The biopolitics of global health: Life and death in neoliberal time

Biopolitics, governmentality, neoliberalism

In his lectures at the Collège de France in 1978–9, French philosopher Michel Foucault proposed to develop a genealogy of his analytic category ‘biopolitics’ (Foucault, 2010). Quickly, though, his analysis turned to liberalism and neoliberalism using ‘governmentality’ as a guiding concept (Foucault, 2010; Lemke, 2001). While this shift is often interpreted as a change in focus, Stephen J. Collier has argued that Foucault’s analyses of biopolitics and liberalism are fundamentally interconnected: Foucault found in liberalism the initial articulation of a ‘new kind of governmental reason that understood individuals and collectivities not as legal subjects (of sovereignty) or docile bodies (of disciplinary power) but as living beings’ (2011: 16). ⁵ Biopolitics, Collier concludes, is neither a form of governmental reason nor a logic of power, but a novel ‘problem-space’ upon which the political reason of liberalism came to bear: a problem-space concerned with the vital characteristics of populations (Collier, 2009, 2011).

Central to Foucault’s analysis of liberalism is the concept of ‘governmentality’. At its core, governmentality encompasses two interrelated ideas. The first is that techniques of power and forms of knowledge are mutually constituted – that they co-determine each other’s existence. This mutual entanglement is captured in Foucault’s use of the term ‘power-knowledge’ but also in his idea of a ‘political rationality’. As Thomas Lemke puts it, ‘a political rationality is not pure, neutral knowledge which simply ‘re-presents’ the governing reality; instead, it itself constitutes the intellectual processing of the reality which political technologies can then tackle’ (2001: 191). ⁶ The implication here is that it is not possible to study any particular technology of power or form of knowledge without also analysing the associated mode of reasoning or governmental technique. The second key idea behind governmentality is that in modern societies ‘government’ does not occur exclusively through the state – although this how the term is frequently used in common speech – but through processes of self-government as well. Thus Foucault defines ‘government’ as encompassing everything from the production of knowledge about living subjects all the way through to the government of the self (Burchell et al., 1991: 2; Foucault, 2009: 191).

While his 1978 lectures traced the genealogy of governmentality back to the Ancient Greeks, in 1979 he turned his attentions to neoliberal governmentality (Foucault, 2010). The neoliberal form, he argued, includes a distinctly American version articulated through the work of a range of Chicago School economists but most centrally by Theodore Schultz and Gary Becker (Schultz, 1961; Becker, 1962). According to Foucault, Chicago-style neoliberalism is characterized by the consistent expansion and application of economic thinking to all spheres of social activity. As he argues, ‘American neo-liberalism seeks … to extend the rationality of the market, the schemas of analysis it offers and the decision-making criteria it suggests, to domains which are not exclusively or not primarily economic: the family and the birth rate, for example, or delinquency and penal policy’ (Foucault, 2010: 323). Instead of seeing the economy as one domain among many, American neoliberalism depends on the application of an economic lens across the entirety of human existence, including the biopolitical domain of the living characteristics of populations. Within a neoliberal political rationality, the primary mode of decipherment of the world, that is, the way that reality, social activity and human action are all rendered both intelligible and governable, is economic. ⁷

This expansion of the economic form holds consequences not just for the objects of neoliberal governmentality but for its subjects as well; for the particular figure of the human that it envisions. Just as all domains of social activity and human life come to be deciphered through an economic lens so too does the individual come to be seen primarily as an economic agent (Foucault, 2010). However, in the neoliberal thought of the Chicago School, human action is not seen as driven by the immediate gains of economic exchange, which had been the case with the homo oeconomicus of classical economics. Instead, the neoliberal vision of rational action incorporates a re-jigged temporality such that future benefits are brought into the present weighting of costs and benefits through a logic of self-investment. The site of self-investment is one’s own human capital, defined by Gary Becker (1962: 9) as consisting of the embodied attributes of individuals that make them economically productive. Instead of the worker of classical economics who sells their abstracted labour for a wage, the agent of human capital invests in their own embodied knowledge, capabilities and, importantly for my argument, their health to secure a future return on investment in the form of an income stream. Social activity is still viewed in economic terms, human behaviour still predicated on cost–benefit calculating rational actors, but under the logic of neoliberalism, homo oeconomicus becomes a future-oriented self-investing entrepreneur of the self, concerned with optimizing the return on investment in his or her own embodied human capital.

Governing the conduct of this neoliberal homo oeconomicus then, consists in altering costs and benefits in such a way as to ‘make rational’ the desired form of future-oriented self-optimizing conduct (Lemke, 2001: 200). Of course, governmental rationalities have always incorporated certain prescriptions for the behaviour of populations, hence the famous definition of governmentality as the ‘conduct of conduct’ (Burchell et al., 1991: 2). What is distinct about neoliberal governmentality is the alignment it achieves between its prescriptions for individual conduct and its prescriptions for minimal state provision. Neoliberalism as a political rationality, then, configures the self as an entrepreneur and the state as a firm, and prescribes the conduct for both according to a logic of optimizing future rates of return on investment, especially through practices of self-investment. In the biopolitical domain, this equates with an emphasis on those (cost–effective) health interventions directed towards encouraging individuals to enact health-maximizing behaviours.

In the sections that follow, I analyse the DALY metric as one instantiation of this neoliberal political rationality. I show how the DALY metric is itself a technology of power that inscribes a neoliberal political rationality into the evidence base of the contemporary global health regime. First, I explain the particular historical context out of which the DALY metric emerged and the problems to which it was proposed as a solution. I then turn to the metric’s technical dimensions to illustrate how DALY calculations not only quantify the global burden of disease, but also accomplish an economization of life. I then discuss in greater detail the political rationality that underpins DALY calculations, focusing on its reconfiguration of life as life/time and the particular figure of the human as homo oeconomicus that it presupposes.

The World Bank and world health

Throughout the 1980s and 1990s, the field of international health was beset by a number of tensions: debate over comprehensive vs. selective primary health care, vertical vs. horizontal approaches to health interventions, and budgetary crisis, as well as crises of legitimacy at the WHO. Against this backdrop, the World Bank ‘moved confidently into the vacuum created by an increasingly ineffective WHO’, marking what has since become recognized as the beginning of the transition from international to global health (Brown et al., 2006: 86). Although the World Bank’s initial interest in health extended only to population control, by the early 1980s the newly founded Population, Health and Nutrition Department began lending for stand-alone alone health programmes on the rationale that enhanced health and nutrition would lead to increased economic growth (World Bank, 1980). However, with World Bank money came their associated structural adjustment policies, which, in the domain of health, focused on more efficient use of available resources and an increased role for the private sector in financing health services. While this approach drew much criticism, it did not stem the influence of the World Bank and by 1990 World Bank lending for health surpassed the entire WHO budget (Brown et al., 2006). From the late 1980s to the late 1990s, World Bank lending for health, nutrition and population projects grew sevenfold, with a growing proportion of these loans made with the explicit intention of reforming the structure of health systems (Fair, 2008). ⁸

The changing structural organization of world health coincided with a shift in the field’s conceptualization of its primary targets due to the ‘epidemiological transition’. In the decades after the Second World War, the attention of development demographers was focused largely on ideas about demographic transition, especially at the nexus of population control, fertility decline and ‘modernization’(Wahlberg, 2007). By the 1980s and early 1990s, considerable interventions had been made into the demographic profiles of many postcolonial nations. Fertility was largely falling and child survival rising (Feachem et al., 1992; Jamison et al., 1993). But this set of successes raised concerns over the coming ‘epidemiological’ or ‘health transition’ (Omran, 1971). A pre-transition environment dominated by high fertility and high mortality was seen to be giving way to a population profile of low mortality and low fertility, with an accompanying shift in disease profile from pandemics of infection to (far more costly) non-communicable diseases. This transition was seen as heralding a new era which would require new ways of knowing and administering the life and health of the global population (Feachem et al., 1992; Jamison and Mosley, 1991; Jamison et al., 1993).

While the health transition held general implications for the orientation of the world health agenda – away from population control and towards diseases of old age – the precise consequences of the transition for the global incidence of disease and preventative health interventions were unknown (Feachem et al., 1992; Frenk et al., 1989; Jamison et al., 1993; Murray and Lopez, 1996a). The World Bank thus undertook a wide-reaching Health Sector Priorities Review that yielded a constellation of studies in descriptive epidemiology, health systems planning and economic forecasting in the hopes of reducing the uncertainty of the impending transition (Jamison et al., 1993; Murray and Lopez, 1996a; World Bank, 1993). The most significant of these studies – the Disease Control Priorities Project (DCPP) and the Global Burden of Disease Study (GBD), served as background papers to the landmark World Development Report 1993: Investing in Health (Jamison et al., 1993; Murray and Lopez, 1996a; World Bank, 1993). Importantly for my purposes here, the World Development Report 1993: Investing in Health (World Bank, 1993) also introduced the DALY metric.

The quantification of health and disease

Although the World Bank’s Health Sector Priorities Review began in the late 1980s, it received renewed attention under Lawrence Summers’ tenure as chief economist of the World Bank beginning in 1991. Head of the Health Nutrition and Population Division of the Bank, US health economist Dean Jamison was then commissioned as lead author of the Investing in Health Report and subsequently recruited fellow US health economist Christopher Murray and Australian statistician Alan Lopez to undertake a study of the incidence of ill health worldwide. The immediate purpose of the study was to discern the ‘global burden of disease’, but the overarching goal was to provide the evidence base necessary to design emerging health systems according to a logic of economic optimization.

To measure the global burden of disease, Murray and Lopez devised an innovative method. They had two aims: to account for the ‘full loss of healthy life’ due to disease, death and disability on a global scale and to create an evidence base for global health priority-setting according to cost–benefit analyses. Previous large-scale studies in descriptive epidemiology used mortality statistics, disease prevalence rates, or risk-of-death calculations to determine the number of deaths due to various diseases (Feachem et al., 1992). In contrast, the DALY metric sought also to account for the impact of diseases and conditions that may not be fatal, but by virtue of their duration and disabling effects contributed to losses in the form of diminished productivity and strain on health systems. ⁹ The DALY metric thus used ‘life-years’ as a smaller unit than calculations of individual human lives and one that could be modified to account for differing degrees of illness severity. ¹⁰

In its simplest presentation the DALY metric ‘expresses years of life lost to premature death and years lived with a disability of specified severity and duration’ (Murray and Lopez, 1996b: 7). That is:

DALYs = YLL + YLD

where YLL are the years of life lost to premature death and YLD are years of life lived with disability. One DALY is equivalent to one year of healthy life lost, either wholly to premature death, or fractionally to disease or to disability. DALYs are a decremental, or health-gap measure, that gauge the loss of health from some imagined ideal state. They are thus a global health bad, something to be added up and hopefully, minimized.

DALYs represent an internationally standardized quantum of life measured as a unit of time, that is, as life-years. Unlike older health statistics, which used either prevalence data or incidence rates to determine aggregate disease incidence, the DALY metric uses time, in either days or years, to render intelligible not just the incidence of death and disease but their relative burden. Unlike vital statistics, which measured life as a coherent unity from birth through adolescence and adulthood until death, DALYs measure the loss of life as the loss of its component units of time. Instead of lifetimes, DALYs measure life/time; life-as-time in the unit of individual life-years. And, unlike mortality statistics, which were difficult to incorporate into cost–benefit calculations without breaking the taboo of putting a dollar figure on life itself, DALYs were designed to facilitate cost–benefit analyses in the units of DALYs gained per dollar spent (Jamison et al., 1993; Murray, 1996; Murray and Lopez, 1996a; World Bank, 1993).

The DALY metric thus disaggregates the temporal coherence of lifetimes into commensurable units of life/time. But DALYs incorporate a reworked temporality in another way too, by purporting to measure in terms of its present value the future impact of life/time units lost to death and disease. According to the initial presentation in the Investing in Health report, DALYs measure ‘the present value of the future stream of disability-free life lost as a result of death, disease, or injury’ (World Bank, 1993: 27). Life is here imagined in distinctly economic terms, as something the essence of which can be captured in terms of its present value, and located in the speculative future. The anticipatory move of determining the present value of future losses of life-years depends on two interrelated steps. First, one must determine the ideal against which death and disease can be measured as losses. As Murray and Lopez put it, ‘Disease burden is, in effect, the gap between a population’s actual health status and some “ideal”, or reference status’ (Murray and Lopez, 1996b: 7). In determining this ideal state of health Murray and Lopez adopted the broadly egalitarian principle that health is a universal good. Only sex and age are taken into account as variables in calculating disease burden; ideal life expectancy is assumed to be the same across the entire global population. Second, the present value of future losses of life-years must be quantified and calculated. These goals are accomplished through a number of technical calculations incorporated into the DALY metric; an age weighting function, a time-based discounting function, a set of disability severity weights and the use of an internationally standardized life expectancy. I address each in turn.

Age weighting

Age weighting is performed according to a function that gives different value to years of life lost at different stages of the life course. It was incorporated by Murray and Lopez by ‘consensus judgment’ in order to reflect the idea that ‘most societies attach more importance to a year of life lived by a young or middle-aged adult than to a year of life lived by a child or an elderly person’ (World Bank, 1993: 26, 213). However, as they go on to explain, even if life was held to have the same intrinsic value at every age, they might still ‘attach greater importance to years of productive adult life’ because of the importance of adults as ‘net producers’, that is, for their increased human capital and resulting increased contribution to economic growth. The different age weights are defined by the exponential function ka^(-βa) where a is age, β is the constant value 0.04 and constant k is chosen so that the total number of DALYs produced by the calculation is the same as though uniform age weights had been used (World Bank, 1993: 213). As a result of this function, the relative value of life rises steeply from zero at birth to its peak at age 25 before falling gradually with advancing age (see Figure 2). Its effect is to redistribute the burden of DALYs away from the early and later years and concentrate them on the middle, economically productive years of life, those years most critical to the World Bank’s priority of economic growth.

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Figure 2.

Age patterns of age weights and DALY losses.

Disability severity weighting

The third technical dimension of the DALY metric is disability severity weightings. These were included to capture the contribution of morbidity to the global burden of disease, in addition to more traditional measures of mortality. Disability severity weights range from zero, reflecting perfect health, to one, reflecting total disability equivalent to death. The fractional weighting of compromised health states results in years of life lived with disability being valued less than years lived in perfect health. The disability weighting feature of the DALY metric has been subject to extensive critique – inspiring the so-called ‘DALY wars’ – because it, quite literally, dis-counts the lives (or at least, life-years) of the disabled. This critique has been framed in a number of different ways: as universalizing a particular (Western) conceptualization of suffering, as decontextualizing health and illness from highly variable social conditions, and as violating United Nations sanctioned disability rights (Anand and Hanson, 1997; Arnesen and Nord, 2000; Bastian, 2000; Murray et al., 2000). What is most salient for the argument here is gleaned from the very definitions of the disability severity weights. In addition to the activities of daily living (e.g. dressing, eating, bathing, toileting), the dimensions of functional capacity deemed relevant are recreation, education, procreation and occupation (Murray and Lopez, 1996b; World Bank, 1993). The inclusion of education and occupation – and thus indirectly of productivity – couple these disability severity weights to potential contributions to economic growth (see Figure 3). Life is discounted insofar as it is compromised in its economically productive potential.

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Figure 3.

Disability weight definitions.

Standard life expectancy

Finally, the DALY metric incorporates the use of a standard life table for calculating years of life lost at any given age. In measuring ‘premature death’ one must define a natural limit to life or a point at which death is no longer premature. But instead of using actual life expectancies – as these vary considerably from place to place – the global burden of disease study employed a standard life table for all populations with the life expectancies at birth of 82.5 for women and 80 years for men. As mentioned earlier, the impetus for using standard life expectancy was the egalitarian principle that death and disease that occur at any particular age should contribute equally to the global burden of disease regardless of where they occur. That is, the death of a woman at the age of, say 57, should contribute equally to the burden of disease whether that woman dies in San Diego or Soweto. But by universalizing a standard life expectancy, the DALY metric effectively decouples the calculation of the global burden of disease (measured in DALYs) from the actual health conditions experienced by populations in various corners of the globe. While the impetus for doing so is broadly egalitarian, its consequences may be decidedly less so, a point I will return to. The main point for my discussion here, though, is that it moves life, and the limit to life experienced through death, out of the realm of actually existing material conditions and locates it instead in the speculative future of potential life/time.

When combined, these technical dimensions of the DALY metric yield the formula shown in Figure 4.

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Figure 4.

DALY formula including technical dimensions.

The various intricacies of these functions are less important than the fact that their incorporation into DALY calculations demonstrates the application of an explicitly economic lens to the quantification of the global burden of disease. Furthermore, the economization of life accomplished by the DALY metric – through its distinctly economic figuring of health, disease, death and life itself – is masked by the seeming objectivity of numbers when the DALY metric is presented in its simplest form as the counting and addition of years of life lost to premature death, disease and disability.

The economization of life

Each of the technical dimensions of the DALY metrics is underpinned by a general conceptualization of health as a form of ‘human capital’; that same Nobel-prize-winning concept most fully developed by the Chicago School’s Theodore Schultz and Gary Becker (Becker, 1962; Schultz, 1961). Although human capital theory met with resistance and controversy upon its initial introduction and development in the 1950s and 1960s, by the 1990s, it had become a central tenet of both micro and macro economic theory, and key to the rapid expansion of the field of economics through so-called economic imperialism (Becker, 1992; Fourcade, 2006; Fourcade-Gourinchas, 2001; Mitchell, 2006).

Becker (1962: 9) defined human capital as those ‘activities that influence future real income through the imbedding of resources in people’ including the knowledge, skills, dispositions and health that are embodied in people that make them economically productive. Some of the ways to invest in one’s human capital, Becker argued ‘include schooling, on-the-job training, medical care, vitamin consumption, and acquiring information about the economic system’ (1962: 9). These investments vary in their relative effects on earnings, that is, in their relative return on investment. ‘But all improve the physical and mental abilities of people and thereby raise real income prospects’ (Becker, 1962: 9). The epistemic underpinnings of human capital theory, then, inevitably invoke a neoliberal political rationality in which an economic lens is applied across the entirety of human existence and, importantly, practices of individual self-investment are privileged over welfare state provision.

While Becker acknowledged the importance of health as a form of human capital, the concept was more fully theorized by Becker’s student Michael Grossman (1972, 2004). He conceptualized health as something consumers demand for two reasons. First, as a consumption commodity it ‘enters into their preference functions’, that is, people prefer a state of health over a state of ill health. Second, and importantly for the argument here, health is conceptualized as an investment commodity because it ‘determines the total amount of time available for market and nonmarket activities … [such that] an increase in the stock of health reduces the time lost from these activities’ (i.e. time away from market and non-market activities) (Grossman, 1972: 225). Health as a site of investment yields life, here configured as a form of time. The return on investment in health as human capital is an increased dividend of time. The monetary value of increased life-as-time, or, conversely, the ‘monetary value of the reduction [of lost productive time]’ Grossman continued, ‘is an index of the return to an investment in health’ (1972: 225). Investing in one’s health extends the duration of possible participation in market and non-market activity, and maximizes the term over which investment in one’s human capital can be realized. Premature death represents the foreshortening of the term of investment. Health, on the other hand, extends life. But figuring health as a form of human capital results in the reconceptualization of life a revenue stream.

With health as human capital, and lifetimes disaggregated into life/time, life is reassembled as a revenue stream. But perhaps more worryingly, premature death becomes not just a foreshortening of time, but a form of failed investment, or, more accurately, a failure to self-invest. Grossman explains:

[I]t is assumed that individuals inherit an initial stock of health that depreciates over time – at an increasing rate, at least after some stage in the life cycle – and can be increased by investment. Death occurs when the stock falls below a certain level, and one of the novel features of the model is that individuals ‘choose’ their length of life. (Grossman, 1972: 225)

With health imagined as a form of human capital, the length of one’s life becomes the result of investing, or failing to invest, in one’s own health. Death is no longer a disease outcome, it is rendered a decision outcome; a decision outcome that the future-oriented, risk-minimizing economically maximizing rational actor should, obviously, avoid through self-optimizing practices of investing in one’s own health. This rendering of health as human capital, the disaggregation of lifetimes into life/time and reassembly of life as a revenue stream presupposes a neoliberal homo oeconomicus who must optimize their own health in the present in order secure future life/time.

This conceptualization of the length of life as a consumer choice can be seen in the DALY metric’s use of a standard life expectancy table. Despite the egalitarian principle behind the standard life expectancy, when the duration of life is conceptualized as resulting from individual investment choices, entire high-mortality populations are recast as failed investors; as having failed to invest adequately in their own stock of health capital. Of course, individuals choose their length of life to approximately the same degree that they choose where they are born. Any rational actor would choose to be born amidst a low mortality population; every homo oeconomicus should invest in their own health so as to ensure maximal life expectancy. But recasting life expectancy as an investment choice locates it firmly within the territory of individual agency, with the result that individuals born amidst high-mortality populations are immediately rendered failed investors. When cast in the light of human capital theory, the ‘egalitarian principle’ involved in the DALY metric’s use of a standard life table starts to look far less egalitarian.

The DALY metric was conceived in a broadly egalitarian spirit and designed for the purposes of carrying out cost–benefit analyses of potential health interventions so as to design emerging health systems according to a logic of economic optimization. But more than just facilitating cost–benefit analyses, the DALY metric accomplishes an economization of life itself by disaggregating lifetimes into component units of life-as-time and reassembling life as revenue stream to be maximized through practices of self- investment in one’s own health, configured here as human capital. Death, on the other hand, results from a failure to self-invest appropriately; it is not a disease outcome but rather a decision outcome. Death, on the logic of the DALY metric, results from the unsuccessful entrepreneurial management of the self, the ultimate failure of neoliberal homo oeconomicus.

Conclusion

The World Bank’s World Development Report 1993: Investing in Health, is frequently identified as a key moment in the transition from international to global health. In this article, I located the epistemological origins of this historical shift in a less-known aspect of the Investing in Health report: its introduction of the DALY metric. But to engage with the epistemological side of this history is not to eschew its material effects: the introduction of the DALY metric has profoundly shaped the terrain of global health over the past 25 years. For example, it was upon reading the World Development Report 1993: Investing in Health that Bill Gates decided to invest his philanthropic billions in the cause of global health (Norheim, 2014). And it was according to the logic of DALY calculations that the Gates Foundation has prioritized its own global health spending. Upon her election to the post of Director General of the WHO in 1998, Dr Gro Harlem Brundtland adopted Investing in Health as her ‘roadmap’ to reforming the WHO in order to reassert its central place within the new neoliberal global health landscape (Chorev, 2012). The priorities of the WHO in the intervening period have been shaped by the global burden of disease, calculated in DALYs, as well as the availability of cost–effective interventions. Examples include the creation of the WHO’s Framework Convention on Tobacco Control, the world’s first legally binding public health treaty, and increased attention to the burden of non-communicable diseases more generally (Kenny, forthcoming).

The DALY metric was initially conceived as a new summary measure of population health that could incorporate both mortality and morbidity into a single unit of analysis and facilitate cost–benefit analyses for the purposes of designing health systems according to a logic of economic maximization. But, as I have argued here, the DALY metric accomplishes an economization of life by disaggregating lifetimes into component units of time and reassembling life as a revenue stream to be maximized through practices of self-investment in one’s own health – configured here as human capital. Life is reimagined as time and the individual as a neoliberal homo oeconomicus, as an entrepreneur of the self. Death is recast from a disease outcome to a decision outcome and represents the personal failure of a neoliberal homo oeconomicus. In contrast to its seemingly objective simple presentation, I have argue that the DALY metric is best conceived as a biopolitical technology of power that underpins the contemporary neoliberal global health regime.