Reflections on Biopedagogies and/of Public Health

Introduction

What is “health”? How does a “healthy” person feel or look? What does one need to “do” to be a healthy citizen? How is public health shaping the ways in which people understand their bodies and live their lives? Informed by poststructuralist theories that underline the power of language and cultural practices in shaping identities and subjectivities, we are interested in the various “pedagogies” of public health in circulation in the historical present. We are concerned by the manner in which these teachings—on how to live, how to eat, how to move—seem to function as part of an apparatus of governmentality that works to provide social meanings and regulate lives. In keeping with the mission of Cultural Studies↔Critical Methodologies to provide an explicit forum for the intersections of cultural studies, critical interpretive research methodologies, and cultural critique, we offer here a series of articles that contribute to the advancement of knowledge given that they advance the critical interrogation of biopedagogies of public health and thus extend, through empirical and/or theoretical exploration, the examination of issues relating to the government of population health put forth by Foucault, Lupton, Petersen, Wright, and many others. This collection of articles speaks to the various methods to evaluate, monitor, and survey the body and health, as they are constructed within various “pedagogical sites” (e.g., schools, doctor’s offices, websites, magazines, the family) and shaped through a range of cultural practices (e.g., popular media, new technologies such as apps or wearable digital devices). The authors featured here come from a variety of locations to explore how “truths” about the body and health are negotiated (accepted, accommodated, resisted) in various social and cultural spaces, and to highlight “health disparities” and the underlying social, cultural, and political conditions required for “health.” Using a variety of methods of writing and representation, they clearly illustrate the complex array of biopedagogies of health in circulation, demonstrate the fluid and complex nature of subjects in relation to biopedagogies on offer, and explore how embodied experiences are impacted by—and in turn impact—social practices and relations of power.

Prior to turning to our colleagues’ work, we would like to present a series of reflections or ideas that have been working away at us as we were preparing this special issue. In brief, we would like to argue that (a) within neoliberal societies, an assemblage of private and public institutions, media, corporations, and, foremost, public health agencies are circulating a dominant discourse, which some have identified as the “health imperative.” (b) That this imperative obliterates political engagement and leads to the creation of the fit and productive biocitizen through self-tracking, self-diagnosis, and various market solutions to develop and maintain wellbeing. (c) That the health imperative leads to a biomorality that incites the contra-juxtaposition of the biocitizen to the unfit, unwell, and unproductive bio-Other. (d) That in sexist, classist, ableist, ageist, neo-colonial, Islamophobic, homophobic, and transphobic contexts, we observe how public health invests in ill-designed “rescue missions” to save the bio-Other. And (e) that public health initiatives are part of—as well as instrumentalized within—larger corporate schemes to expand markets in the name of health. We then conclude with thoughts on the place of cultural studies and critical methodologies in the larger project of health and social justice, while connecting to the three themes favored for this special issue: biopedagogies and spaces, identifications, and affects/effects.

The Health Imperative

Foucault (2008) argues that, in modernity, the bio or life of the population is increasingly subject to control, surveillance, and regulation. Modern biopolitics ¹ has always involved the management of bodily processes at the populational level (for instance, when regulating births, deaths, illness, hygiene, or health). In late capitalist societies, however, biopolitics has a slightly different taste. With biomedicalization (Rail, 2011), we see the expansion of medical authority and practice into new realms, and this brings us to consider a new relation between medicine, health, and life itself. Everything “bio” may now be medicalized and made the object of surveillance (Clarke et al., 2003; Schneier, 2015). The impulse of biomedicalization fits perfectly with neoliberal restructuration. ² This has given life to “bioeconomic” and “biocultural” discourses (see Rail, Murray, & Holmes, 2010) that are so prominent today that there is no need for coercion. Advertising, marketing, and other weapons of mass persuasion are sufficient for individuals to buy into a dominant discourse of health. But an entire “assemblage” (Deleuze & Guattari, 1987) of private and public institutions, media, corporations, and, foremost, public health agencies constitute the private and public government of the body. This government is creating concern among citizens, partly by reinforcing their fears of illness and inciting the active monitoring of their own health. In such a hypochondriac cultural landscape, the person who feels ill accrues a kind of social debt that must be redeemed by locating herself within compensatory discourses and consumption praxes. Lupton (1995) has documented this and written about the “health imperative,” which operates as a moralizing command in a way that obliterates political engagement: The body becomes the only “truth system.” The health imperative is better understood in the context of late capitalist societies within which health has emerged as a fertile new ground for corporate profitability (Rose, 2007). It works through dominant discourses representing bodies that are purported to be malleable and amenable to various bodily ideals, as well as through bodily practices that are normalized within the vast wellness market. Zizek (2008) has written about joy and said that the moral injunction to “enjoy” sabotages enjoyment. We would suggest correspondingly that the moral injunction to be healthy sabotages health.

The Production of the (Feel) Good Biocitizen

Dominant discourses associated with the health imperative produce particular subjects and have specific effects and affects. For instance, these discourses constitute the modern subject who believes that her body is a site of agency, freedom, and empowerment. This neoliberal subject is a dream producer and consumer in the sense that she is imagined to be proactive, to take personal responsibility for her health, and to produce the satisfactory health that she will enjoy and consume. Devolving responsibility to the individual is a long-standing neoliberal tactic and a capitalist ideal for marketing (Lippman, 2014). This remains true for the broad health market. Individuals are encouraged to develop what Lipovetsky (1989) calls a “therapeutic sensibility.” In a biomedical and popular culture of risk and prevention, this sensibility means an interest in all portions of one’s “bio” or life, and a fascination for salvation through bodily knowledge and transformation.

The work of biopower ³ and biopedagogies is explicit in the increasing self-observation, self-diagnosis, and self-treatment of bodies. Body examination extends to inner body examination. There are osteoporosis, diabetes, blood pressure, cholesterol, bone density, bowel cancer, and all sorts of other self-diagnosis kits. As a way to create new markets, companies simply make more curves that indicate more risk. This results in the creation of new biomarkers that serve as proxies for diseases, and that can be the objects of additional self-diagnosis tools (Dumit, 2012; Hadler, 2004). Such tools are wide ranging and focus on the usual biomarkers but also monitor nutrition, weight, BMI, sexually transmitted infections, hair loss, whiteness of the teeth, libido, stress, and so on. In terms of inner health, people may get total body scans or they may now go to virtual kiosks to check their inner workings. DNA sequencing sets the stage for a surge in preventive medicine and for proposals to treat the pre-diseased (for example, the 23andMe tests to determine health risks; see Lippman, 2014). Fascination is fed and anxieties are created with TV series featuring doctors, surgeons, or computer simulations of “inner life” and everything that may go wrong.

The novel ways in which the digitization of bodily and medical information is occurring are also dominant features of self-diagnosis applications or apps. Already with telemedicine, remote care, and eHealth, individuals have experienced the shifting of responsibility and the transformation of both health care and public health. Now, with mobile and wearable technologies, a whole new level of digitization is reached to colonize the entire domain of health. In the world of digital human information, many stakeholders now compete for attention, including members of medical professions, health insurance companies, pharmaceutical companies, medical technology companies, hospitals, patient support associations, government agencies, fitness and weight loss industries, educational institutions, entertainment industries, and digital device and software developers (Lupton & Jutel, 2015; Rozenkranz et al., 2013).

Nowhere are the concepts of biopedagogies and self-imposed digital surveillance more apparent than in self-tracking, self-quantifying, and life logging, which are enabled by ingestible, wearable, and implanted technologies, biometrics, sensors, monitoring devices, and apps. In early 2014, for instance, it was estimated that there were 181 wearable devices currently in the market: 10 for industrial purposes, 13 for gaming, 28 for entertainment, but also 43 for medical purposes, 86 for fitness, and 121 for “lifestyle” (Lupton, 2015). As far as health and wellbeing are concerned, apps are also in rapid expansion: There are now more than 100,000 apps dedicated to mobile health, and the global health and fitness mobile app market, which is currently worth about $4 billion, is expected to increase to $26 billion by 2017 (Boxall, 2014).

As a mode of digitized embodiment, apps rely on the idea of Do-It-Yourself Health and the belief that the body is amenable to control if sufficient vigilance and self-responsibility are exercised. Via physical activity, makeovers, nutrition, pharmaceuticals, neutraceuticals, and all manners of biotechnologies, individuals are examining their inner and their outer body, and led to believe that if they behave as their apps’ algorithmic logic suggests, they may discipline and normalize their flesh to become “optimized subjects” (Kember, 2012).

As problematic as it is to use it in such a context, the concept of “empowerment” is nevertheless a hallmark of the digital health rhetoric (Lupton, 2013). Apps are positioned as neutral, objective technologies for self-diagnosis, creating a liminal space between the engaged biocitizen and the expert medical professional. But while the apps seek to position ordinary users as empowered consumers of health information, three factors come to mitigate this:

Along with digital biopedagogies, the dominant neoliberal discourses associated with the health imperative produce particular subjectivities. For example, discourses constitute and circulate the concept of the “good citizen” as someone who is autonomous, strong-willed, responsible, entrepreneurial, and relentlessly striving to improve himself or herself. While at work or working out, this subject embraces and consumes both corporate and personal wellness programs in search of health, productivity, and happiness. With the help of public health, biopedagogies, and social media—something not far from what Murray and Steinberg (2015) refer to as “bioconvergent media”—the health imperative celebrates a new type of individualism involving self-examination and self-treatment via therapeutic discourses and practices, to the exclusion of social groups, organizations, and communities (Lupton, 2015). Such emphasis on the individual entails many undesirable consequences, not the least being the stigmatization of the unwell.

Biomorality and the Production of the Bio-Other

Many theorists have written about biomorality, but Zupancic (2008) has summed it up in the simplest way by noting the following axiom: A person who feels good is a good person. Biomorality thus corresponds to the moral demand to be happy and healthy. Biomorality engenders biocitizens. Following Foucault, Rose and Novas (2005) argue that biocitizens are “made up” from above (by medical and legal authorities, public health professionals, insurance companies, etc.), but they also make themselves. Active biocitizens inform themselves and live responsibly, adjusting lifestyle and all areas of their physical and social environments so as to maximize health. But all those who make up biocitizens and virtuous sub-populations also contrast them to dangerous Others. These are the weak-willed, the lazy, the amoral, the unruly, those who do not live responsibly and engage in “risky” behavior or do not get involved in preventive behavior, in brief, those who are “made up” as domestic bioterrorists who exploit the tax-supported institutions that produce health and wellbeing. We call these individuals “bio-Others” (Rail, 2011) as the health imperative seems to justify them being robbed of their full citizenship. Bio-Others are dangerously undisciplined and in great need of policing. Given the ambient biomorality, coercion to leave the company of bio-Others and join that of biocitizens takes many forms, including surveillance, marginalization, abjection, public blaming, digital bullying, police brutality, and economic discrimination and exploitation.

In Western societies, history shows how many social groups have been designated as the contaminating “Other” against which public health measures were undertaken (Peterson & Lupton, 1996). At one point or another and in many countries, the working classes, Indigenous people, immigrants, Roms, women, gays and lesbians, disabled individuals, and non-Europeans have all been the target of biopolitical projects that we now regard as classist, xenophobic, sexist, homophobic, ableist, racist, colonialist, and/or genocidal. Today, in neoliberal societies, all of these projects are still on-going, but with the advent of biomorality and phenomena such as genomics, securitization, ageism, Islamophobia, and transphobia, many more bio-Others are being “made up.” Public health discourses, in particular, have performative powers and often produce the illnesses that they describe, as well as construct social identities for those who are not well. Everywhere, the “white” individual is used as a reference point against which bio-Others are measured and contrasted. The heterogeneous entities that form the health imperative assemblage converge to shape identities based on distinctions that were fabricated long ago as part of the patriarchal and colonial project (see Cloos’ piece in the present issue; Cloos, XXXX).

Health discourses and biopedagogical tools available on the market work in tandem to produce sub-populations on the basis of behaviors and diseases: “Women are more at risk for depression”; “Indigenous individuals have more diabetes”; “Lesbians drink and smoke more and get more breast cancer”; “Roms use less condoms and do not get their important shots”; “Asian women consult physicians less”; “Latina women are more promiscuous and more likely to get cervical cancer”; “African American women are more obese and prone to cardio-vascular disease.” Minority sub-populations are then characterized according to risk factors. In such a racist and culturalist approach, sub-populations are constructed as being at higher risk (i.e., always in juxtaposition to the White, middle-class, heterosexual norm) for everything that threatens health. This contorted logic is present in social and scientific discourses. It also feeds apps and various technologies and services sold under the pretense of improving health. Typically ignored in all these messaging are the complex intersecting colonial, historical, social, political, and economic conditions that influence the lives and health of marginalized sub-populations. Often discussed out of context, at-risk groups are reified into a lifestyle, and risk factors are interpreted as personal choices et voilà! Dominant biomedical, epidemiological, and biomoral discourses converge to circulate negative stereotypes about bio-Others as lacking willpower, judgment, or moral fortitude.

Rescue Missions to Save Bio-Others

Rescue missions are trendy. Popular media are thirsty for stories of White men saving Others. Reviving the spirit of 19th-century philanthropists, many biomoralists seek to reach out from their own perfectly constructed world. Public health officials are equally adept at designing programs aimed at saving the degraded and abject. Many rescue missions are weapons of mass conviction but are couched in humanitarian rhetoric that renders them palatable. Such missions are designed to save bio-Others and take many forms:

In the end, all five types of rescue mission insist that bio-Others “do it” by themselves and for themselves. Such insistence on personal responsibility is the perfect corollary to a politics that aims to legitimize injustice, poverty, and un-wellness. McAll (2008) has used the concept of “health transfer” to characterize the distribution of health in Canada. We would like to extend his analysis to speak of health in a globalized world. Health is unevenly distributed and, in general, more present among those few who are positioned to appropriate the resources and the work of others. It is notably via the exploitation of the work of many Others (usually female, poorer, darker) that the (usually male, richer, whiter) few forge their wealth and wellbeing. The richer few get Others to work in a way that exempts the former from brutal working conditions. The richer few also protect their wellbeing by appropriating resources (e.g., green spaces, better housing, leisure time) linked to health and this leads to the social exclusion of Others who are, then, less healthy. In this way, there is a transfer of health between sub-populations, and exploited Others often become bio-Others. At the global level, the health of workers in the South is transferred for the health and wellbeing of those in the North.

To sum it up, biomorality leads to rescue missions that are generally afflicted by the savior syndrome. Such missions have a depoliticizing effect. They entrench existing power structures, exacerbate class divisions, and reproduce patriarchal and colonial hierarchies that pave the way to the transfer of health from the masses to the lucky few. Ironically then, biomorality connects to “psychopathology” in the sense that an entire section of the world population is antisocial, sometimes criminal, and lacks a sense of moral responsibility for the health and wellbeing of others. This is how bio-Others come to have “disposable bodies” as Karim (2014) has shown, and why their lives are at times “ungrievable” as Butler (2009) would say.

Instrumentalizing Public Health to Expand Markets in the Name of Health

The health imperative obliterates political engagement and leads to the creation of the happy, fit, and productive biocitizen, which is juxtaposed against the unfit, unwell, and disposable bio-Other. We would like to raise a few questions in regard to the impact of the health imperative on public health. First, we need to raise the original question of power: Who contributes to establish the health imperative and why? Who gets to moralize lifestyle and how? Who gets biocitizenship privileges and what is their financial, physical, psychological, and social price? In late capitalist societies, those whose areas of interest are in health and wellbeing have seen their skills and knowledges “highjacked” by commercial interests (Krupka, 2015): What are the consequences for the type of rescue missions that are planned? What are the consequences for bio-Others? We could also ask who gets to label bio-Others, particularly in the context of societies that thrive on classism, ableism, ageism, sexism, racism, homophobia, transphobia, Islamophobia, Romphobia, and the genocide of Aboriginal people? Who is the next bio-Other?

Second, we might consider the situation of public health enthusiasts. What opportunities emerge but also what dangers lurk when we try to wrestle health away from the biomedical monopoly? When we become part of a power/knowledge system that defines health? When we circulate biomedicalizing discourses or gain in status and become expert labelers of bio-Others? Protecting and promoting public health should not be seen as medicalization projects or as means to improve economic productivity and create private profits (Lippman, 2014). We need to challenge all attempts to link healthy bodies with their neoliberal productive capacity. The health imperative, coupled with biomedicalization discourses such as those we are witnessing in public health, are ways to regulate the terms in which a subject’s “free choice” might be exercised. They appear to safeguard the rights of autonomous persons, offering them the tools for self-surveillance and self-regulation so that they can become entrepreneurial managers in the development of their own health. In reality, however, the optimized biocitizen is tied to a neoliberal bioindustrial complex inculcated into a regime of truth that ultimately hijacks the subject in the guise of freeing it.

In/Conclusion

We would like to suggest here that biopedagogies and/of public health are opposed to deep thinking. Instead, they bring us all to a state of “bovine acceptance” and encourage us to become “happy athletes of capitalist productivity” (Cederström & Spicer, 2015). To counter such tendencies, we could do with a broader range of health discourses required to challenge, counter, and transform patriarchal and neo-colonial tendencies and hence move closer toward social justice. To generate subaltern knowledges as well as more equitable social policies, we need methodologies that “take sides” as Becker (1967) would say. We must craft cultural studies of health in a way that opens doors to subjugated knowledges, as our field too often incorporates difference in a way that makes no difference. We need cultural studies that work across lines of power, and that are bold in their academic-activist research partnerships. The pieces that are presented hereafter are committed to cultural studies and critical methodologies in the larger project of health and social justice, while connecting to three themes favored in this special issue: biopedagogies and spaces, identifications, and affects/effects.