about SDH) and what we do instrumental approach to research produces a very narrow understanding of relevance. Considering ‘what works’ at the individual level ‘while ignoring more important macro-level determinants is’. are particularly pertinent. given the endorsement of ‘user-driven research’. They have to be responsive not only to the scientific community but also to public decision makers’ (Gibbons et al 1994:148). Crucially. By commissioning research on ‘what works’. as Davey Smith et al (2001:185) state. It follows that. he found that sixty percent of these studies did not mention social and economic issues. HEALTH SOCIOLOGY REVIEW They ‘are required to address the specific questions provided under the research themes’ (Government of South Australia 2007a:1). as in Lomas. researchers in South Australia get to produce research about ‘what works’ against pre-set questions and/or targets. but a fit between what the government tells us to ‘research’ and their particular policy agendas. individual-level research project. make ourselves relevant’ (see also Davies 2003:92). With such studies into the effectiveness of a range of interventions on individuals. as problems of inappropriate lifestyles or lack of social capital. 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. much Volume 17. When Dennis Raphael (2005:18) conducted a study of research on SDH and health inequalities. the suggestion that ‘users’ should drive research and policy carries significant implications for reflections on the ‘know-do’ ‘gap’. I suggest. At the federal level researchers have to shape research proposals to the Australian Research Council in terms of declared ‘national priorities’. “add value” to ourselves. ‘tantamount to obtaining the right answer to the wrong question’. governments set boundaries on the kinds of issues that will be considered. The space to scrutinise and critique the models of explanation built into these questions and priorities is severely constrained. However. bypassing a range of important and often prior questions – ‘What is going on? What’s 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). This result. improve our productivity. 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. August 2008 173 . Although Gibbons et al (1994:162) refer to the need for ‘hybrid fora’ for generating research agendas. and with this foreclosure severely limits the space available to researchers to challenge specific policy directions. Those who do not do so often pay the price of not being funded. As an example. – researchers seeking funding are constrained to shape their projects to fit these paradigms. As an example. Here. see above) concern that the only research that will be available for ‘utilisation’ is research commissioned and funded by policy-makers. Hence. on the answerability of researchers to decision-makers: ‘scientific specialists now have a double responsibility.
References Australian Government (2006) Research Quality Framework: Assessing the quality and impact of research in Australia.org. Black. the ‘wrong’ questions may well produce poor outcomes. in my view. Hence. However. and Scott-Samuel. Given that the values and ideologies of policy-makers shape research agendas in ways that may well be limited. The best possible outcomes in terms of SDH. C.unisa. Birnbaum. Ball. D. (1999) Women Policy and Politics: The Construction of Policy Problems Sage: London. for all her help gathering material for this paper. N. Bambra. 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. needs to be involved in framing research questions. Acknowledgment I wish to thank my research assistant. (2001) ‘Evidence based policy: Proceed with care’ British Medical Journal 323:275-279.edu. it becomes possible to argue that a wide range of participants. including funding arrangements. in this case institutional relationships between researchers and governments. August 2008 .au/rqie/rqfhistory/ docs/TheRecommendedRQFwebsiterelease14 November2007 [Date of access: 10. Bolam 2005) and civil society groups (Sanders et al 2004).02. this probably will result in an increased ‘uptake’ of some research.htm [Date of access: 10. C. it is unlikely. 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. because research questions frame ‘problems’ in particular ways.Carol Bacchi more attention than this needs to be paid to the nature of this relationship. 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.07] Australian Research Alliance for Children and Youth (ARACY) (1995) ‘Closing the know-do gap’ 12 August. this challenge can be mounted on the grounds that. aracy. subjectivities and policy outcomes. Fox. 174 HEALTH SOCIOLOGY REVIEW Volume 17. (2005) ‘Towards a politics of health’ Health Promotion International 20(2):187-193.03. Lomas’s suggestion that researchers simply accommodate these values and beliefs needs to be reconsidered and debated.07]. including the lay public (Popay et al 2003.au/conference2005_jlomas. because of the ways these relationships shape social relations. R. A.. The main message that emerges from this form of analysis is the need to take into account dominant regimes of governance. (2000) ‘Policy scholars are from Venus: Policy makers are from Mars’ The Review of Higher Education 23(2):119-132. Given this situation. it can be argued. The Recommended RQF available at: www. to result in an increased commitment to the insights generated by SDH research into the social causes of ill-health and health inequalities. Issue 2. (2001) ‘“You’ve been NERFed!” Dumbing down the academy: National Educational Research Forum: “A national strategy – consultation paper”: A brief and bilious response’ Journal of Education Policy 16(3):265-268. are unlikely to eventuate unless groups other than users have input into priority setting.J. when reflecting on the ‘gap’ between ‘knowledge production’ 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. Anne Wilson. One such space is identified in this paper: the need to challenge the idea of ‘user-driven research’. Sydney available at: http://www. As suggested above. 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 (Raphael’s argument). in particular in this instance funding regimes. Bacchi. S. we need to pay more attention to structures of governance. researchers committed to social structural preventive health agendas need to put in question institutional arrangements that foreclose the possibility of advancing these agendas.
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Luhmann Social theory provides a lens through which we can analyse the role of trust in health systems. Through the analysis and critique of existing social theories of trust. political. and continues to be. Through the study of social organisation. this paper challenges several of their theoretical assumptions. John Coveney and Wendy Rogers Department of Public Health Flinders University Australia Introduction S ociology has been. However. social theory. much of the literature fails to define or explain adequately the theory of trust. while Luhmann looks at the relationships and mutual interaction between social systems. health system.Copyright © eContent Management Pty Ltd. this paper demonstrates a need for further empirical research into the multidimensionality of trusting relationships. Current theoretical assumptions are also problematic as they fail to recognise the role that social factors (such as socio-economic status. trust. compared with 764 in the preceding 15 years (Schlesinger et al 2005). judicial). there were 1612 articles on the topic of trust in the medical and health literature. Moreover. the application of social theory provides a useful lens through which the role of trust can be explored (Brown 2008). In the years 1995 – 2003. failing to investigate trust as determined by a ‘web’ of mutually interacting relationships between individuals and social systems. However. and broader social systems (for example. Paul Ward. physician. health systems. 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. Health Sociology Review (2008) 17: 177–186 Trust in the health system: An analysis and extension of the social theories of Giddens and Luhmann ABSTRACT KEY WORDS Sociology. While useful for understanding the impact of trust on health promotion and illness prevention. These suggestions may assist with finding a more comprehensive way of empirically researching trust in healthcare. fundamental for understanding the complex role of trust in the relationship between society and its health systems. sociology offers a number of theoretical frameworks through which we can view trust in the health setting. the majority of theoretically informed trust literature addresses ‘institutional’ or ‘interpersonal’ trust individually. institutions. as well as between patient. While both offer compelling insight into the concept of trust. causing serious limitations to its scope and usefulness (Beasley and Bacchi 2007). while suggesting new directions for research in public health. August 2008 177 . 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. and the development of society. Giddens. it has been argued that the subject of trust theory is ‘disembodied’. For example. Issue 2. Received 1 December 2007 Accepted 5 March 2008 Samantha Meyer. class and age) play in an individual’s willingness to trust. Giddens addresses trusting relationships between the HEALTH SOCIOLOGY REVIEW individual and the system. social capital has been used in numerous studies investigating the link between socioVolume 17. economic. and offers suggestions for a reconstruction of their theories. This paper specifically addresses the limitations of the trust theories of Anthony Giddens and Niklas Luhmann.
Rather. Theory provides a broad framework which shapes society’s view of the world (Cooper 2001). Applying theory to research affords the opportunity to measure trust as a changing process. Carpiano 2006). Luhmann (1988:100) argues that ‘a conceptual distinction is not yet an empirical theory’. Paul Ward. 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’. and society at large. are all essential for Volume 17. In terms of healthcare. Giddens 1990). Russell’s (2005:1397) argument that interpersonal trust in healthcare is ‘built. Whilst trust is undoubtedly an important domain of social capital (Bourdieu 1984. Brownlie and Howson 2005. there are serious limitations to its scope and usefulness in practical. there must first be a theoretical framework. Institutional trust is the trust placed in the system or institution. Issue 2. Salvatore and Sassatelli 2004. hospitals. August 2008 178 HEALTH SOCIOLOGY REVIEW . Kim et al 2006. ‘facework’). and the way in which trust functions in (or for) society. Bordum 2004. Why is trust important to public health? Mechanic and Meyer (2000:657) state that ‘trust is fundamental to effective interpersonal relationships and community living’. Furthermore. In health systems. the trustworthiness of individual health professionals. more central aspect of the article. supports both Giddens’ and Fukuyama’s theories that trust in the system is dependent on trust in the system’s representative (Fukuyama 1995. both of which will be necessary for the smooth functioning1 of social systems. as failing to do so has the potential to undermine the public’s overall trust in the health system (Rhodes and Strain 2000). while defining and describing trust helps to differentiate it from other concepts. health centres. and building on areas of trust. a theoretical framework is necessary to view the foundations of trust and explain how it is (re)produced (Mollering 2001). Lochner et al 2003. The ultimate goal of such an endeavour regarding health systems will be both understanding and responding to distrust. The second. healthcare institutions (for example. Ward and Coates 2006). 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). Giddens and Luhmann specifically recognise two forms of trust. Both practitioners and medical institutions (for example. 2005. the application of social theories of trust would question its measurement in the current social capital literature. this is placed in the medical system (or in Luhmann’s case. while social theory provides a useful conceptual framework for exploring trust. and in order to analyse trust in health systems. Lupton 1997. Mechanic and Meyer 2000. ‘abstract’). Gilson 2003.Samantha Meyer. institutional (Luhmann 1990) (or in Giddens’ (1991) terms. Subramanian et al 2003). is a critical analysis challenging several theoretical assumptions and revealing the limitations of their analyses of trust. 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. sustained or damaged through face-to-face encounters with health providers and is more likely to increase with long-term doctor – patient relationships’. real life situations. and therefore a decline in trust may lead to continuous vigilance and anxiety within society (Crawford 2004). GP clinics) and forms of professionalised knowledge. GP surgeries) must provide a trustworthy environment. including their analyses of modernity and reflexivity. Since the theories of Giddens and Luhmann are covered quite extensively in sociological literature. hospitals. John Coveney and Wendy Rogers economic status and inequalities in health (Kawachi et al 1997. Both regard interpersonal trust as being negotiated between individuals (a decision to trust someone or not) and as a learned personal trait. and interpersonal (Fukuyama 1995) (or in Giddens’ (1994) terms. As noted earlier. the first aspect of this paper provides an explanation for aspects of their theories relevant to understanding the critiques and limitations we present. Indeed. systems based (Fukuyama 1995) or faceless (Giddens 1994). this paper does not aim to provide a detailed summary of their work as a whole. 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. In other words. also the social systems which influence and interact with the medical system).
contradictory and change over time. healthcare professionals) have to convince patients to share personal information (including details of their symptoms). Wynne 1992. in the future. In order for someone to trust (rather than base a decision on rational choice). In order for patients to permit these procedures and release personal information. US. 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’. Welsh and Pringle 2001. encourage patients to submit and adhere to treatment (Hall et al 2001). August 2008 179 . A theoretical understanding of trust: Giddens and Luhmann Both Giddens and Luhmann have made significant contributions to the trust literature. and take potentially poisonous chemicals into their bodies. decreasing confidence in the power of science (Irwin and Michael 2003. Health system representatives (for example. Gilson 2003. Issue 2. trust obviously plays a major role since trust in health systems and health professionals has been shown to increase a patient’s willingness to seek care and utilise health services (Russell 2005). the lay populace is constantly bombarded with ‘health messages’ which are often conflicting. It is also important to understand the impact of trust relationships on the functioning of a health system. In this way. In other words. Williams and Popay 2001). This is similar to Simmel’s notion of a ‘leap of faith’ (Mollering 2001). enable providers to encourage necessary behavioural changes. 2) trust in modernity. and the emergence of so-called ‘high trust’ and ‘low trust’ societies (Fukuyama 1995). the whole notion of trust will become increasingly important. Birungi 1998). Volume 17. 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. the ‘trustfulness’ of both medical practitioners and the system on which their knowledge is based. To compound the increasing levels of distrust. is limited to prominent themes in Giddens’ and Luhmann’s theories which are crucial for a critique of their work: 1) the conceptualisation of trust. 3) notions of reflexivity. The consequences of such liminality are that lay people begin to question the validity of medical knowledge and hence. Gifford 2002). Davies 1999. This may be linked to broader epistemological challenges about the authenticity of knowledge (Popay et al 2003. In the past decade. and may grant patients more autonomy in decision-making about treatments (Gilson 2003). while providing new insights into the way health system management might be improved (Gilson 2005). the function of trust warrants serious consideration in public health research. enhance the quality of interaction between patients and physicians. so that any changes which need to be made to improve trust can be determined (Hardin 2006). their decision must combine good reason (from past experience). HEALTH SOCIOLOGY REVIEW In addition. Bauman 1987. Williams 2000. Scambler and Britten 2001). through a process of negotiation (Giddens 1991). 1996. Sweden) (Hardin 2006). Some decisions are based on inductive inferences from past experiences believed in some way to be reliable for the present. Mechanic and Meyer 2000. Trust provides an important lens through which we can view significant relationships within health systems because it highlights often unrecognised dimensions of these relationships. submit to tests. with a further element that satisfies their ‘partial understanding’ (Giddens 1991). 2001). Empirical literature has highlighted declining levels of trust in health care along with other institutions (Russell 2005. As a fundamental dimension of the effectiveness of a health system. trust in the health system (or any other social system) can no longer be simply taken for granted or expected. These have led many theorists to suggest we are all in a state of liminality or ‘no mans [sic] land’ (Armstrong 1993. facilitate disclosure by patients. increasing individual and societal reflexivity (Giddens 1994). The following discussion however.Trust in the health system: An analysis and extension of the social theories of Giddens and Luhmann health systems to function in the interest of society (Rhodes and Strain 2000). UK. 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. and the capacity of experts to deliver to the patient control over their bodies (Crawford 2004. it has to be worked on and won.
‘Trust occurs in a framework of interaction which is influenced by both personality and social systems. brackets2 out ignorance or lack of information (Giddens 1991). created a demand for expert systems. Therefore. medicines we take. have made the interpenetration of self-development and social systems more pronounced. Luhmann (1988) addresses the concept of trust in terms of its function in/for society. because both decisions function as ways of rationally pursuing individual actions (Luhmann 1979). the need for assurances through trusting relations grows accordingly (Borch 2005). the interactions between social systems and individuals for Luhmann are not conceptualised in a one-way. Expert systems of knowledge now penetrate nearly all aspects of social life in conditions of modernity (Giddens 1991. Habermas 1989. This expansion has played a central role in mediating the organisation of social relations and in turn. Giddens (1990) discusses how modern social forces (such as the expansion of electronic communication). or through ‘re-appropriating’ different forms of technology for themselves (for example. In his book Consequences of Modernity. This gap will be discussed in the second section of this paper. As modern circumstances of uncertainty increase. 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. He describes it as a commitment to something other than just cognitive understanding (Brownlie and Howson 2005). In contrast to Giddens. the notions of trust and risk come to have particular applications in the functioning of society Volume 17. either through a rejection of certain aspects of technology (for example. 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. Giddens (1991) points out that whilst we are more and more dependent on expert systems over which we have little knowledge and control. the growth of complementary and alternative medicine). In terms of the function of trust for social systems. In this way. self care). for both individuals and social systems. we acknowledge that exper t systems cannot themselves adequately anticipate the future. In terms of the function of trust for individuals. The corollary is obviously also the case. Luhmann’s communicative theory rests on the relationships or interactions between individuals and social systems. a doctor) is highly contingent on trust in a variety of social systems. Paul Ward. unidimensional manner. and therefore trust is theorised as a medium of interaction between social systems and individuals. the decision to place trust or distrust reduces complexity. Modernity A key component to understanding Giddens’ theory of trust is a process he calls ‘reflexive modernisation’ (Beck et al 1994). Trust is only required where there is ignorance. they need to reduce complexity in order to function properly. and cannot be exclusively associated with either’ (Luhmann 1979:6). which fits with his overarching structural-functionalist theory. This acknowledgement has resulted in what Giddens (1991:144) calls the ‘sequestration of experience’. Issue 2. providing them with the capability to act and make decisions (Pearson et al 2005). Giddens (along with Beck) argues that society is constantly forced to anticipate outcomes and assess risk as a result of modernity and increased reflexivity.g.Samantha Meyer. trust has become a central motif in late modernity for individuals and social systems. Scambler and Britten 2001): for example. rather. John Coveney and Wendy Rogers Trust invested in people or abstract systems made on the basis of a ‘leap of faith’. trust is best understood in a multidimensional sense (Brown 2008). there is no need to trust in a situation of complete knowledge (Giddens 1991). August 2008 180 HEALTH SOCIOLOGY REVIEW . and with increasing complexity. whereby trust in individuals (e. drawing upon a sense of safety in the continuity and order of the world and its events. Giddens (1991) suggests this may be linked to a quasi-religious element or ontological security. with trust in one social system being both highly dependent on trust in other social systems and individuals (Luhmann 1979). the food we eat. Both Luhmann’s 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 individual’s decision to trust.
Their level of professionalism. For Luhmann. Luhmann (1988) then goes on to distinguish trust from confidence. whereas for Luhmann it is both HEALTH SOCIOLOGY REVIEW In other words. and he outlines the problematic relationship between trust and time. For Luhmann. Giddens (1991) argues that trust acts as a medium of interaction between modern society’s systems and the representatives of those systems. the meeting ground for what he terms ‘faceless’ and ‘facework’ commitments (Giddens 1990). Risk is now conceptualised as a fundamental means by which lay people and technical specialists organise the world (Giddens 1991). a patient can learn to trust a surgeon (who is part of an external system. ‘To show trust is to anticipate the future. 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. he shows how individuals and social systems limit the horizons of trust by reducing the complexity of ‘their’ worlds. Giddens and Simmel deal with this problem by linking trust with ‘leaps of faith’ or ‘blending ignorance and knowledge’ (Giddens 1991. faceless commitment is the perceived legitimacy. technical competence. It is to behave as though the future were certain’ (Luhmann 1979:10). As noted earlier. Whilst Luhmann acknowledges the unavoidable contingencies in the decision to trust. Giddens regards trust as a response to an increasingly reflexive society. rather than the individuals who in specific contexts ‘represent’ it. the notion of time is also a central concern in relation to trust. Luhmann’s (Luhmann 2005) central thesis around the move to modernity is that social and personal systems strive to reduce complexity. Individuals have come to depend on learning and confirming trusting relationships between the boundaries of internal systems and the external environment (Luhmann 1988). In modernity. Facework commitment is dependent on the demeanour of the ‘expert’ (in health systems. August 2008 181 . The access point is the meeting ground between the physician and the medical system. which fits with his overarching Structuration Theory. The grounds for this interaction are referred to as access points. the medical system). trust is seen as both an outcome of. or other health professionals). which fits with Beck’s theory of the risk society (Beck 1992. and do not know anything about in terms of demeanour or personality. Mollering 2001). we turn our attention here to Giddens’ ideas about the function of trust in the structure–agency dialectic. and other aspects of their personality affect our impressions and expectations. Trust as a function of (or for) society In this section of the paper. there is confidence or expectation rather than trust. the outcome of. the medical system). Giddens argues that institutional trust presupposes and is determined by interpersonal trust. He argues that if there is no risk considered. What or how much is at risk has a substantial influence on a decision to trust. 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. Risk is an important aspect of trust because it adds another aspect to partial understandings. In essence. the physician. 2005). 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. arguing that individual trust takes into account both past experience and the associated risks involved in the decision to trust. mannerisms. The awareness of risk is what moves an individual’s decision from the assumption of confidence. whereas confidence occurs when no alternatives are considered and decisions rely solely on expectation. and the ability of the ‘expert system’ (for example. and a means for responding to an increasingly complex society. Since we have already covered issues of reflexive modernisation.Trust in the health system: An analysis and extension of the social theories of Giddens and Luhmann (Giddens 1991). 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). to one where trust is required. For instance. they may have learned to trust between the Volume 17. and response to increasing complexity in society. that they have never met. access points carry a reminder that it is the fleshand-blood people (who are potentially fallible) who are its operators (Giddens 1990:85). Alternatively. Issue 2. However. Giddens (1991) says that ‘to live in modernity is to live in an environment of chance and risk’.
there is insufficient space to discuss it all in this paper. and relationships. However. that trust is linear. trusting relationships can be understood as a complex ‘web of interaction’. 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. systems. While Luhmann has. it is essential to address the role that both interpersonal and institutional forms of trust play in society. and broader social systems that influence the health system. external). 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). the medical system. If trust is the result of complex relationships/interactions between the physician. While participants in their study spoke of a lack of trust in local GPs. If the patient did not trust the surgeon but instead. and made significant contributions to understanding the complex trust relationships that exist between and within different social groups. both are purely theorists and their work has not been tested empirically. of course. Towards a more comprehensive social theory of trust Giddens and Luhmann have both been influential in the pursuit of understanding trust. much more to say on such issues. As stated earlier. Giddens maintains that interpersonal trust is necessary before there is potential for institutional trust. Determining the relationship between interpersonal and institutional trust is essential to understanding the role of trust in health systems. Issue 2.Samantha Meyer. is rational from the point of the system because it helps it to preserve the higher level of inner order. and the role of familiarity in trusting. As previously outlined.. The contradiction between Giddens’ and Luhmann’s views presents an opportunity for empirical investigation. Giddens (1991) argues that in modernity. both ignore the web of interactive relationships which may influence individual trust. in order to fully understand trust. The following critiques aim to identify the gaps in Giddens’ and Luhmann’s work in order to provide contemporary theoretical perspectives for future empirical research on trust in the ‘real world’. an adequate sociological theory of trust must offer a conceptualisation of trust that bridges the interpersonal and systemic levels of analysis. this could not be separated from the mistrust of both local and national healthcare and wider social systems (Ward and Coates 2006). trust on all levels needs to be addressed when determining how to improve trust within health. The idea of developing a further social theory of trust is not to refute or dismantle the theories of Giddens and Luhmann. Paul Ward. John Coveney and Wendy Rogers boundaries of systems and believe that both the health system and the medical professional (the surgeon) will operate in their best interest (Russell 2005). after extensive literary review. Lewis and Weigert (1985:974) argue that: . Luhmann discusses trust as a major component in the reduction of complexity between and within modern social systems. However. no other empirical trust literature addresses trusting relationships as a multidimensional web. However. Giddens (1991) argues that modern individuals have become sceptical Volume 17. complication and chaos would result and their action would not be rational.. The differentiation of the approaches to trust/distrust (internal vs. levels. presenting a need for further investigation into the relationships (individual and system level) that affect trust. asked the neighbour who is a pilot (whom they trusted) to do their surgery. By constructing their theories of trust relationships as linear.3 while Luhmann argues the reverse. rather than dividing them into separate domains. August 2008 182 HEALTH SOCIOLOGY REVIEW . in comparison to its external environment. society is continually drawn into the present through reflexive organisation and constantly forced to anticipate outcomes and assess how things are likely to diverge. that trust in the system is necessary before an individual can have trust in the system’s representative. 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. For instance. Rather than linear. gaps in this theory become obvious when applied to practical real life situations.
August 2008 183 . The strength and importance of the cognitive versus the emotional base of trust depends on the type of social relationship.. but does not address the interdependence it also creates. as well as the personal characteristics of the individual. and therefore. Further empirical research is necessary and may afford insight into the practicality of reflexivity as a factor in an individual’s decision to trust. to argue that principles in complex society have no choice but to trust is far too simple. for Giddens the shortfall is compensated for by a ‘leap of faith’ which can be understood as intuition. and the latter group lack the resources for questioning experts. This idea has been termed ‘stratified reflexivity’. Within healthcare. are not making a reflexive choice to trust. The cognitive attitude is present in all forms of trust. cited in Lewis and Weigert 1985). but the experience and rationality that reinforces the cognitive ‘leap’ varies considerably (Lewis and Weigert 1985). in situations where there is a lack of information. all of which must be comprehended sociologically as having varying levels of importance for individuals (Lewis and Weigert 1985). risks are weighted against the potential positive outcomes. 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). the point of such reasons is really to uphold his [sic] self-respect and justify him [sic] socially. Giddens agrees that technology transfer has increased complexity in society. Conversely. and under what conditions individuals trust. individual weight in variables of trust. as well as numerous other factors beyond the realm of this paper. Giddens fails to pay significant attention to the role played by gender. As noted earlier. nationality and so on in constructing differing risk experiences (Alexander 1996). numerous factors including new communication technologies and advances in knowledge transfer have significantly altered the landscape in which individuals question the judgement of experts. they exercise that choice (Shapiro 1987). Trust remains a risky undertaking. Along with other prominent trust theorists (Simmel. They prevent him [sic] from appearing to himself [sic] and others as a fool. and it conceptualises the reality of the structural patterning of reflexivity existing in society (Ward 2006). the ‘information poor’ may not have access to similar information. emotional and behavioural dimensions. implies more dependency and less reflexivity or self-sufficiency. and therefore. At most. the ‘information rich’ may have the means to investigate alternative therapies or seek forms of selfhealing when they mistrust their physician. there is enormous variability in the extent to which. When the available evidence is not sufficient. However: .Trust in the health system: An analysis and extension of the social theories of Giddens and Luhmann about modern institutions (such as science). in reality. in the event of his [sic] trust being abused. but not for trust itself. and hence trust in modernity must be worked on and won. 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. Indeed. Issue 2. vast gaps between the ‘information rich’ and the ‘information poor’ (Elliot 2002). The vested interests of the dependent individual are thus vulnerable to the actions of others (Bluhm 1987). and may have no choice but to depend on their physician for medical advice. Interdependence. level of dependency. HEALTH SOCIOLOGY REVIEW Further empirical research is required to determine what these variables are.. social/ cultural networks. ethnicity. the situation. age. no longer accept the judgements of experts. Trust is best conceptualised as a multi-faceted phenomenon with distinct cognitive. One final remark on the work of Giddens and Luhmann forms the basis for a research question rather than a critique. they are brought into account for the placing of trust. A number of factors affect our ability to act as reflexive agents. However. social class. trust always extrapolates from available evidence. For Luhmann. There are for example. For instance. the system under consideration (Bonoma 1976. and the conditions under which. Fukuyama) both theorists discuss trust in situations where there is a shortfall of information. Institutions are necessary and must function effectively in the context of societal interdependence in spite of distrust. Volume 17. as an inexperienced man ill-adapted to life. an act of knowing or sensing without the use of rational processes. the decision to trust.
Bauman. see Luhmann (1979. C. Theoretical expansion and further empirical research may provide insight into whether we can ever really understand why people trust. in recognising this weakness. This issue warrants serious consideration for public health and should be included in future health research agendas. Extensive empirical literature poses the argument that trust is quantifiable. we may also look at this challenge as one that is out of the realm of sociology. Issue 2. August 2008 Luhmann then proceeds to explore and explain the importance of trust in social systems (and of social systems trusting each other) from a theoretical perspective. (1993) ‘Public health spaces and the fabrication of identity’ Sociology 27:393-410.E. we recognise the idea of a ‘smooth functioning’ system is intrinsically impossible. the question however. There must be other ways of building trust which do not depend on the personal element. Future research may help to identify modes and possibilities for health system transformation. 2. Future empirical research must be based on a more comprehensive and contemporary social theory of trust.K. Studying the 184 HEALTH SOCIOLOGY REVIEW .E. Beck. determinants. Postmodernity and Intellectuals Cambridge University Press: Cambridge. U. While this paper offers insight into the current gaps in theoretical trust research. For further information on social systems theory and familiarity. 1988).P . However. through understanding the variables and conditions under which people trust. we cannot anticipate positive changes in. Concluding remarks and areas for further empirical investigation Social theory is beneficial to public health because it helps us to understand how. a challenge of epistemological or psychoanalytical nature. but this is not a central component of the paper. P . means to remove or compensate for what we are lacking. C. there is a need for further investigation through extensive. We also acknowledge that functionalism assumes equal power within society. John Coveney and Wendy Rogers While we recognise that a gap between knowledge and ignorance exists. M. Andreassen. Until we can determine what the conditions. and variables of trust are.. conditions or determinants of trust is more useful than attempting a further definition of trust (Butler 1991. This paper is an effort towards identifying the gaps that continue to exist in current trust theories.. there is potential to gain insight on how to encourage trust in health systems. (1996) ‘Critical reflections on reflexive modernization’ Theory. J. in this sense. Giddens often uses the term ‘brackets’. while suggesting future directions for empirical research. (1992) Risk Society: Towards a New Modernity Sage Publications: London. Kummervold. Luhmann (1979:46) poses a question which may form a research program within public health: . remains worthy of empirical investigation. and Bacchi. Volume 17. and why trust functions in society. Armstrong. cited in Hosmer 1995). it is all too obvious that the social order does not stand and fall by the few people one knows and trusts. Trondsen. theoretically based empirical work. whether based upon experience. and there is not instrument for measuring an exhaustive set of them’ (cited in Hosmer 1995). P (2006) .Samantha Meyer. Gammon. knowledge. (1987) Legislators and Interpreters: On Modernity. Butler (1991:647) argues ‘currently there is no agreement to what these trust conditions are. However this paper takes a functionalist approach in presenting agents as having a responsibility to keep the smooth functioning of society.. When arguing that trust is imperative for the smooth functioning of any health system. nor act to alter the declining levels of trust in healthcare. But what are they? References Alexander. ‘Patients who use e-mediated communication with their doctor: New constructions of trust in the patient-doctor relationship’ Qualitative Health Research 16:238-248. we put forward the need for further empirical work. where. Bracketing. Paul Ward. D. Endnotes 1.. Z. Beasley. In understanding why people place trust.. Rather. and Hjortdahl. 3. (2007) ‘Envisaging a new politics for an ethical future’ Feminist Theory 8:279-299. Culture and Society 13:133-138. 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. D. or faith. the explanation for this remains fairly abstract and in need of empirical investigation. H.
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and at the same time. associated changes to ‘lifestyle’ and the emergence of ‘obesogenic’ environments are viewed as underpinning the dramatic rise in the prevalence of overweight and obesity. Issue 2. ethnicity. complex and contradictory facets of consumption. that ‘consumerism has become a way of thinking and a way of life. 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. paradox. Health Sociology Review (2008) 17: 187–198 Consuming bodies: Mall walking and the possibilities of consumption ABSTRACT In popular. Rather than view consumption within a dualist framework of either ‘neoliberal choice’ or ‘modern evil’.Copyright © eContent Management Pty Ltd. 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. excess body weight has transitioned from risk factor to ‘disease’ status. Using mall walking as a case study. kinship. we seek to establish a theoretical foundation for consumption in obesity literature. obesity discourses. then it is no surprise that the literature on consumption studies has continued to grow. as Edwards (2000) notes. Mall walking provides a unique opportunity to examine the multiple. with overconsumption identified as the principal culprit. as do Henderson and Petersen (2002:2). mall walking. Mass consumption. academic and policy discourses it is taken for granted that consumption plays a vital role in the obesity epidemic. this paper aims to critique the way in which consumption is understood within the obesity literature. mall walking highlights the inherent paradoxes of consumption: of how consumption is positioned as the problem. Received 31 November 2007 Accepted 5 March 2008 KEY WORDS Consumption. As anything in social life can become an object of consumption (Baudrillard 1988). including gender. August 2008 I HEALTH SOCIOLOGY REVIEW 187 . of how bodies and spaces are reappropriated and transformed by people who are located in an environment that is characterised as ‘obesogenic’. Consumption is a thoroughly multi-disciplinary topic. and this has led. sexuality and locality. where differences in theoretical and empirical foundations of perspectives remain fundamental to debates Volume 17. 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. In addition to the generation of identities and social relations. to ‘a contested terrain of definitions’ (2000:13). and provides the very basis for our concept of self. or identity’. age. As a result.
in an environment that the obesity literature identifies as ‘obesogenic’ (Swinburn et al 1999). as consumption remains ideologically wedded to a simplistic discourse of moral economy. construct and display their own sovereignty through what they consume. The second section describes the study and phenomenon of mall walking. In order to examine the differing modalities of consumption. Whilst our study spans different socioeconomic locales. as the obesity literature clearly highlights that in most Western countries. August 2008 188 HEALTH SOCIOLOGY REVIEW . Edwards 2000. 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. mall walking takes place in the socio-economically disadvantaged areas. and in particular. and not Volume 17. with the most disadvantaged groups at greater risk of being obese or overweight’ (King et al 2006:281). suggests that ‘little health promotion theory has been informed by recent socio-cultural theoretical developments in understanding consumerism. Lupton. its inherent paradox. for consumption is implicated in the causative factors of obesity. the stroller (usually male) who seeks to bathe in the crowd. Michael Davies and Karen Turner concerning questions of consumption and consumer societies. Issue 2. The heterogeneity (and history) of consumption theory is important to the following discussion of obesity. While it is not our intention in this paper to describe the historical antecedents of consumption (as this has already been well documented by.Megan Warin. It is this blurring of consuming bodies. In particular. consumption refers to the process of consuming. taking a political economy approach. people can be ‘unconstrained rational actors seeking to maximise positive personal outcomes’ (Edwards 2000:11). 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. rather than a singular understanding. The ethnographic context provides a platform upon which to critique and extend the theoretical trope of consumption. Edwards 2000). devouring or even eating’ (Edwards 2000:10). of ‘using up. Australia (an area with high prevalence rates of obesity and related diseases) that we problematise the taken-for-granted and causative aspects of consumption. but simultaneously positioned as a strategy to promote healthy lifestyles. Vivienne Moore. Mall walking highlights the constraining and enabling capacities of consumption. for example. we aim to highlight a key feature of consumption: that is. centrally implicated in discourses of obesity. Rather than ‘buy into’ and reproduce dualist discourses of ‘good’ or ‘bad’ consumerism. we argue that health promotion and prevention initiatives need to consider the multiple ways in which consumption operates in people’s everyday lives. and immerse (himself) in the sensations of the shopping arcades and city. ‘there are inverse gradients between socio-economic positions and adult BMI. locating this activity in the historical and socio-economic context of the region. or. writing in 1994. 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. Rather. health and spaces that provides a window to critically engage with the dialectical tensions of consumption. can be seen to fall victim to the lures of packaging and advertising and the negative consequences of consumption. Clarke et al 2003). this paper takes as its starting point contemporary theoretical insights that acknowledge the ‘fulcrum of dialectical contradiction’ (Miller 1995:33) that surrounds consumption. for we are immediately led to multiple and complex meanings of consumption. At its simplest and takenfor-granted level (as it is currently used in much clinical literature). We argue that within the current obesity literature this is still the case. But from this semantic representation consumption can then branch out into multiple analyses. Consumers can. It is through the case study of mall walking in the northern suburbs of Adelaide. As the name suggests. In acts of desire to consume. commodity culture and everyday life choices’ (Lupton 1994:111). the paper is divided into three sections. This is not Walter Benjamin’s 19th century solitary flaneur [or Friedberg’s flaneuse (1993)]. on the one hand. The first section briefly examines the ways in which consumption has been used in health discourses. Miller 1995. The relationship between health and place is vital here.
These authors suggest this is somewhat surprising. Consumption of food is therefore essential for health. In the medical literature. Commodities and activities (such as what we eat. transnational trade in children and women. they take on the properties of ‘health giving’ or ‘sick making’. health is no stranger to Marxist analysis. (both in key UK policy documents in the 1990s and the uptake of this rhetoric by advocacy groups). arguing that commodification of body parts leads to exploitation of vulnerable and marginalised bodies (Scheper-Hughes 2001a. Similarly. considering the encompassing language of consumerism in health care. Featherstone 1991. Some people and populations are identified as engaging in too many of these ‘sick making’ activities or ‘lifestyles’ (Cockerham 2006). objectified and exchanged in commercial transactions. August 2008 189 . and the shifts in health care delivery from clinical to consumer spaces (such as breast screening facilities in Australian retail stores. Falk 1994). Scheper-Hughes and Wacquant 2002). HEALTH SOCIOLOGY REVIEW Such shifts in health can be traced in all sectors of health care. for they are important forms and foci of capital (both symbolic and economic). and smoking is viewed as ‘sick making’. in which they can become gifted. but debates over defining which foods and how much to consume is increasing contentious as the accumulation of consumption is reflected in rising obesity. the anthropologist ScheperHughes has been a long standing critic of the commercial exchange of organs in a global economy. where. Despite this recent anthropological and sociological literature into health and consumerism. Indeed. In contrast. 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). (Over) consuming bodies and the pathologisation of consumption Explicitly tied to discourses of consumerism are bodies (Bourdieu 1984. 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. and in the growing market of health tourism in desirable locations). Volume 17. many practices relating to bodies have attracted the charge of unwelcome and exploitative objectification and commodification (such as slavery. tooth brushing is universally viewed as health giving. from the changing language of ‘patients’ to ‘consumers’. 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.Consuming bodies: Mall walking and the possibilities of consumption simply view consumption as a negative (and moralistic) desire to consume goods. What is healthful for babies is not necessarily appropriate for athletes or the sedentary elderly. and the commodification of spaces in which health care is delivered. Debates centre not over whether eating is unhealthy. in which the health care system has become what Sack (1992) describes as ‘the consumer’s world’. 2001b. the sports industry. in health promotion discourse. The health attributes of a commodity vary in the extent to which they can be viewed as ‘health giving’ or ‘sick making’. As Seale et al (2006) argue. the brand of cigarettes we (used to) smoke and how much we drink) are symbolic attributes of consumer culture (see also Bourdieu 1979/84). and it is these activities and bodies that are being increasingly surveilled and governed under the banner of health promotion (for example. and the military use of bodies) (Seale et al 2006:26). how and where we exercise. 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). but whether the diet is unhealthy given a particular pattern of individual characteristics such as age and activity levels. Issue 2. the UK’s Body Mass Index Surveillance Programme 2005-6). fragmented. Bunton and Burrows argue that health promotion is itself deeply embedded in the domain of consumer culture (Bunton and Burrows 1995:210). and has historically been a classic consumerist model of buying and selling skills and products. eating and activity are intrinsically different due to their essential nature for existence. or often even whether a particular food is unhealthy.
highly palatable. in particular. but also mapped local shopping centres and neighbourhoods in an attempt to understand the environments in which they lived. stupidity and insensitivity to want’ (Douglas and Isherwood 1996:vii). and it is these clichés that continue to be drawn upon in obesity 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). in policy documents (Evans 2006). where we not only conducted interviews and participant observation with the women. inconsistent mess of ordinary mundane worlds [that are] so often absent in writings on consumption’ (Miller 1995:51). the food and beverage industry (including advertisers and the media) … the sedentary entertainment industry (tv. The following section seeks to move beyond this polarisation and global homogenisation of consumption. 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. in the obesity literature acts of overconsumption are repeatedly blamed for the excesses of modern life. etc. It was during our fieldwork in a local shopping centre that we noticed a flyer for mall walking. Opposed values of consumerism Volume 17. Obesity is the direct outcome of overconsumption. energydense foods’ (Hill and Peters 1998). ‘Fat people’. the person as an active health consumer and the consumer space of a shopping mall. as Longhurst argues. These perceived causes of obesity are widespread. obesity and consumption are thus implicitly connected through a discourse of excess. that the complexities of consumption can be understood. or where the pattern of consumption generates a cumulative disease risk that can be defined as ‘pathological consumption practices’ (Hayward and Yar 2006). and both obesity and consumption are castigated as demonstrating ‘greed. and were immediately drawn to the differing meanings and spaces associated with consumerism. and are easily echoed by primary school children (Hardus et al 2003). according to Lobstein (2006:74) the usual suspects (or ‘sins’): … the pharmaceutical industry with an interest in medicalising the problem. consumption is discursively constructed as the effect of an ‘unlimited supply of convenient. Consumerism is taken as a broad brush.Megan Warin. and ‘obesogenic landscapes’ slip into ‘obesogenic lifestyles’. Miller notes the ways in which early studies of consumption fall into a series of both colloquial and academic clichés (Miller 1995:52). relatively inexpensive. where unhealthy choices are said to be the default option (Swinburn and Egger 2004). video games. lay perceptions found in the media (Lawrence 2004) and clinical discourses. It is in the attention to the layering of consumption practices and forces. This project took us to different socio-economic locations across Adelaide. or as the result of an obsession with mandatory consumption (Dixon and Broom 2007).. These damaging consumption practices take place in ‘obesogenic environments’. Vivienne Moore. Obesity is part and parcel of ‘the postmodern condition’ or ‘culture of surplus’ (Rundle 2007).) … and the transport industry … which needs to resist moves to reduce car use and to make roads pedestrian friendly and cycle friendly. August 2008 190 HEALTH SOCIOLOGY REVIEW . In this range of negative discourses. at both local and global levels. and includes. who are all in the clinical range of obesity.. experience and understand their body shape.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). Issue 2. and the weight loss industry with products to sell . are ‘aware of negative social stereotypes of corpulent bodies … and live with guilt about taking up too much space’ (2005:252). 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. While the commodification of health has raised the positive concept of agency and choice within consumerism. presented as a form of ‘social anaesthesia’ or ‘commodity fetishism’ (see also Miller and Rose 1997). by examining the ‘contradictory. Michael Davies and Karen Turner From clinical accounts to sociological analyses.
lured by cheap passage and promise of home ownership and semi skilled labour. and the median weekly income is $AUD580 which is well below the average Australian income. While there is now greater diversity of income throughout this region. as Thomas (2003) argues.1%). and is single storey.1%). Mall walking is a class related activity.Consuming bodies: Mall walking and the possibilities of consumption are thus rolled into one: mall walkers are subjects consuming health. Participant observation was the most appropriate methodological approach. we took photographs and video footage. primarily around an emerging automotive manufacturing industry. as its name suggests. particularly its single storey box-like design. and our interpretations ‘checked’ with participants on subsequent visits. 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. As we walked with group members we engaged in informal conversations. Our main focus was the Elizabeth mall walking group. culturally deprived and often sexually abused group who lived in Adelaide’s northern suburbs’ (The Australian 2003). had informal meetings with management and shop proprietors. which provided important contextual data into their lives. is a central landmark of the area. We also took detailed ethnographic observations of the temporospatial dynamics of mall and its changing life over the course of a day. While the mall has had several refurbishments and additions over the years (and was undergoing major redevelopment during our fieldwork). unlike many shopping centres today which attract customers through multi-level architecture and car parking. and we joined another mall walking group at a nearby complex for two morning sessions. and is double that of other locations in Adelaide (city of Adelaide 7. The surrounding areas are home to a row of car dealers. In Adelaide it began in 2001 and now occurs across six different shopping precincts. and conducted open-ended interviews with key informants (regular walkers and instructors). that we can examine this relationship between subject and object in consumption. and embodied and spatial performances of identity (2003:104). 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). 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). Moreover. Issue 2. With permission. including promotional material that was used in architectural displays to advertise the mall’s refurbishment. August 2008 191 . contacted the instructor who ran the weekly mall walking classes. Unemployment is high (14. The city of Elizabeth was settled in the 1950s by white British migrants. it continues to be stereotyped as a location of low income households (and described by a criminologist as housing the most ‘socially isolated. walking the circuits over a period of four months. explained our interest. It is in the space of the mall. 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). With its red rose emblem adorning the top of the tower. The mall. A third of households earn less than $AUD400 per week. and objects in a consumerist environment. 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. it retains a flavour of its original 1960 structure. The ethnographers in this study (Warin and Turner). 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. sign posted by a multi-story tower that dominates the skyline and is visible from a significant distance. and were invited to participate. We joined the mall walking at two shopping centres as participant observers. as ‘being there’ and actively taking part in the process of mall walking allowed us to come closer to experiencing and understanding people’s motivations to be a part of this activity. The Elizabeth City Centre shopping mall (which was undergoing a major renovation during our fieldwork) is 30 kilometres HEALTH SOCIOLOGY REVIEW north from the CBD of Adelaide. and gambling and smoking shops. Fieldnotes were ‘written up’ after mall walking sessions. Volume 17.
Michael Davies and Karen Turner Like similar locations in Australia (Brisbane’s Inala. In public health discourses of obesity. Issue 2. Stunkard and Sorenson 1993). Jane. Some participants have been coming since mall walking began. policy impacts and socio-cultural influences. and which shops were relocating and where. The mall (which also houses community and welfare services) has been a social and commercial pivot of this community for decades. Walkers enter via a side entrance and meet at a popular ice cream chain outlet. August 2008 192 HEALTH SOCIOLOGY REVIEW . Aching backs from heavy manual labour. For some. community and mall walking must be considered. qualified sports instructor with infatiguable enthusiasm. 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. ‘lose weight’ and to ‘keep fit’. a middle-aged. Although they did not use the term ‘obesogenic’. They heard about mall walking via leaflets in the malls. some walking quickly and decisively. 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). Jane led the group through five minutes of the warm up exercises before they peeled off into small walking groups. footpaths and affordable exercise facilities. this region fits with the characterisations of ‘obesogenic environments’ mentioned above. In line with studies that have mapped the inverse relationship between socioeconomic status and obesity (Sobal and Stunkard 1989:261. everyone had a working knowledge of where the renovations where up to. The majority of people who come to the walks are women aged over 50. and the renovation is clearly part of a plan to ‘make over’ the cultural identity of the region. paying their two dollar fee to the team leader.30 am before the centre opens to the public. through local newspapers and word of mouth. poverty is embodied by working class people. 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’. Swinburn. Melbourne’s Broadmeadows and Sydney’s Mount Druitt). opportunities or conditions of life have on promoting obesity in individuals or populations’ (1999:564). In an economically deprived area. and others are new ‘recruits’. describing their neighbourhoods as unsafe. As the social historian Peel (2004) argues (having grown up in this area). and Volume 17. It is in the ongoing refurbishment of space that mall walking takes place twice a week. mall walking par ticipants reiterated these attributes. the primary reason why people attend is to ‘stay healthy’. Vivienne Moore. As shop owners were getting their windows prepared for the day’s trading. It is in this context that the shopping mall. Broader than the physical environment.Megan Warin. and like the advertising tag line (‘walk for fun. and residents are well aware of the negative stereotypes that come with the territory. and those using walking sticks or with hip replacements walking slowly. and have lived in the area all their lives. on a Tuesday and Thursday morning at 7. Architectural promotions in the shopping mall emphasise the magical transformation of bodies and spaces through the bright displays of café latte and chardonnay sipping faces. As in Popay et als (2003:18) study of lay understandings on the relationship between health inequalities and place. ranging from 15 regulars at Elizabeth to 120 at the larger multi-level shopping centres. Different shopping centres have different numbers of walkers. and ‘in their own accounts. and ‘as part of a Weight Watchers program’. Walkers were defined by groups of friends. While very few people stopped to look in windows or the prices of items. fitness and better health’). they smiled and waved at the walkers: some even knowing each other by name. Egger and Raza (1999) define obesogenic environments as ‘the sum of influences that the surroundings. this included ‘keeping my weight down’. this is a highly stigmatised area. and each set their own pace. poor people say their bodies often fail them’ (2004:83). obesogenic environments include such aspects as economic constraints. 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). and lacking appropriate lighting.
This is in stark contrast to several other shopping centres in the area which embody a sense of danger through their layout. as they had a privileged insight into the workmanship and weekly changes. These positive effects of mall walking accord with an interpretation of consumption’s social. family shopping is explicitly used in marketing strategies to emphasise warmth. when cultural meanings are examined. importance. The metaphor of safe. and in the case of mall walking. and then others at the table who had overheard similarly conveyed their support. limited the use of buses to access shops. interact with fellow walkers. In addition. and compromised day-today social interaction’. in fact they said. In their study of ‘deprived communities’ in the UK midlands. Asked why they walk in an indoor mall rather than in the large green parks that are abundant throughout this geographically flat area. who suffered from asthma and was unable to exercise outdoors at this time of year. She explained: ‘It might be the only hug they get that week’. As the main doors opened to the public. Andrew told her how he wouldn’t see her next week as he’d be in hospital (and proceeded to tell her why). Miller et al 1998. and convenience of the mall as a place to shop (see also Miller et al 1998:92-93). one small suburban shopping centre is surrounded by 12 foot fences that are locked at night. the climate was controlled so they could come in rain or hot weather. Parry et al (2007:135) similarly note how ‘fear prevented older adults taking outdoor exercise. Angela put her hand on his shoulder and said: ‘we’ll be thinking of you’. it is the network of relationships that sustain the event. Miller similarly found that ‘malls are places that perennially constitute and reconstitute social relationships through various practices of shopping and identity’ (1998:26-27). This is what Schnact and Unnithan (1991) argue in their analysis of mall walking and urban sociability. Issue 2. safety. ‘health’ is often a minor component of people’s reasons for engaging in exercise regimens. As Lupton (1994) argues. these early morning mall walkers were intimately connected to and involved with the refurbishment. especially to those walkers who didn’t have partners or family close by.Consuming bodies: Mall walking and the possibilities of consumption which shops were brand new to the mall. who took on a mothering role by constantly offering hugs. Trevor (a widower in his 70s) pointed out a group of school children in the mall. August 2008 193 . These rationales echo Shcnact and Unnithan’s (1991) findings. 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. one could easily argue that it was the friendships and social interaction that drew people back week after week. Erkip 2003). It was after the walking at the regular café (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. Mall walking does not promote hyperVolume 17. saying that he was scared of young people and by walking in a group he felt a sense of security. and there were toilets handy if need be. In many ways. 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). and in doing so. gave the group a particular sense of ownership through space and time that the everyday shopper would not have. and others have meshed store windows with shopkeepers serving behind wire screens. To be in a shopping mall before trading begins. In focusing on the literature that emphasises consumption spaces as investments in social (rather than economic) relationships (Warde 1996. Many mall walkers said that the flat surface was easier to walk on and there was no threat of tripping over broken pavements. the ‘walking is incidental’. as opposed to economic. security guards and shop owners. Again and again walkers emphasised that mall walking is not just about walking. Perhaps the most striking evidence of support was displayed by Jane the instructor. to mingle with the tradespeople. The constant temperature and filtered air was particularly important for Mary. who suggest that people are drawn to mall walking because they can do low impact exercise in a HEALTH SOCIOLOGY REVIEW climate controlled and safe environment.
from a public health perspective. consumerism for their own means. Mall walking points to how people in lower socio-economic geographies adapt to. and where engaging in social relations and shared activities take precedence overconsumption. allows engagement with both active and passive constraint on consumption. this is the ‘positive’ consumer model which Schnact and Unnithan (1991) ascribe to. 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. A similar argument concerning the tactical use of space by health consumers is demonstrated in Knowles’ (2000) work. consumerism is often presented in terms of personal empowerment and freedom of choice in which citizen based consumers buy into appropriate participation. as the motive for walking shifts from working off excess pounds to purchasing more. Behind the rhetoric of freedom of choice is however. Trentmann (2004:384) suggests that groups suffering from social exclusion and low income may very well be left out of a consumerist dream world. By operating during hours when the shops are closed. these consumption spaces promote health and are important sites for the creation and maintenance of social relations and communities. spending a large part of their days in nearby shopping malls when the shelters are closed. Within neoliberal politics of health care. The concept of health propels an entirely new set of meanings into the equation for it brings with it a different understanding of consumer. ‘as a legitimate avenue of human gratification and way of spending time’ (Knowles 2000:221). Shopping malls are open long hours. and clients ‘play at’ being consumers by filling their plastic coffee cups with water as they sit for hours in the food halls. Consumption spaces are sites for human creativity and action. 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. in which people negotiate and play with space. they are purchasing symbolic power by taking ownership of a privately owned. Although not explicitly stated. but creates its own forms of social connectedness and social practice. The shops become an audience to the activity of the walkers. public space). Issue 2. The role of consumption in mall walking and obesity is much more complex and ambiguous than authors like Schnact and Unnithan (1991) suggest. mall walking constrains consumption. So on the one hand. As well as providing a haven. 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. and with the knowledge of this demographic. provide warmth. where consumption is being balanced by constraint. 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). quiet and private.Megan Warin.2 Mall walking creates an additional social context for the mall as depot. and use. an array of masked attempts to either Volume 17. only speaks to one side of the consumption paradox. shopping malls provide clients with the idea of consumption. August 2008 194 HEALTH SOCIOLOGY REVIEW . Michael Davies and Karen Turner individualism. contemplating consumption as a way of being in the world. 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. Moreover. Her research into the community mental health care system in Montreal reveals how psychiatric ‘clients’ transit around the city. the shift in time to allow occupation when the centre is closed. advocacy and the improvement of health care for larger numbers of people (Gesler and Kearns 2002:141). light and company. Vivienne Moore. However. but uses many of the features that make consumption both easy and pleasurable to counteract the effects of consumption. keenly aware that the early morning walks afford mall walkers a sense of active participation in healthy ‘lifestyles’. Both passive and active constraint undergoes decompression once the centre opens to the public.
discount process and multiple types of care within the one clinic’ (Kearns and Barnett 1997. August 2008 195 . and the controllability of consumption. The irony occurs through using obese bodies as managed consumption for advertising. in his earlier essay Consumer Society (1988:33-4) had stated: We have reached the point where ‘consumption’ has grasped the whole of life. Issue 2. pay a fee. where all activities are squeezed in the same combinatorial mode. and in our ‘anarchic and archaic cities’. massaged.Consuming bodies: Mall walking and the possibilities of consumption reduce the role of the State as a welfare provider. separate. one hour at a time and where the ‘environment’ is complete. monopolising a visibility on the urban landscape to sell a product. completely climatised. The walkers are subject to a number of conditions for walking on private property. all previously dispersed. endorsing the health promoting activities and having an obvious presence at any function that the mall walkers had. must wear a uniform: a name badge. that exhortations to consumer choice alone are unable to ensure a stabilisation. while attempting to exploit the mall walkers as advertising. 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. and culture. In this study. Kearns and Barnett suggest that medical services take advantage of this consumerist landscape. as Miller argues (1995:17). interpreting ‘activity’ as ‘consumption’ is also likely to increase as privately owned space assumes the social role traditionally held for public spaces. In this ‘malling of medicine’. The use of mall walkers as corporate advertisement reflects a societal shift in the recognised risks and responsibility of those involved in overconsumption. where the schedule of gratification is outlined in advance. cited in Gesler and Kearns 2002:144). Digital photographs were taken by management representatives and included in their newsletter. and by representing belated awareness of excess consumption as responsible progress. leisure. During our fieldwork mall management were centrally involved in the walking program. who. and a short sleeved. embodying some of the characteristics of their retail and fast food neighbours: ‘fast service. increase surveillance of populations. and more or less irreducible entities that produced anxiety and complexity in our real life. Consumption is thus not synonymous with choice. Kearns and Barnett argue that is not uncommon to see medical services being advertised or located in shopping malls or hubs. is the lack of choice whereby consumption provides the only arena left to many people through which to forge a relationship with the world. promoting the central role that the complex has in improving the health of local residents. the presence of centre management and an invited local politician (attempts were made to secure South Australia’s State Health Minister). Mall management has an increasing interest in demonstrating that they are responsible corporate citizens while seeking to maximise consumption. The obesity epidemic means that the aggregate public health risks are perceived to be great and increasing. More broadly. the mall management are also reinforcing the shift in perceived responsibility for consumption excess. have finally become mixed. In their hegemonic theory of consumption. nature. but. This is a clear explication of Baudrillard’s views. Jane explained to us that the management of the shopping mall were particularly interested in making the exercise mutually beneficial. 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). which involved a longer than usual get together at the end of the walk at the designated mall cafe. corporate body. and for example. finished and culturalised … work. Volume 17. much less a reduction of the epidemic. further demonstrating their involvement with community life and public face as a socially responsible. or offer limited choice with an array of predetermined and limited options for action. Certificates of achievement were distributed and birthday cake eaten. All of the mall walking sites HEALTH SOCIOLOGY REVIEW celebrated birthdays. climate controlled. and domesticated into the single activity of perpetual shopping.
consumption needs to be distinguished from ‘common sense’ understandings. and are ‘out of place’. however. bodies and boundaries of consumption leads to contradiction and paradox. but to highlight the ways in which a critical and theoretical account of consumption must be taken into account in the obesity debate. overeating. Schools. overconsumption. 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). Mall walking. television advertising. and encouraging people to walk rather than use private transport. as we have argued. malls do not fit with traditional health promotion theories as they are discursively and negatively constructed as ‘cathedrals of consumption and desire’ and hence. From a public health perspective on obesity. and the singularity of negative discourses. For the mall walkers involved in this study. as a stock of ‘lifestyle’ choices and structural constraints that have caused an obesity epidemic. Analytically. by ignoring the inherent tensions of consumption there is an overemphasis on the significance of consumption. As a space of consumption.Megan Warin. and poor lifestyle choices are held accountable. like that of Clarke et al (2003:2) is to demonstrate the ‘wide-ranging. 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. yet seeks to broaden the ways in which the theoretical (and rhetorical) trope of consumption is used in understanding obesity. Michael Davies and Karen Turner Leisure activities and health. 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. Firstly. consumption needs to be critically unpacked and examined so we can be attuned to its diverse and contradictory meanings. suburban spaces) are being targeted as ‘environmental’ sites for obesity intervention. remembering that this is a particular group of people in a particular locale. August 2008 196 HEALTH SOCIOLOGY REVIEW . are highly commodified services (and have been for some time). for it creates diverse personhoods. In the obesity literature this paradox is absent and consumption is primarily used in two distinct ways. This blurring of spaces. rather than an investigation of the social consequences within varied conditions of differential empowerment and resources. Our aim. In either construction (‘common sense’ or analytical). Volume 17. Edwards (2000:6) argues that it is important to note that this ‘sense of contradiction is not easily resolved’. Issue 2. social relations and communities that are discounted through hegemonic accounts. Shopping malls are a new spatial form that synthesise health and consumption which have previously been held apart by being located in different sites. in which contradiction is embodied (and enabled) in people’s everyday lives. and should not simply be viewed as examples of ‘cultural erosion’ or ‘the fall of humanity’. consumption generates far more diverse meanings than Baudrillard considers. As Miller (1995:290) suggests. 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. It is not our aim to provide ‘exit solutions’ to consumption in the obesity literature. Vivienne Moore. Our argument does not discount these interpretations. contentious and contested’ meanings of consumption in health and obesity discourses. and that attempts to polarise consumption are perhaps attempts to rationalise and weaken a power that is both illusory and real. work places and urban spaces (most often open. Overweight. by banning fast food advertising during children’s television viewing hours. demonstrates that consumption sites can also be productive spaces in the transformation of bodies and health promotion programs. 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. Secondly. exercising bodies do not belong in these spaces. performed at different times or accomplished by different people. improving school dinners and canteen options to healthy foods. consumption is presented as a negative ideological force of exploitation.
. Crawford. The North-West Adelaide Cohort Study (Working paper series number 9) Unpublished manuscript. This project was funded by a University of Adelaide. Falk. Other ‘consumption pathologies’ include shoplifting. S.) Routledge and Kegan Paul: London. (2006) ‘Health lifestyle theory in an Asian context’ Health Sociology Review 15(1):6-15.id. (2001) ‘Is obesity a disease?’ International Journal of Obesity 25(10):1401-1404. University of Melbourne and the authors thank the audience for constructive feedback and criticisms. R. M. City of Playford Community Profile (2006) (results from the 2001. drug misuse and materialism (Miller 1995:34). M. A. in her analysis of a Parramatta shopping mall in Sydney. R. Cummins S. D. A. Taylor. 26-43. B.. Critique of the Judgement of Taste (trans. Culture 2(1):9-28.C. and Burrows. Media. Research Establishment Grant. D. (eds) The Sociology of Health Promotion. (1988) ‘Consumer society’ in Poster. Hardus P van Vuuren. Dixon. M. Issue 2. D. A. S. draws the reader’s 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.asp?bhcp=1 (accessed January 2008). J. W.. Faculty of Health Sciences. F.. and Petersen. and Kearns.. 206-222. Baudrillard. Practices and Politics in Consumer Society Open University Press: Buckingham. (2006) ‘The ‘chav’ phenomenon: Consumption.. Nice. J. and Yar. S. Thomas (2003:12). (2002) Culture/Place/ Health Routledge: London and New York. August 2008 197 . Douglas. Hayward. J. McKay. Erkip. K. Wilson. P (1979/1984) Distinction: A Social .com. References Appleton. D. (eds) The Body: Social Processes and Cultural Theory Sage: London. B. (2000) Contradictions of Consumption: Concepts. 2. pp. (ed) Jean Baudrillard: Selected Writings Polity Press: Cambridge. Nettleton. Bunton. (2006) Obesity in North and West Adelaide. and Turner. (eds) (2003) The Consumption Reader Routledge: London and New York. The original version of this paper was presented to the Anthropology Department. L. function and meaning in the contemporary retail built environment’ Annals of the Association of American Geographers 83:18-47. R. (1995) ‘Consumption and health in the ‘epidemiological’ clinic of late modern medicine’ in Bunton. Featherstone. (2006) ‘“Gluttony or sloth”?: Critical geographies of morality and bodies in (anti)obesity policy’ Area 38(3):259-267. (2005) ‘McDonald’s restaurants and neighborhood deprivation in Scotland and England’ American Journal of Preventive Medicine 29(4):308-310. Ruffin. and .au/ playford/commprofile/ Default. (1996) The World of Goods: Towards an Anthropology of Consumption Routledge: London and New York. media and the construction of a new underclass’ Crime. S. Evans. Heshka. (1993) ‘The ‘magic of the mall’: An analysis of form. Hepworth. and Burrows. M. K. Available at http:// www. London. R. Clarke. Edwards. Friedberg. and Broom. D. Cockerham. Lifestyle and Risk Routledge: London. C. and Housiaux. P (1994) The Consuming Body Sage: . and Isherwood. M.. Doel. Goss. HEALTH SOCIOLOGY REVIEW Volume 17. S. and Allison. M. (2007) The Seven Deadly Sins of Obesity: How the Modern World is Making us Fat University of New South Wales Press: Sydney. (ed) (2002) Consuming Health: The Commodification of Health Care Routledge: London and New York. Henderson. Critical Analysis of Consumption. A.. R. B. Bourdieu. Worsley. (1991) ‘The body in consumer culture’ in Featherstone.Consuming bodies: Mall walking and the possibilities of consumption Acknowledgements The authors would like to thank the participants who so generously shared their time and experiences with us. and MacIntyre. T. M. W. (2003) ‘The shopping mall as an emergent public space in Turkey’ Environment and Planning A 35(6):1073-93. D. 1996 and 1991 census of population and housing). Gesler. Endnotes 1. pp.. (2003) ‘Public perceptions of the causes and prevention of obesity among primary school children’ International Journal of Obesity 27(12):1465-1471. (1993) Window Shopping: Cinema and the Postmodern University of California Press: Berkeley CA. R.
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This ‘government of girth’ reaches an apogee in the problematisation of children and body weight. once historically considered as a physiological state. governments in many jurisdictions in many countries have debated the obesity problem (for example. epidemic. Moreover. or body weight. National Health and Medical Research Council 1997.Copyright © eContent Management Pty Ltd. Foucault. The issue of population fatness has engaged numerous groups. Issue 2. August 2008 199 . however. and. have arguably never been greater. is presented as all the more frightening when no known effective prevention or cure is at hand. Australia. New HEALTH SOCIOLOGY REVIEW O Zealand. It will also look at the way in which obesity has engendered social anxiety fuelled by moral panic. United Kingdom. reaching into virtually every social group. The term ‘moral panic’ was originally used to describe social unease arising from an exaggerated media representation of youth Volume 17. New Zealand Ministry of Health 2004. with several international journals dedicated to the topic. in the modern context. is now regarded as a state of moral pathology representing an ‘epidemic’. Received 9 October 2007 Accepted 5 March 2008 KEY WORDS Obesity. This paper examines the development of obesity and will discuss the ways in which fatness has been rationalised within health discourses. USA). as well as interventions to address and arrest its spread. but numerous other public and private organisations. A fixation on obesity is not merely a medical and public health matter. 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. US Department of Health and Human Service 2001). organisations and institutes whose raison d’etre become its prevention and management (International Society for the Study of Obesity 2006). the anti-social child. Three subject positions in childhood provide a number of opportunities to problematise children: the sick child. Each of these amplifies concern about the state of health of children. The obesity crisis has engaged not only health communities. Fatness has historically invited comment from a variety of social and moral perspectives. social and popular discourse (Sobal 1999). It will explore the way that the corpulent body. the permissive nature of parenting and potential moral social decay. The prospect of this disease sweeping through populations. and the innocent child. in so doing. Research into the causes of obesity. obesity is widely discussed as part of medical. sociology. It will look at how the problem of obesity has become a major issue in medicine and public health. has created moral alarm as well as a medical crisis. 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). Health Sociology Review (2008) 17: 199–213 The government of girth ABSTRACT The current preoccupation with body weight in western cultures is arguably unprecedented. and. 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. This paper aims to examine the growing concern and interest in individual and population girth.
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). rather than confined to specific so-called ‘vulnerable’ groups. morality inculcated. suggests that scholars of governmentality leave themselves open to accusations of reinforcing a top-down. in particular the engagement of so-called stakeholder organisations and groups who have legitimised their role in the field. 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. Indeed. Some critics of governmentality as a theoretical lens point to a selective choice of abstract rules of rationality to support governmental processes. Dean and Hindess 1998). assistance provided for the sick and needy. The theoretical starting point for this paper derives from the notion of government. this paper will not portray it as a scientific fabrication or an ideological invention. This form of government is effective not merely by engaging with the health problem itself: its distribution. 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). It is precisely because concerns about obesity arise from its growing prevalence across the population.. this would seriously limit the explanatory possibilities of governmentality. laws promulgated and enforced. But such a view is not the case. in Europe for many centuries economic activity was regulated. governmentality recognises that the state plays only a limited role in managing the conduct of individuals and populations.John Coveney culture in the 1960s (Cohen 2003). cause and cure. There is nothing new in this form of government. If true. state-centred approach to government. which has been developed from Foucault’s examination of governmentality (Burchell et al 1991. in many jurisdictions. and more about the horizontal networks of governing. the state has been remarkably slow in bringing its powers to bear to intervene in the problem of obesity. have intensified professional and public concerns. one commentator goes as far as to catastrophise obesity as the ‘terror within’. The increasing traction of the obesity problem has happened largely without the exercise of state political authority. in the face of many health and welfare problems of immediate importance (for example poverty. 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). whereby individuals problematise their own choices. Indeed. 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). It operates by recruiting the hearts. hunger and mental health). minds and conscience of individuals resulting in the ‘forging of alignments Volume 17. The consequences of these representations. Gard and Wright 2005). In Australia. And unlike other examinations of obesity (see for example. political power is exercised well beyond the state (Rose and Miller 1992). for example. capable of wreaking havoc that is likely to even dwarf September 11th or terrorist attempts (Saguy and Almeling 2008). August 2008 200 HEALTH SOCIOLOGY REVIEW . In fact. An important armature of governmentality is the imperative of self-government or selfsurveillance. that the amplification of alarm has been so loud. Petersen (2003). if at all. for example. Campos et al 2005. Governmentality is less concerned with hierarchical relationships with state-centred government. obesity has risen as a national and an international concern. As Rose and Miller (1992) have pointed out: . Issue 2.. and that within contemporary politics. 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. habits. through practices that had little to do with the state. The use of the term ‘moral panic’ in this paper does not subscribe to this definition. It will instead attempt to explain how. order was maintained.
Acting on Australia’s Weight was developed in 1997 as a HEALTH SOCIOLOGY REVIEW In other words. new relationships between expertise and politics are formed. In Australia for example. and men were 1. Finally. new partnerships with similar interests are brought together. Noting the widespread nature of the problem. energising and amplifying each other. 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). Women were. 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. emphases added). August 2008 201 . after Rose (1996). and new horizons for individual perfection are demarcated. It then examines new subject positions opened up by discourses on obesity which engage not just health concerns but also social and moral considerations. according to the report. public health and moral positions that are inevitably intertwined. Issue 2. the report says: During the 1980s there was a steady increase in the proportion of adults who were overweight or obese. and is not confined to specific population pockets or vulnerable groups.The government of girth between the personal projects of citizens and images of the social order’ (Miller and Rose 1988). obesity is spreading throughout the whole community in an epidemic-like fashion. to a serious state of pathology. 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. While the paper will principally draw on examples from Australia. The paper begins by examining the recent rise of medical and popular interest in obesity. this reflects increased reporting of scientific announcements and developments on the topic. other forms of media increasingly began taking an interest in reporting obesity and overweight (Dugdale and Dixon 2007).3kg heavier in 1989 than 1980. 0. One was the vivid portrayal of obesity as a modern ‘epidemic’ spinning out of control (Koop 1994). strategic plan for the prevention of overweight and obesity. Walden 1985). The substantive thesis developed in this paper attempts to show how the problem of obesity opens up medical. In other words. the appearance of obesity in childhood. The obesity ‘epidemic’ While increased body weight has been a feature of health commentary in western post-war years (Whyte 1959. disease states in themselves. the successful management and treatment of obesity is notoriously difficult (National Health and Medical Research Council 2004). Volume 17. albeit at one end of a physiological spectrum. in fact. Establishing overweight as a spreading ‘epidemic’ effectively moves it from being a mere state of health. Thus while self-help books and magazines (especially those marketed towards women) have traditionally been a major source of information on overweight (Tebbel 2000). rather than extreme inactivity and excessive food intake among the few (National Health and Medical Research Council 1997. Part of the concern is the recognition that while prevention of fatness is itself a difficult enough proposition. and. In part. gaining momentum. in the mid-1990s a number of developments launched obesity into the headlines. fatness and body size are no longer risk factors for other diseases. on average. the paper situates obesity within a field of governmentality by demonstrating how. In terms of prognosis. Particular attention is paid to the spread of obesity across and within populations.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. in relation to the latter. Yudkin 1967. the likelihood of a solution to the obesity problem is poor. they are now. But it is also probably indicative of the way in which the scale of the problem of fatness as ‘epidemic’ registered in the public’s consciousness as something to be alarmed about. the analysis of growing concerns about obesity are relevant to other settings. The notion of obesity as a population ‘epidemic’ was captured in a number of key reports.
and with low levels of fruit and vegetables. the ordinary. Calculations of fatness in the form of Body Mass Index (BMI) were commonly featured in public discussions. but is being increasingly seen in so called developing countries. such as type II diabetes and respiratory problems.John Coveney The epidemic-like phenomenon of obesity also arose from new ways of calibrating population fatness. The ramifications of these calculative rationalities are interesting. the school and the workplace – can now. ‘obesogenic environments’ are. for example diabetes. The higher prevalence in less advantaged populations has given rise to media disquiet. Issue 2. Indeed. sugar. palatable and more readily available (Drewnowski and Specter 2004). have been shown to be much cheaper (Drewnowski and Darmon 2005) and increasingly more popular (Kant 2000) than socalled ‘healthful’ alternatives. In terms of population health this has meant that the degenerative diseases of affluence. the degenerative diseases normally associated with increasing body size. with all candour. especially for disadvantaged groups who bear the greatest burden of obesity (Drewnowski and Barrett-Fornell 2003). And the resulting quantification of fatness as either ‘overweight = BMI over 25’. In Australia. Thus the ordinary daily living and working conditions of most people – in the home. we can say that. Moreover. This can be seen for example in the ways in which fatness is not confined to affluent countries. are now evident in children (Fullerton 2005). And far from being par t of disordered living. The ar rival of the term ‘obesogenic environment’ (Swinburn et al 1999) was another declaration that engaged professional and public consciousness. which have been a continuing feature of many poorer countries. even moralising. ‘obese = BMI over 30’ or ‘very obese = BMI over 40’ effectively and efficiently segregated populations into categories of fatness. August 2008 202 HEALTH SOCIOLOGY REVIEW . be described as ‘toxic’ and injurious to health (Savige et al 2004). adding a new dimension to the fatness ‘epidemic’. The spotlight on children is a particular driver of moral panic over the obesity ‘epidemic’. for example. everyday environments in which most people now inhabit (Broom and Dixon 2007). that poor people are less able to control eating and lifestyle (Saguy and Almeling 2008). after the obesity ‘epidemic’. most men (63%) are ‘too fat’ (Cameron et al 2003) on the basis of BMI categorisation. it has now become ‘normal’ to be abnormal. Unease about population fatness was also amplified by increased recognition that fattening foods are more likely to be those that are cheap. In other words. Spreading across the globe The second factor that fuelled interest in fatness has been its transmission across populations (Chopra et al 2002). Moreover. in fact. obesity is more common in lower socio-economic groups (Friel and Broom 2007). parents in disadvantaged groups may not be exercising enough responsibility to prevent children from becoming fat. heart disease and some forms of cancer. now accompany the nutritional deficiencies. And like most other risk factors for chronic disease. it has been argued that healthy diets are simply unaffordable. Brazil and China) now more closely represent those found in western cultures. even diseased. 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). 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). 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. If the majority position demarcates that which is ‘normal’ (De Swann 1990). Spreading across the population The third factor that has increased the concern about fatness has been its transmission within populations. diets high in fat. The term ‘Generation O’ (O for ‘Obesity’) has been used to indicate the way in which today’s children may overall have less healthy outcomes than their parents (Cole 2006). Volume 17. The ‘obesogenic environment’ described those conditions where there was ready access to fattening food and little opportunity or encouragement for adequate physical activity. and salt.
using the mundane activities of family life. Thus subject positions open up possibilities for the ethical evaluation of conduct by which individuals. Issue 2. And it is the quest for the ‘normal’. The truth claims. This is where action to combat Australia’s weight problem needs to start and is the focus for the national agenda (Department of Health and Ageing 2003). where children are regarded as harbouring greater real and potential levels of disease and illness than what has been considered to be the case. credible criteria. Since discourses are socially and historically specific. and indeed societies. This is starkly clear in the most recent Australian strategy on health. or. in this case in relation to ‘proper’ child-rearing. so too subject positions can become available in relation to the development of particular discursive fields.30pm rule. And since childhood is considered to be the point in the lifecourse at which good habits can be inculcated. discourses that delineate (in)appropriate conduct. Truth claims do not force or coerce individual subjects to play their part in the fatness problem. Other parents. The second is ‘antiVolume 17.The government of girth Thus we can see fatness opening up in new territories fuelling concerns. much of the effort in the fight on fatness is directed to children. but also social rules (Armstrong 1983). play a vital role in establishing the norms of not only health and medical. Thus children are positioned as ‘normal’ in relation to sufficient sleep. Subtitled The National Action Agenda for Children and Young People and their Families. It is in the attainment of ‘normality’ that parents are judged by others and indeed by themselves in terms of doing the ‘right thing’. ‘normalises’ bedtime and sleep for young children to allow for adequate rest and optimal performance at school. Childhood has therefore become a major point of engagement in the war on fat. and parents negotiate this normality by invoking rules of bedtime. The prevention of weight gain. August 2008 203 . there is debate about priorities and avenues of least cost-most benefit (National Institutes of Health 1998). Grieshaber (1997) demonstrates how subject positions for parents and children are opened up by discourses on appropriate bedtime and sleep regimes for children. truth claims engage more productively through their ability to problematise the choices individuals are able to make. the solution. or discourse of expertise. or by ensuring overall adequacy of sleep. excused themselves from it by referring to the overall adequate amount of sleep their children were getting.30pm rule recommended by child care and parenting manuals. informed by discourses on child psychology and physiology. We will look at three subject positions that are opened up by the discourses in childhood overweight and obesity. For example. make judgements about moral adequacy. the plan frames children as the central targets. Subject positions may be thought of as categories or norms for personal and public deportment. while acknowledging the 7. or indeed. The first is ‘sick children’. 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. beginning in childhood. Poor results of management regimes in obese adults have helped focus efforts on the prevention of fatness in children. which they felt was ‘normal’. Making the ‘right’ choice – that is the rational choice – results from the process of selfproblematisation and the recognition of one’s self as a morally responsible subject. Advice by experts. Essentially they are ‘points of enunciation’ (Barratt 1991) constructed within particular forms of knowledge and practice. a morally responsible eater (Coveney 2006). and the focus for the rest of this paper will be to examine the ways HEALTH SOCIOLOGY REVIEW fatness in children has allowed for the availability of different subjectivities or subject positions.e. As authoritative. i. which requires parents to be aware of what are regarded to be rational parenting practices. Some parents in Grieshaber’s study positioned themselves in relation to ‘set’ bedtimes and enforced the 7. Healthy Weight 2008: Australia’s Future is explicit in its attempts to address children as preventable agents in the national fight against fatness. offers the most effective means of achieving healthy weight in the population. In justifying its position the report says: Obesity develops over time and once it has developed it is difficult to treat. in this case.
Issue 2. The growth chart provided an opportunity to see if children were growing normally. both in an individual and a social sense. one in 1985 and the other in 1995. Armed with a new tool for surveillance. The assessment of children’s healthy weight on a growth chart is usually accomplished by plotting current weight against age. 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. NSW Department of Health 2002). Recently. discussed and widely reported (see for example. under the pur view of ‘surveillance medicine’. Sick children During the late 19 th and early 20 th Century children’s health became a national priority in many countries and the assessment of child growth and development. were made available (Cole et al 2000). that is ‘in a field delineated not by absolute categories of physiology and pathology but by the characteristics of the normal population’ (Armstrong 1995). the number of children who could be classified as ‘fat’ had doubled from 10% to 20% (Magarey et al 2000). although there have been a number of critiques of the criteria. became frequent points of entry into parent – professional relationships. Moreover. And while caution was recommended in using BMI fatness to predict children’s current or future morbidity. they provided for the first time agreed and expertly derived universal categories of fatness against which children can be measured. As we shall see. 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). especially to the pressures of the free market and the consequences of the failure of measures designed to protect children’s innocence. Volume 17. the simplicity of a numerical representation of fatness became both fascinating and frightening. However. The findings sparked national concerns and in their wake a number of summits and symposia were held where the problem was debated. while growth charts are generally used over a period of time to track children’s growth trajectory. making the number itself an incontestable fact. what Rose calls ‘the power of the single figure’ (Rose 1999). The impact of the new cut-off points for assessing fatness in children can not be overestimated. based on BMI. 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. this is made difficult by the fact that longer. however. annuls the complexity of any background judgements and uncertainties thereby. In terms of the fate of children. especially where there is conflation of the categories of ‘overweight’ and ‘obesity’ (Gard and Wright 2005). August 2008 204 HEALTH SOCIOLOGY REVIEW . They found that over the 10 year period. Thus a need to account for length or height in the assessment of fatness is required. in effect. This is not to suggest that fatness in children is a myth or that the BMI standards are false. BMI cut-offs are strictly categorical: children either do or do not fit into the spaces delineated for fatness. taller children are likely to be heavier. cut-off points for overweight and obesity in children. the force of numbers. especially parents.John Coveney social children’. researchers analysed data from two surveys. where children are considered to be problematic. In Australia for example. Indeed. 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. and indeed the whole population. it is seen as a problem for adults. Children that fell outside the ‘normal’ trajectory of growth predicted by the chart were regarded as requiring investigation. child growth surveys in many countries took on new meanings. the issue of overweight and obesity in childhood is not confined to children. of the weight and height of children. though not necessarily too fat. where we will examine the discourses where children are regarded as highly vulnerable. Last is the subject position of ‘innocent children’. The definition of a universally recognised cut-off point for children that is regarded as constituting unhealthy fatness has not generally been available.
or leisure past-times – has received high scrutiny. as we shall shortly see. we can see a number of consequences. and the image of the ‘bronze Aussie’. For the Australian culture. been made before (Tomkinson et al 2003). If children see the only exercise their parents get is picking up the TV remote to change channels. exercise. 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). such as day care and schools (Pollard et al 2001. The school setting. the art of ‘good’ management of children rest on success in instilling into them a rational. close assessments of children’s physical activity and recreational habits (Commonwealth Department of Health and Ageing 2005). celebrity chef. then they will get the message that that is how to be’ (Phelps 2002). While meals eaten by children at home have long been of interest to nutrition experts. Naturally parents do not escape expert scrutiny or personal responsibility for the behaviour of their children. which is embedded in the modern free market ethos. has been a prime target for the collection of data and the implementation of interventions to address increasing weight in children (Olds et HEALTH SOCIOLOGY REVIEW al 2004). While the scientific link between physical activity and health is one that has a long heritage in western medicine (Smith and Horrocks 1999). Issue 2. Volume 17. especially outside play at school or outside school hours (Phillips 2005). The findings demonstrate that children are not partaking of enough of those activities normally associated with childhood. of course. Inspection of children’s eating habits has also increased. Dr Kerryn Phelps. dealing with it is. Indeed. responsible attitude in order for them to make ‘good’ choices (Banwell et al 2007). president of the Australian Medical Association spoke for many when she told the NSW Child Obesity Summit ‘Parents must lead by example. as one in which children spend a large part of their time and one which has traditionally been used to regulate children’s bodies. very different. The portrayal of children as slothful or sick. 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. Children are assessed according to time spent on daily pursuits – sport. By highlighting the questionable nature of the foods provided to children in schools.The government of girth and not just those who were classified as too fat. August 2008 205 . Fixing children in a grid of expertise either normalises or abnormalises them in relation to physical activity. ready to compete on the field or in the pool. is very much a national icon (Lupton 2004). of course. cooperation rather than coercion has become the key (Fallding 1957). launched an expose of school dinners on national television. Drummond and Sheppard 2004).000 signatures for better food in schools (Editorial 2005). especially in relation to food choice. In New South Wales in Australia. sleeping etc. the importance of physical activity within health discourse now becomes crucial. Indeed. low rates of physical activity are arguable even more problematic because sport and fitness have been principal cultural goals. Like body weight where the development of an index of girth was developed as a way of calibrating children on a continuum of fatness. raises major moral questions about the extent to which children are protected from the corrupting social influences which induce laziness and gluttony. and the endeavour to discover what children do – be it sport. These assessments have. autonomous. The lives of children in Australia have been opened up for examination and mapped against a number of lifestyle measures: for example. now new meaning is given to food provided in various institutions. and examining ingredients in some detail. these examinations take on new focus and importance. the program created a national storm resulting in a petition of over 270. renders children as problematic. – from which overall estimates of physical activity are made (Booth et al 2002). the nexus between what we eat and how active we are has never been made so obvious. Jamie Oliver. In the UK for example. But now armed with a new imperative arising out of childhood fatness rates. But while identifying obesity as a problem is one thing. similar indices exist for physical activity. leisure. However. In the modern era of democratic management of children. the freedom to choose.
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 children’s food choices (Donkin et al 1993; Taras et al 1989), and peer-pressure has been demonstrated to alter children’s 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 children’s 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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The government of girth
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 manager’s 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 today’s 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 children’s innate ‘goodness’, derived from children’s 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 children’s 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 obesity’s 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 child’s 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 children’s 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 child’s 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 one’s duty to one’s self through the visible display of body fat provides endless opportunities for public scrutiny and private guilt. And while neglecting one’s self is one matter, neglecting children is something of another magnitude. Fatness in childhood is not only about the ‘parlous state’ of children’s 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 Rose’s 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
Volume 17, Issue 2, August 2008
HEALTH SOCIOLOGY REVIEW
the obesity ‘epidemic’ has not weighed down the market place which has seen an explosion of imaginative entrepreneurial products designed to address the problem. for example. The resulting activities. 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. The quest to balance pleasure through moderation and self-control was brought about through following a ‘style of life’ (Petersen 1997). Coalitions of expertise on obesity have proliferated taking the place of central governments in providing expert opinion on the changing rates. The problematisation of body size has required even greater levels of self or ethical evaluation. 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). while encouraging the development of effective policies for prevention and management. provides a field of self-surveillance for both obese and non-obese subjects within the new fields of non-infectious diseases. growing pockets of cynicism and resistance are evident in a number of areas. The DMC represents an amalgamation of compatible interests such as scientists. the size acceptance movement constructs the problem of overweight as itself a ‘problem’: one where there is a pre-occupation with thinness (Sobal 1999). the food industry in Australia collaborates with government to fund surveys on children’s eating habits (CSIRO 2006). Marketing opportunities are opened up through collection of data when. a social acceptance of the personal choice to stay fat might be a long way off. 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. Growing mountains of flesh – for which no easy or immediate dietary cure or curtailment is available – is of course. researchers and practitioners with the aim to improve global health by promoting the understanding of obesity through research and dialogue. and communication specialists. 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’. 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). fatness is an everpresent health hazard. never only a health problem. For example. often as publicprivate partnerships. 3. Given Western history and the enduring legacy of puritanical systems of thought (Leichter 2003). For modern subjects we can see a new dietetics emerging. like obesity. new problem definitions and new solutions. the International Association for the Study of Obesity has brought together a range of policy makers. August 2008 HEALTH SOCIOLOGY REVIEW 209 . 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). For example. and where pedometers measure the distance individuals covered in a day. It is one where physical activity is commodified through home gyms and treadmills. Given that the causes are believed to be integral to modern lifestyles – normal eating. The government of the self by oneself (a relationship Foucault (1986) calls rapports a soi). Issue 2. A new specification of the subject: The fatness problem has opened up new opportunities to problematise everyday life. Food and eating are always moral problems (Belasco 1997). living and playing – the opportunities for self-appraisal in the midst of ‘just doing ordinary life’ becomes overwhelming. policy makers.The government of girth of decentralised agencies and organisations often with quasi-governmental status. And we should note that while the problem of overweight is mostly taken seriously. And we must not believe that the public Volume 17. Indeed. Mass information distributed through a multiplicity of media sources provides the constant reminder that for adults and children alike. food companies. set the agenda for what is regarded as appropriate business in nutrition. And it is one where body weight is monitored by bathroom scales that ‘speak your weight’ or even calculate individual body fat.
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