The Imperative of Health: Public Health and the Regulated Body

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Deborah Lupton

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    Acknowledgements

    I am grateful to the University of Western Sydney, Nepean, for providing me with a grant allowing release from some of my usual teaching duties in second semester 1994 to assist in the completion of this book. I thank the two anonymous reviewers of the penultimate draft of the book for their helpful critical comments. Thanks are due too to Gamini Colless for his continuing support of my work.

    Parts of my article ‘Risk as moral danger: the social and political functions of risk discourse in public health’ published in the International Journal of Health Services, 1993, 23(3), 425–35, are reproduced in Chapter 3. Chapter 4 and 5 include reworked excerpts from another of my articles, ‘Consumerism, commodity culture and health promotion’ which was published in Health Promotion International, 1994, 9(2), 111–18.

  • Conclusion

    Throughout this book I have sought to problematize the taken-for-granted nature of health promotion discourses. I have attempted to demonstrate that public health and health promotion act as apparatuses of moral regulation, serving to draw distinctions between ‘civilized’ and ‘uncivilized’ behaviour, to privilege a version of subjectivity that incorporates rationality, to promote notions of the human body as separate from the mind/ will, needful of careful management and control and to represent certain social groups as uncontrolled, and therefore, the threatening Other. However I have also argued that these governmental texts, discourses and practices should not simply be regarded as means of brainwashing, oppression or indoctrination, but as the sites of struggle and the constant renegotiation of meaning, subjectivity and bodily practices. Indeed, as I have shown, the imperatives of public health and health promotion may also be considered both sources of pleasure in themselves and incitements of the ‘sins’ they seek to control. As I have observed in earlier chapters, in health promotional discourses the privileging of rationality may be viewed as an attempt to suppress the disorderly aspects of human nature, as well as those threatened by disease and illness states and death, to deny the body, to project anxieties about contamination and dirt onto marginalized groups. Yet the continued attempts to suppress the body only serve to reincite desire and highlight embodiment. As the psychoanalytic perspective argues, rationality and irrationality are in a dialectical relationship; each could not exist without the other. Indeed, the quest for rationality itself emerging from the Enlightenment could be described as an irrational fantasy of mastery and domination, an expression of the desire for a perfectly ordered universe (Sofia, 1993: 26). Hence the ultimate irrationality and perverse nature of rationality as it is expressed in public health and other governmental sites.

    I began this book by discussing the importance of reflexivity on the part of researchers and practitioners in the fields of public health and health promotion. I argued that the adoption of socio-cultural theory and critique encourages workers and researchers to devote more attention to the epistemological and ontological aspects of their endeavours. Their ability to question the practices, knowledges and belief systems of public health and health promotion, including their own privileging of ‘health’, ‘knowledge’ and ‘rationality’, needs to be fostered. The critical analysis of discourse encourages practitioners and researchers constantly to be reflexive and to confront the political dimension of their own use of language and discourse, including their truth claims, as part of their professional activities. Such praxis should include not only analysing the discriminatory or stereotyping characteristics of discourses and practices and interrogating their normalizing assumptions, but also highlighting the multiple and alternative forms of subjectivity, rationality and bodily practices that are available in the dispersed and contested sites of governmentality. Questioning the dualisms, or binary oppositions, that dominate meaning is an important aspect of the critical awareness of language and discourse. For example, as shown throughout this book, the insistence on discriminating between men/women, the masculine/the feminine, moral/depraved, well/ ill, controlled/chaotic, active/passive, Self/Other and disciplined/unruly has been central to medical and public health discourses and remains so. Such essentialisms are too reductive, failing to recognize the plurality of difference that exists in the social world.

    One approach to develop reflexivity is the use of writing tasks to encourage individuals to explore the conditions of their own lives in the context of broader power relations. Writing narratives or stories and reading them ‘across and against each other’ is a means of laying bare the socio-political nature of the construction of individual lives and allows for the possibility of ‘rewriting’ stories (Game, 1991: 47–8). There are strong possibilities here for the manner in which health promoters and educators and other public health workers might be trained themselves, and in turn learn to train others in different ‘ways of seeing’. Fox (1993: 114–15) describes a postgraduate programme at a British university training individuals in the caring professions (including health workers) which uses ficto-critical writing as a means of encouraging reflexive thought on work practices. The participants write fictional accounts based on issues in their lives, past or present, on a topic decided by the group each week. They then read their writing aloud and discuss them in a small group setting. The use of fiction is to enable participants to write about potentially sensitive or embarrassing issues without feeling as if they are exposing themselves. Sociological writing and practices are themselves challenged by this approach, including questions concerning the nature of knowledge and theorizing, and the dialectic between subjectivity and the social collective.

    Students and practitioners may also be encouraged to engage in media analysis, discourse analysis and other methods of revealing the ways in which knowledges and truths are created and power relations reproduced through language and discourse. For example, the AIDS cultural activist and academic Cindy Patton (1990: 158–9) has described her strategies for teaching about AIDS at the tertiary level, involving encouraging discussion on the political nature of ‘facts’ and how they make a difference to people's experiences and concerns, comparing different genres of writing about and visually portraying AIDS, from New Right pamphlets and government policy documents to novels and plays about living with AIDS, inviting outside speakers who can provide a number of different perspectives on the epidemic, from hospice workers to lawyers, and teaching ‘practical deconstruction’, or reading texts such as pamphlets, media reports, everyday conversations and medical literature for their discursive practices. She gives as an example the interrogation of the term ‘emergency’ to describe the AIDS epidemic. Patton looks at whose interests are served by describing the epidemic as an ‘emergency’, the ways in which this discursive choice implicates certain public health laws, invokes issues of blame, quarantine and the policing of marginalized groups. She and her students pursue discourses related to ‘emergency’, including gender, post-colonial social organization, definitions of ‘public’ and ‘health’ and who is empowered to make such definitions (1990: 107–8; see also Grover, 1992; Lupton, 1994c).

    The process of interrogating a text, of laying bare its discursive and ideological dimensions, may create resistant readings which may ‘disarticulate to one extent or another the intertextual articulation of a text’ (Fairclough, 1992: 136). An example of a ‘demystification’ of a commodity through such a critical interrogation of discourse and representation is that conducted by Klein in his book Cigarettes are Sublime (discussed in Chapter 5). According to Klein (1993: ix), one of the purposes of writing his psychoanalytically informed work on the sublime nature of the cigarette and smoking (which process he dubs ‘fumo-analysis’) was to acquire another perspective on the satisfactions that smoking provides. He argues that attempts to elucidate the smoking experience will provide smokers with a new perspective on their habit, perhaps disenthralling cigarettes by removing the mystique around them, and thus stripping them of their very attractiveness (1993: 2–3). Klein himself had written his book as a (successful) strategy for giving up smoking, and therefore describes his work as ‘both an ode and an elegy to cigarettes’ (1993: 3).

    It is important to bear in mind that such pedagogical processes have themselves the potential to be confining and authoritarian, perpetuating rather than challenging relations of power. Donald (1992: 142–3) points to the paradox in teaching people to be autonomous and ‘think for themselves’; in doing so, one is directing them to behave in certain ways, thus restricting their autonomy (see also Lather, 1991: 101). This dilemma, I believe, does not negate attempts to demystify the taken-for-granted nature of public health and health promotion, to expose their epistemological bases, to construct alternative positions, viewpoints and knowledges with the awareness of their nature as cultural practices. To disrupt the confining nature of the types of subjects and bodies offered by public health and health promotion, it is necessary to realize their contingent, constantly moving and dispersed nature, to acknowledge that ‘positions of resistance can never be established once and for all. They must, instead, be perpetually refashioned to address adequately the shifting conditions and circumstances that ground them’ (Lather, 1991: 100). The point is not to seek a certain ‘truth’, but to uncover the varieties of truth that operate, to highlight the nature of truth as transitory and political and the position of subjects as inevitably fragmentary and contradictory. If it is acknowledged that discourse formations and subject positions are not bounded systems, but are open to dispersal, contradiction, contestation and opposition, then the opportunity to construct alternative discourses and subject positions is facilitated. Public health and health promotion become recognized as institutions that reproduce accepted understandings of truth and certain versions of the subject within specific historical and social conditions.

    There may seem to be a certain lack of security and order in this approach to subjectivity and the social world, particularly in this post-Enlightenment age, when individuals are acculturated to accept the notion of the unified self as the ideal towards which they should strive. But ontological uncertainty, ambivalence and fragmentation need not be negative. As Smart (1993: 103) has asserted, ‘[t]he prospect of living without certainty or necessity may cause us to respond with fear, anxiety, and insecurity, but equally it allows us to live with imagination and responsibility … it constitutes a site, space, or clearing for political possibilities, rather than a distinctive political strategy’. He (1993: 103–6) argues that this perspective allows individuals to assume responsibility with others for their shaping of their destiny, rather than accepting fate, providing a space for the acknowledgment of differences and diversity, new ways of relating, new forms of experience and the social. As this suggests, the ‘resistance’ emerging from such processes of interrogation need not be confined to the micro-level. Individual recognition of the processes by which one's own subjectivity is shaped through the discursive practices and regulatory activities of institutions such as public health and health promotion in ways that are often confining and discriminatory, if articulated and shared by others may lead to collective action that seeks to contest taken-for-granted imperatives and strategies.

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