The New Public Health: Health and Self in the Age of Risk

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Alan Petersen & Deborah Lupton

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    Acknowledgments

    This book was made possible with the assistance and support of many people and institutions. Alan would like to thank Andrew Lyon (Coordinator, Glasgow Healthy City Project), Ruth Stern (Coordinator, Camden Healthy Cities Project), Julie Taylor (Coordinator, Liverpool Healthy City 2000), Dr Greg Goldstein (WHO, Geneva), Heather McDonald (WHO, Geneva), Stephen Barton (Faculty of Health Sciences, Flinders University of South Australia), Antoinette Ackermann, and Linda Petersen and staff at the Healthy Cities Project Office in Copenhagen for giving willingly of their time and for providing items of information on the Healthy Cities project. He would particularly like to acknowledge the generosity and support of Dr Margaret Reid and the Department of Public Health at the University of Glasgow for allowing him the opportunity to share some of his early ideas with others at the Lilybank Seminar and for providing office space during the period of his stay in Glasgow. Lynne Hunt, of Edith Cowan University, Western Australia, introduced him to Margaret, for which he is grateful.

    Alan would also like to thank the following people with whom he discussed aspects of the work while in the UK in 1995: Dr Robin Bunton, Dr Lesley Jones, Dr Sarah Nettleton, Roger Burrows, Dr David Armstrong, Professor Nikolas Rose, Dr Ade Keans, Jill Russell, Dr Graham Hart and Dr Simon Carter. Closer to home, he would like to thank everyone in the Sociology Program, Murdoch University, Western Australia, for providing such a supportive and stimulating environment; Associate Professor Patricia Harris for reading and offering feedback on his earlier draft chapters (the usual disclaimer applies); Dr Charles Waddell (Department of Anthropology, University of Western Australia) for his constant encouragement; and Murdoch University, which funded a period of study leave in which he was able to undertake research and meet the above people. Finally, he would like to thank Ros Porter, who has accompanied him on his journeys and has been a constant source of support.

    Deborah thanks her previous place of work, the University of Western Sydney, Nepean, for granting study leave for the first semester of the 1995 academic year, during part of which she wrote the first drafts of her chapters. She also thanks Gamini Colless for his continuing support of her work. We both thank Elizabeth Weiss from Allen & Unwin for her guidance on this project.

    Both authors contributed in equal measure to this book. Alan wrote Chapters 5 and 6 and most of Chapter 1 and Deborah wrote Chapters 2, 3 and 4, with each of us editing drafts of the other's work. The Introduction and Conclusion are joint efforts.

    Introduction

    ‘Lose weight!’ ‘Avoid fat!’ ‘Stop smoking!’ ‘Reduce alcohol intake!’ ‘Get fit!’ ‘Practise safe sex!’ ‘Play safe!’ In contemporary Western societies the health status and vulnerability of the body are central themes of existence. Individuals are expected to take responsibility for the care of their bodies and to limit their potential to harm others through taking up various preventive actions. Increasingly they are also expected, as part of their responsibilities of citizenship, to manage their own relationship to the risks of the environment, which are seen to be everywhere and in everything. With the emergence of concerns about ecological crisis, we have all been forced to confront the global nature of threats to both self and society and to consider what we, individually, can do to protect our health and that of our fellow citizens. Everyone is being called upon to play their part in creating a ‘healthier’, more ‘ecologically sustainable’ environment through attention to ‘lifestyle’ and involvement in various collective and collaborative endeavours. All these concerns, expectations and projects come together in, and are articulated through, an area of expert knowledge and action that has come to be known as ‘the new public health’.

    The new public health takes as its foci the categories of ‘population’ and ‘the environment’, conceived of in their widest sense to include psychological, social and physical elements. With the development of this perspective, few areas of personal and social life remain immune to scrutiny and regulation of some kind. Given the scope of the new public health, and its impact on virtually all aspects of everyday life, there has been surprisingly little critical analysis of its underlying philosophies and its practices. The new public health has been warmly embraced by people of diverse backgrounds and political persuasions. It has been represented as the antidote to all kinds of problems linked to modern life, particularly problems of the urban milieu. The uncritical acceptance of the basic tenets of the new public health is disturbing in light of the increased potential for experts to intervene in private lives and for established rights to be undermined. We suggest that this reticence is in itself indicative of the power of the discourse of the new public health to shape public opinion. In this book, we highlight what we believe are some important dimensions of the new public health and critically appraise their implications for concepts of self, embodiment and citizenship.

    Although the sociology of medicine, health and illness is a burgeoning field, and has been so for some time, very few sociocultural analyses of public health have been published (recent exceptions include Bunton et al. 1995; Lupton 1995; Petersen 1996). Sociologists working in public health areas have generally taken a consensual view of public health, engaging in a type of ‘social epidemiology’ in gathering data on people's health-related practices, beliefs and behaviours; or they have adopted an interpretive phenomenological approach, seeking to identify the ‘authentic’ lived experience of health and illness. These approaches therefore tend to work within the goals and discourses of new public health, servicing it rather than challenging it. While numerous Marxist and feminist critiques of public health have appeared over the past two decades or so, they have generally focused on specific aspects such as deficiencies in the provision of preventive services for underprivileged social groups, or the ‘victimblaming’ approach in health education. Little attention has been paid to analysing the fundamental principles, discourses and practices of public health from an epistemological position, or to exploring public health as a sociocultural practice and a set of contingent knowledges. While we would not argue that other types of research should necessarily be cast aside by sociologists, we maintain that there is room for a more theoretically informed perspective on contemporary public health.

    Over the past decade or so, there has been an upheaval in the humanitie and social sciences instigated by the adoption of poststructuralist theory. In its emphasis on the ways in which language, knowledge and power interact to construct and reproduce our way of experiencing our selves, our bodies and the social and material worlds, poststructuralist theory has challenged many of the assumptions about truth and knowledge previously held dear by scholars and researchers in the humanities and social sciences. No area of study, whether it be sociology, psychology, education, philosophy, cultural studies, geography, literary studies, history or anthropology, has remained impervious to this challenge. Indeed, these recent developments in sociocultural theory have blurred the boundaries between the disciplines. All of the above fields now include scholarship into the construction of knowledge and experience in the context of power relations. Such concepts as discourse, embodiment, spatiality and subjectivity are now ubiquitous in writings on humanity, culture and social life.

    Despite the enormous influence of poststructuralist thought on the humanities and social sciences, the fields of academic inquiry and practice that have traditionally focused on the health of the human body—medicine, nursing and public health—have remained relatively impervious. This is due in no small part to the traditional exclusion from medicine, nursing and public health of the perspectives offered on embodiment, health and disease by the humanities and social sciences. These fields have tended to present themselves as scientific disciplines, built upon an objective knowledge base unsullied by questions of power. Medical and nursing students, therefore, have traditionally spent most of their time studying such subjects as anatomy, biochemistry and physiology, which represent the human body as an atomised collection of chemical and physical relationships—little time has been given over in the curriculum to exploring the body in its sociocultural, political and historical contexts. Similarly, students of public health, their gaze diverted from the human body as a single entity to human bodies in groups, have traditionally been trained in the rationalised, quantifiable techniques of epidemiology, biostatistics, health promotion, health economics and demography; again, they are given little time to explore the sociological or cultural dimension of public health. In the health sciences, the perspectives offered by the humanities and social sciences, poststructuralist or otherwise, have been frequently marginalised, at best treated as ‘add-ons’ to an already crowded curriculum (Lupton 1993; Petersen & Winkler 1992).

    We decided to collaborate in the writing of this book after discovering our common interests and perspectives in relation to the social and cultural aspects of public health. Although this book is a joint effort, it complements and extends ideas we originally developed independently elsewhere, especially in our books, The Imperative of Health: Public Health and the Regulated Body (Lupton 1995) and In a Critical Condition: Health and Power Relations in Australia (Petersen 1994). These previous books share similar concerns, and to some extent, similar theoretical approaches, with the present book. The Imperative of Health, while adopting a poststructuralist analysis similar to the one presented here, was primarily focused on the historical antecedents of public health and the strategy of health promotion, whereas In a Critical Condition covered a far broader range of topics in less detail than the present analysis. We therefore see this joint work as both complementing and extending our previous writings by focusing on a particular range of discourses and strategies supporting the ideals of ‘the new public health’ that we had not examined in detail in the past.

    In this book we demonstrate the ways in which contemporary sociocultural theory throws light upon the new public health as a domain of knowledge and an arena of practice. We explore how new public health knowledges and practices are constructed and reproduced and examine certain dominant assumptions that underpin them. In particular, we focus upon the new public health as a new morality system in ever-more secularised Western societies, a means of establishing a set of moral tenets based on such oppositions as healthy/diseased, self/other, controlled/unruly, masculine/feminine, nature/culture, civilised/grotesque, clean/dirty, inside/outside and rational/emotional. A number of themes run throughout the book. These include the importance of risk as a sociocultural concept in the new public health discourses and practices; the reliance upon the ‘rationality’ and ‘objectivity’ of science to contain disorder that pervades public health; the representation of the human body, the subject and social groups within the new public health; the notion of citizenship as it is constructed through new public health objectives and discourses; and the effects on the new public health of the globalising tendencies of modern societies.

    Our analysis begins in Chapter 1 with the recognition of the fact that the new public health is at its core a moral enterprise, in that it involves prescriptions about how we should live our lives individually and collectively. Although professional experts justify their interventions in the name of objective, ‘disinterested’ science, they selectively order knowledge in such a way that some categories and some utterances and actions are privileged above others, and therefore seem more natural and logical. As we explain in this chapter, belief in the powers of science, in progress through science, and in rational administrative solutions to problems is central to the post-Enlightenment modernist tradition and finds expression in the philosophies and practices of the new public health. Much of our critical analysis is, therefore, oriented to the new public health as a modernist project. Following Michel Foucault, we contend that in modern societies power operates not so much through repression, violence, direct coercion or blatant control as through the creation of expert knowledges about human beings and societies, which serve to channel or constrain thinking and action. Expertise plays a crucial role in modern systems of power through the creation of knowledge about the ‘normal’ human subject. The notion of repression implies the use of naked force to coerce subjects into adopting some officially defined line of action. It is clear, however, that in modern societies power operates largely through a diffuse and diverse array of sites, utilising the agency of subjects so that they largely govern themselves voluntarily as particular kinds of persons. In the public health arena, experts have assisted in this process of self-governance through the advice they offer and through seeking to promote social institutions that facilitate ‘healthy’ choices. The area of citizen rights and responsibilities is an important terrain in the playing-out of these relations of power and knowledge, and can be seen to reflect changing relations of power in modern societies.

    In the following chapters, then, we examine different aspects of the new public health in terms of citizen rights and implied reciprocal responsibilities and obligations. We draw particular attention to the recent emergence of the concept of the entrepreneurial self; that is, the self who is expected to live life in a prudent, calculating way, and to be ever-vigilant of risks. This concept of self, we explain, has appeared during a period of retreat from welfare interventionism and of reaffirmation of the importance of ‘markets’ as regulators of economic activity. The entrepreneurial self is the product and target of ‘neo-liberal’ forms of rule that employ technologies for ‘governing at a distance’ by seeking to create localities, entities and persons able to operate a regulated freedom. With the rise of ‘neo-liberalism’, the concept of rights, which largely took shape during the ascendancy of the welfare state, begins to appear rather limited, and flimsy at that. With the development of a ‘duties discourse’ in parallel with the ‘rights discourse’, citizens are assigned a whole range of new reciprocal responsibilities and obligations which require something of a superhuman effort to fulfil. As we point out at various points in our discussion, being a ‘healthy’, ‘responsible’ citizen entails diligence, self-control and hard work.

    Chapter 2 focuses on epidemiology as it has been applied to pursue the objectives of the new public health. Epidemiological knowledge has played a key role in the construction of ‘truth’ about disease, risk factors, and categories of ‘at risk’ subjects. Further, epidemiologists have worked closely with the public health establishment in the effort to persuade people to make changes to their lifestyles so as to reduce risk at the population level. The development of national ‘goals and targets’ that has underpinned public health planning in a number of Western societies would not be possible without the contributions of epidemiological researchers. Given its close alignment with policy processes, it is surprising that epidemiology as a discipline has remained generally impervious to the type of critical scrutiny to which other sciences have been treated by sociologists of science. Epidemiology's pride of place within the public health establishment can be explained by the post-Enlightenment belief in the scientific theory of causation and in the ability to ultimately control problems through rational administrative control. Although epidemiology has a hallowed role in the new public health, its ‘facts’ are frequently disputed, both by experts and non-experts. Experts may disagree about the interpretations of findings and may be cautious in offering recommendations. Non-experts have their own lay understandings (‘lay epidemiology’) of health risks that may conflict with, and override, established scientific evaluations of risk. Chapter 2 explores these complexities, and highlights some implications for those who are the subjects of as well as subject to epidemiological knowledge.

    Chapter 3 goes on to explore and critique the use of the discourse of citizenship in the new public health, pointing to the complexities and difficulties of adopting the notion of the ‘healthy’ citizen. As we emphasise in this chapter, ‘health’ has come to be used as a kind of shorthand for signifying the capacity of the modern self to be transformed through the deployment of various ‘rationa’ practices of the self. Health is viewed as an unstable property, something to be constantly worked on. It is in the process of working on the self, and of demonstrating the capacity for self-control of the body and its emotions, that one constitutes oneself as a dutiful citizen, and hence as governable. Although the discourses of neo-liberalism might lead us to believe that private life is inviolable in that we have complete personal ‘freedom’ in choosing health-promoting behaviours, the range and kinds of practices we take up and adapt are, in the final analysis, suggested or imposed by the broader sociocultural and political context. Public health knowledges hold a privileged status as providing the ‘truth’ of health-promoting practices. The discourses of the new public health are deeply gendered, although this tends to be obscured by neo-liberal discourse which operates with reference to a disembodied, and therefore non-gendered, subject. As we point out in this chapter, women and men are positioned differently in relation to the discourse of ‘healthy’ citizenship and this has implications for how women and men experience their bodies.

    Chapter 4 examines the multiple meanings of the concepts of ‘the environment’ and risk which have become central to the discourses of the new public health. In new public health discussions, ‘the environment’ and ‘nature’ are referred to as though their meanings were not contentious. However, as we show, both ‘the environment’ and ‘nature’ are shifting categories, inevitably reflecting assumptions about society and about human subjects. We examine these assumptions and spell out some implications of the broadening of the concept of ‘the environment’ in the new public health for self and citizenship. The concept of risk looms large in the contemporary period of heightened consciousness of the threats posed by ‘the environment’. Risks are increasingly seen to be of a global dimension, and public health experts and environmentalists have turned their attentions to ‘saving the “sick planet”’. In this endeavour, the city has become an increasingly important site for intervention. The modern city is seen as distorting the ‘true nature’ of humanity, and its spaces and places have become sites for controlling pathology. Contemporary concerns about the city and its spaces in certain respects represent a return to nineteenth-century understandings of the link between urban conditions and health status. As we show, however, the broad concept of ‘the environment’ has taken concerns far beyond the control of odour and dirt to the examination of the psychosomatic effects of urban life.

    In Chapter 5 we turn our attention to the concept of the ‘healthy’ city which is gaining increasing currency within the discourses of the new public health. This chapter picks up and develops in more detail a number of the themes introduced in earlier chapters, in particular the influence of modernist concepts on new public health thinking and action; the focus on ‘the environment’, and particularly environmental risk; an emphasis on active and individual citizenship; and the tendency to pathologise certain city spaces and places through their identification as sites of risk. The Healthy Cities project of the World Health Organization (WHO), described by its proponents as the ‘local expression of the new public health’, reflects many of the concerns about the ‘healthy’ city, and provides a major focus for our discussion in this chapter. However, as we point out, the development of the Healthy Cities project gives only a partial indication of the popularity of the concept of the ‘healthy’ city. Many cities that are not formally part of the WHO project have adopted core principles of the new public health and are linked to one another via national and international ‘networks’ of Healthy Cities. We describe the context of concerns about the ‘healthy’ city, namely the problem of managing ‘eco-crisis’. As we show, the ‘healthy’ city exhibits quintessentially post-Enlightenment modernist features, such as the concern with rational planning, the control of space, and the use of organic and scientific metaphors in descriptions of city functioning. Thus far there has been little critical reflection in the new public health on the concept of the city and on the political strategies deployed in advancing the ideals of the ‘healthy’ city.

    In Chapter 6 we critically appraise the notion of ‘community participation’, seen by many as definitive of the new public health. Again, we focus on the Healthy Cities project since, in new public health rhetoric, Healthy Cities provides a key means for realising the ideals of active citizenship and ‘community participation’. For citizens, ‘participation’ has become not simply a right but a duty. In the discourse of neo-liberal democracy, participation is taken as a prerequisite of the fully democratic society. However, in the light of many criticisms by groups who have been excluded from participation, and of attacks on established rights during a period of state retreat from welfare, the meaning and utility of this concept need to be questioned. In this chapter, we draw attention to the personal and interpersonal demands and responsibilities required of those who are called upon to conform to the participatory ideal, and make some critical observations on the concept of community. There is now an extensive body of feminist and other literature critiquing the concept of ‘community’, yet the term continues to be used in public health as though its meanings and implications were unproblematic. ‘Community’ tends to be used in an overly restrictive way, with the emphasis on place (the ‘neighbourhood’) as the basis for identity. The effect of this is to deny the importance of other non place-based identities that cut across, and may even conflict with, place-based affiliations. We show how this place-based definition operates to ‘fix’ identity and to exclude those who are deemed not to be members of the ‘community’. The chapter concludes by calling for a critical scrutiny of the discourse of liberation for its unacknowledged implications and its constraining and often coercive and discriminatory effects.

    In the Conclusion we draw attention again to the central themes of the book, particularly the way that the new public health, almost in spite of its own rhetoric and objectives, continues to rely upon a traditionally modernist, science-based approach to dealing with health issues. This approach, we argue, perpetuates standard binary oppositions that serve to cast moral judgments of blame upon certain social groups, just as did nineteenth-century public health. These moral distinctions, we argue, have important material effects, including discrimination and the limiting of access to resources such as health care. We end the book by reflecting upon the ways in which individuals working in or researching the domain of the new public health may seek to find alternative approaches that may avoid some of the limiting, stigmatising and judgmental tendencies we have here identified.

  • Conclusion

    In this book we have analysed a number of discourses, practices, strategies and assumptions central to ‘the new public health’, seeking to show how they are located within certain ways of seeing subjectivity, embodiment, and the material and social world. A strong theme emerging from the discussions in this book is the manifold ways in which the new public health is directed, overtly or covertly, towards the ‘making up’ of specific kinds of individuals. We began our discussion by noting that the new public health is at its core a moral enterprise that involves prescriptions about how we should live our lives and conduct our bodies, both individually and collectively. The new public health contributes towards understandings of citizenship and communities, and of the relationship of individuals to other humans, other living things and the non-living world. We have also drawn attention to the dominant concept of ‘risk’ and how it is phrased as a property of individuals or as an external threat, and emphasised the importance of risk for the ontology and conduct of selves and bodies. We have addressed the central role played by concepts of place and space in the new public health discourses, particularly in relation to notions of the ‘healthy city’, the ‘community’ and ‘the environment’. We have further shown how certain social groups—the poor, the working class, women, gay men and lesbians, non-Europeans—and geographical locations—for example, the city, the slums, working-class areas, the continent of Africa—have historically been designated in Western societies as the contaminating ‘other’, against which public health measures are undertaken. Despite its rhetoric of egalitarianism, the new public health continues this routine of distinguishing between ‘clean’ or ‘safe’ and ‘dirty’ or ‘risky’ places and people. The central monitoring strategies of the new public Health—epidemiology, statistical surveys, and the calculation and attribution of risk—serve to define and delimit notions of ‘normality’ and ‘pathology’ for both groups and individuals.

    Many people have thrown their support behind the new public health because they are genuinely concerned about such issues as inequalities in health, lack of access to health care services, the constraints of bureaucracy, professional dominance, the limits of biomedicine, and environmental degradation, and are seeking an alternative vision of a ‘healthier’, ‘more sustainable’ society and ecosystem. Part of the broad appeal of the new public health is undoubtedly due to its adoption of a language of ‘empowerment’ and a rhetoric advocating social and environmental change. We have argued, however, that the moral and political implications of the new public health apparatus tend to be obscured by a post-Enlightenment modernist discourse that emphasises the role of science and rationality in social progress and the liberation of the human condition. The arguments and evidence presented in this book indicate the need for a more critical appraisal of the new public health, whose agenda has been largely set by professional experts and is closely aligned with official objectives. New public health knowledges and related practices have implications that may not be in accordance with what its supporters envisage.

    One central tension emerging from our sociological analysis of the new public health is the relationship between the state and the individual. Although much of the apparatus of the new public health is invested in state-funded and state-run organisations, particularly within local and federal bureaucracies, it is clear that the discourses of the new public health seek constantly to shift the responsibility of the state for protecting the public's health from the state to members of the public themselves. This shift, as we have argued, is supported by the neo-liberal humanist philosophies held by governments in contemporary Western societies. While new public health authorities and agencies continue to adopt overtly coercive strategies such as quarantine, isolation and enforced medical treatment when they seem required and most justified (such as in the face of a serious epidemic of infectious disease), they are equally, if not more, reliant upon the use of strategies that position citizens as acting of their own free will and in their own interests to protect their own health. These discourses are particularly articulated in the goals and practices of health promotion and community participation. Discourses of personal responsibility and good citizenship have potentially great appeal to the late modern subject, who has been acculturated to accept and privilege the notion of autonomous individuality, not simply through health-related discourses and institutions but also through such institutions as the family, the mass media, and the education and legal systems. As a result, the new public health philosophies tend to make eminent ‘sense’ because of their emphasis on people participating in activities to improve their own health status. It is for this reason, among others, that the new public health philosophies, discourses and strategies have been little challenged thus far.

    We have argued, however, that the strategies of self-care that have become central to the philosophy of public health can lead to a narcissistic preoccupation with the self. The notion that individuals should conduct themselves like an enterprise implies that they should be in competition with others and seek to maximise their own potential even when, as is invariably the case, this is at the expense of others who are less able or less willing to conform to dominant sociocultural norms. A strong emphasis on the ethic of self care would seem to be directly at odds with the stated ideals in the new public health of nurturing social support, redressing inequality, and creating a tolerant, democratic polity. It can serve to divert attention from increasing inequalities in wealth and power and from attacks on established rights during a period of retreat from welfare provision. Although the development of a new duties discourse implies empathy and concern for fellow citizens and ‘the environment’, it is not clear how this can be reconciled with competitive individualism and entrepreneurial ideals.

    Science itself has been directly implicated in systems of domination and there is now abundant research, particularly from feminist perspectives, that analyses the ways in which science reinforces inequalities in power and knowledge at the local and global levels (see, for example, Harding 1986; Haraway 1991; Braidotti et al. 1994). This work highlights the role of underlying dualisms—subject/object, mind/body, male/female, nature/culture, truth/falsity, public/private, clean/dirty, and so on—in sustaining relations of power through processes of exclusion and hierarchical ordering. In the view of Braidotti et al.,

    Dualism, in the masculinist hegemonic thinking that marks the production of Western science, is a system of exclusion of ‘others’ from patriarchal subjectivity. The very definition of ‘the scientific mind’ is coterminous with rationality, masculinity and power. The scientist as model for the subject of knowledge is therefore defined in a set of hierarchical relations to others: the non-scientists. Feminists have criticized scientific discourse as an account of the world that systematically devalues every category that is ‘other’ than the male, Western, bourgeois self: women, children, other races, foreign cultures, lower classes, handicapped people and nature. (1994, p. 31)

    As Braidotti et al. point out, the dualistic ordering of reality affects individuals' sense of their identity and of their place in the world, whether they are men or women. It is a hierarchical ordering that gives priority to male over female, mind over body, culture over nature, subject over object, and so on. The principles of hierarchy, domination and control are deeply inscribed in Western thinking, yet are made to appear ‘normal’, ‘natural’, and altogether neutral (Braidotti et al. 1994, p. 30).

    This important work has so far made little impact on mainstream public health thinking about how problems might be constituted, conceptualised and solved. We have emphasised the continuing belief in the power of science, in social progress through science, and in the rational control of problems as they are evident in the discourses and strategies of the new public health, at many points in our discussion. Belief in science is manifest in the use of metaphors such as those applied in descriptions of the ‘healthy’ city (Chapter 5), in the rational ordering of space (Chapters 2, 4, 5 and 6), in theories of disease aetiology and in the calculation of risk (Chapters 2, 3 and 4). As we have suggested, the use of natural metaphors in the government of the social has a long history in modernist discourse and has been an important means of setting limits on permissible explanations of the body politic. The idea that social systems are ‘naturally’ harmonious, stable and equilibrant denies conflict and power relations and serves to ‘naturalise’ inequality. A questioning of science must entail consideration of how science presently operates within existing systems of power to ‘normalise’ certain patterns of action and systems of thought, such that they appear self-evident, given and therefore beyond dispute.

    If the groundwork is to be laid for a society that is more equitable, more tolerant of difference and more likely to protect and ameliorate the health status of individuals, then priority must be given to challenging the dominance of science in social explanation and in the control of problems. We are not arguing that science as a system of knowledge and action should be rejected wholesale. We are simply challenging its position as the most privileged way of approaching social problems, by showing how science works to construct these problems and by seeking to identify its often unintended outcomes. As we have shown, situated or lay knowledges have far less opportunity to compete with privileged science in defining and dealing with public health problems, and this has often meant that lay individuals have felt far less able to challenge ‘expert’ knowledges or to act when they perceive problems to exist. As Wynne (1996) argues, the objectivist discourses and rationales of science are often experienced by lay people as alien and impoverished models of human nature, values and social relations, clashing with people's own lived and embodied experiences, values and localised knowledges.

    The work of Foucault has been of great assistance to those who seek to develop new perspectives on the workings of science in modern systems of governance and on developing ways of utilising, subverting or resisting it. As Foucault (1980) explains, science has been used not simply to ‘explain’ reality, but to produce, control and normalise it. One of the important insights of Foucault's work, and indeed of those scholarly writings that fall under the rubric of ‘poststructuralism’, is in drawing attention to the interrelationship between discourses, knowledges, practices and power relations when conducting sociopolitical analysis and critique. It is important that the representational practices of such hegemonic knowledges as science and medicine be laid open to scrutiny wherever they appear so that their assumptions can be examined for their moral and political effects.

    Poststructuralist theory has also questioned the notions of the unified self and of fixed subject positions that we have identified as central to new public health understandings. Belief in the knowledges of science and medicine is closely tied to faith in the discourse of liberation which, we have argued, should also be opened up to more thorough scrutiny. In our discussion, we drew particular attention to the unexamined implications of the neo-liberal notion of ‘freedom’ which is pegged to a concept of the autonomous, unified and rational subject who approaches life as if it were an enterprise. As we suggested, this is an idealised concept which should be rejected in favour of a view of the self as unstable, multifarious and (at least in part) discursively constructed. The idealisation of the ‘normal’, ‘healthy’ subject as one endowed with certain ‘natural’ capacities and inclinations fails to recognise the multiplicity of possible subject positions, and can serve to coerce, marginalise, stigmatise and discriminate against those who do not or cannot conform with the ideal. This ideal denies difference—whether this is based on social class, gender, sexuality, ‘race’, ethnicity, physical ability, or age—and the kinds of personal commitments and demands that are required of those who are called upon to conform to it. There are real political and material effects that may emerge from the employment of such discourses, including social and economic discrimination, disadvantage and exclusion.

    In Chapter 6 we outlined some of the problems with the notion of a fixed subjectivity in our discussion of ‘community’ As we argued there, reference to a single, shared basis for identity by those seeking to make visible an identity or to press their claims to disadvantage and marginalisation can be strategically useful. One should seek, however, to challenge imposed identities on the grounds that they reinforce intolerance of difference and of diversity. In particular, the assumption that ‘health’ should be a priority for all, and act as a marker of self-control and a criterion for citizenship, should be questioned. We have pointed to some of the exclusions associated with the assumption that everyone should work and live to maximise their health, ‘Healthism’ contributes to a general intolerance of those who are unable or unwilling to subscribe to the dominant sociocultural norms, and it should therefore be challenged. If society is to be tolerant of difference, provide scope for the full expression of all our identities, and offer support for all its members regardless of background, disposition or ability, then the status of this type of knowledge itself must be questioned.

    In our discussions of the ways in which the new public health seeks to construct specific subject positions, we do not argue for a view that sees individuals as passive, manipulated dupes. Whether or not public health strategies are overtly coercive or reliant upon the alignment of individuals' personal objectives, we need to acknowledge the way that individuals often fail to conduct themselves according to the goals of public health. Foucault's reflections on the practices of the self in his later writings suggest that although individuals constitute themselves as subjects in relation to external imperatives, there is a complex relationship between dominant norms and individual behaviour and actions, leaving much room for playful engagement with norms and even for resistance (see, for example, Foucault 1988, 1991). Foucault was interested in the possibilities that this presented for the development of modes of existence that broke with the ‘normalising’ tendencies in contemporary society, particularly the endless examination of one's inner self which he saw as a dominant characteristic of modern society (see Best & Kellner 1991, p. 63; McNay 1992, pp. 63, 86). The idea of one's life as the enterprise of oneself would suggest that there is some degree of open-endedness and indeterminacy at play in the process of privately managing risk. Public health interventions are consequently liable to produce outcomes at variance with what the experts may have intended. Thus, although rules for personal conduct are recommended to the individual by the social context, often issuing forth from dominant institutions such as public health, different contexts provide different degrees of freedom to act and to interpret, negotiate and resist norms: ‘bodies are active creators of new power relations, and sustain individuals in their confrontations with and against systems of power’ (Outram 1989, p. 23). Individuals routinely turn imposed laws, practices and representations to their own ends as a way of ‘making do’ within, and of subverting, the dominant relations of power (de Certeau 1984).

    While there is much evidence of many people's conformity at either the conscious or the unconscious levels to the imperatives of health issuing forth from the state and other sites, it is also clear that people frequently either directly resist these imperatives, ignore them or fail to take them up in favour of other practices of the self. The attempts of public health reformers to enshrine legislation directed at restricting individual freedom has historically been met with opposition on the part of citizens up in arms about a ‘Nanny’ state. At the more mundane level, people's desire to engage in pleasurable or playful activities, such as their continued consumption of tobacco, their refusal to give up favourite foods to lose weight or their choice not to engage in condom use when participating in sexual activities, is evidence of lack of conformity to public health imperatives, despite widespread knowledge and acceptance of these imperatives. Such activities may be conscious floutings of public health advice or may simply represent attempts to construct subjectivity through alternative practices, privileging the pleasures of smoking, for example, over its imputed long-term health effects (see Lupton 1995, Ch. 5 for an expansion of this argument).

    In writing this book we have not sought to prescribe alternatives for the new public health, to construct ways of developing a ‘newer’ (and by implication ‘better’) public health. We have simply attempted to suggest different ways of viewing the rationales and practices of the new public health, seeking a more reflexive way of viewing it through disruption of its taken-for-granted beliefs and approaches. Thus, for example, we have pointed out that attempts to ‘emancipate’ or ‘empower’ marginalised groups through such strategies as community participation, based on humanistic, neo-liberal principles, may be regarded as ever more complex ways of defining, regulating and normalising the members of such groups. As Usher and Edwards assert: ‘Oppression and emancipation are not polar opposites, the one excluding the other… they are co-implicated in ever shifting patterns arising from on-going struggles’ (1994, p. 226). As this suggests, attempts at emancipation, well meaning as they are, often serve to further constrain and disadvantage those individuals to whom they are directed by prescribing specified ways of behaving. Some readers who are engaged as workers in the new public health may decide that in the absence of viable alternatives their activities remain worthwhile, despite the questions we have raised. Nonetheless, the very raising of these questions, we hope, may serve to unsettle some of the often unexamined assumptions prevailing in those who support the new public health initiatives. This may lead to more reflexive practice and ways of engaging with the ‘public’, and to a recognition of the tendency towards totalising statements and judgments and of the uncertainties and contradictions in the area that are often left unacknowledged.

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