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Critical Public Health

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Understanding health promotion in a neoliberal climate and the making of health conscious citizens
Nike Ayo
a a

Faculty of Physical Education and Recreation, University of Alberta, W1-34 Van Vliet Centre, Edmonton, Alberta T6G 2H9, Canada Published online: 30 Mar 2011.

To cite this article: Nike Ayo (2012) Understanding health promotion in a neoliberal climate and the making of health conscious citizens, Critical Public Health, 22:1, 99-105, DOI: 10.1080/09581596.2010.520692 To link to this article: http://dx.doi.org/10.1080/09581596.2010.520692

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Critical Public Health Vol. 22, No. 1, March 2012, 99105

Understanding health promotion in a neoliberal climate and the making of health conscious citizens
Nike Ayo*
Faculty of Physical Education and Recreation, University of Alberta, W1-34 Van Vliet Centre, Edmonton, Alberta T6G 2H9, Canada (Received 20 May 2010; final version received 27 August 2010) Neoliberal rationality is frequently invoked in critical analyses of health promotion, particularly those analyses stemming from a Foucaultian governmental perspective. Such references made to neoliberalism have been beneficial in highlighting the interconnections between health promotion policy and practice and the larger social, cultural and political systems of governing in which health discourses are embedded. However, beyond referential illustrations of neoliberal ideology, there has been little elaboration as to how specifically the logic of neoliberalism is deployed in such a way as to contribute to shaping contemporary health promotion policies and facilitating the modern-day health conscious movement. In this article, I will elaborate on this issue and add a level of depth to this discussion. I will specifically explore how neoliberal thought and practice is directly implicated in shaping the way health is promoted. This analysis contributes to the growing body of literature on critical perspectives of health promotion. Keywords: health promotion; neoliberalism; governance

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Neoliberal rationality is frequently invoked in critical analyses of health promotion, particularly those analyses stemming from a Foucaultian governmental perspective. Such references made to neoliberalism have been beneficial in highlighting the interconnections between health promotion policy and practice and the larger social, cultural and political systems of governing in which health discourses are embedded. The purpose of this paper is to add a level of depth and breadth to this discussion through specifically exploring how neoliberal rationality has shaped the way health is defined and promoted. Drawing upon Ericson et al.s (2000) five key tenets of neoliberal rationality, as identified in their study of risk and governance within the private insurance industry, I will extend and build upon these principles as they apply to contemporary health promotion strategies. These principles include minimal government intervention, market fundamentalism, risk management, individual responsibility and inevitable inequality as a consequence of choice. Through this effort of situating contemporary health practices within a larger social, political and cultural framework, it is my

*Email: nayo@ualberta.ca
ISSN 09581596 print/ISSN 14693682 online 2012 Taylor & Francis http://dx.doi.org/10.1080/09581596.2010.520692 http://www.tandfonline.com

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intent to elaborate, and highlight specifically how existing health promotion policies both reflects and reinforces the prevailing political ideology of neoliberalism and furthermore operates in such a way as to facilitate the making of the good and healthy citizen. The Foucaultian concept of governmentality will also be drawn upon throughout this article. Foucault was interested in the ways in which humans come to engage in self-constituting practices. In other words, how individuals are made into particular types of subjects (Markula and Pringle 2006) such as the health conscious citizen. For Foucault, governmentality was seen as a method of social control and political rule (Lupton 1999) in which the formation of such subjectivities were brought about. Moreover and key to this concept of governmentality within the context of contemporary neoliberalism is that such social control is neither deemed as being overtly coercive nor forceful, but rather as operating on autonomous individuals wilfully regulating themselves in the best interest of the state (Lupton 1999). In this way, the concept of governmentality provides a useful tool for demonstrating how health promotion works, not by making social and structural changes which impede upon the health and wellbeing of the population, but rather, by inciting the desire within autonomous individuals to choose to follow the imperatives set out by health promoting agencies, and thus, take on the responsibility of changing their own behaviours accordingly.

The pursuit of healthiness Upon examination of this pursuit of healthiness, it becomes evident that health consciousness has become deeply engrained within our social fabric. Since the mid1980s, there has been a drastic increase in the amount of health policy that focuses on health promotion (Burrows et al. 1995). Not only has health promotion been increasingly prevalent in the public policy arena, but it has also gained popular media and corporate attention since this period as well. From the Jane Fonda workout videos of the 1980s and 1990s, to the prominence of the Lululemon athletic apparel of this period, the health, wellness and fitness industries have managed to inculcate an obsessive preoccupation with health. As will be discussed below, this type of health mania has been made possible in the context of a capitalistic, neoliberal climate, whereby healthism and neoliberalism mutually reinforces the vision of the responsible, entrepreneurial citizen (Crawford 2006). Healthism, a term coined by Robert Crawford in 1980 to describe the then newly emerging health consciousness, can be explained as a particular form of bodyism; in which a hedonistic lifestyle is (paradoxically) combined with a preoccupation with ascetic practices aimed at the achievement or maintenance of appearance of health, fitness and youthfulness (Dutton 1995, p. 273). Healthism works under the assumption that everyone should work and live to maximize their own health (Petersen and Lupton 1996). This not only benefits the individual, but it is also presumed to work for the good of society as a whole. As the burden of health care is reduced from the shoulders of the state, it is then placed upon the consciousness of individual citizens. Such health consciousness has resulted in a pursuit of healthiness that is facilitated by a burgeoning health industry propagating throughout nearly every realm of society at an ever increasing pace. New gyms pop up not only on street

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corners (Galvin 2002), but also in work places and grocery stores. Fitness apparel, such as Lululemon Athletica (2009), are no longer confined to yoga, dancing, running, and. . . other sweaty pursuits (lululemon.com), but has instead become a fashionable statement in everyday wear of ones pursuit of health. The purchase of certified organic food products also echoes this same statement; as does a whole slew of other products labelled as natural or green. The intent here is not to condemn such items as bad, but rather to demonstrate how contemporary health consciousness can be seen as contributing to the spur of a consumerist frenzy (Galvin 2002, p. 127), whereby health promoters prescribe a certain lifestyle (Parish 1995) intended to minimize risks, and construct responsible, prudent, health conscious citizens who are expected to buy into this lifestyle. Thus, the enormous amount of personal resources invested into healthy living, be it in time, money, physical effort or a range of aesthetic regimes, is not seen as a narcissistic obsession with the self (Rose 1990), nor is it considered to be frivolous. Rather such personal investment is deemed as a wilful obedience to the duties and obligations imposed by citizenship. In essence, the healthy lifestyle culture as we know it within contemporary Western neoliberal societies can be seen as a moralistic one whereby values such as prudence, hard work, responsibility and asceticism are expressed through such pursuits as listed above. The impetus to undertake such pursuits under the banner of healthy lifestyles exemplify what Foucault refers to as technologies of the self, efforts humans make to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection, or immortality (Foucault 1988, p. 18). It is through technologies of the self that aspects of self-constitution are carried out rendering particular images, statuses and identities into being.

Health promotion in a neoliberal framework To understand the significance of neoliberal rationality in which this citizenry is formed, I provide here an explanation of what is meant by both neoliberalism as well as rationality. A general consensus of the term neoliberalism can be commonly understood as a political and economic approach which favours the expansion and intensification of markets, while at the same time minimizing government intervention. Though the emphasis here is on the market and government structures, neoliberalism is by no means just an economic or political term it is inherently social and moral in its philosophy. An explanation of the concept of rationality will further help to bring this to light. Simply put, Dean (1999) explains a rationality as any body of systemic thought about the nature of things (p. 11). Rose (1996) further elaborates on this as he explains a political rationality to be a kind of intellectual machinery or apparatus for rendering reality thinkable in such a way that it is amenable to political programming (p. 42). Thus, we can think of the political machinery of neoliberalism as a system of thoughts and beliefs about the effective rule of state, society and the market. These beliefs are pervasive in that the corresponding discourses directly shape the ways in which society is governed and expected to conduct itself, right from the privacy of ones own home to the administration of public institutions and across all demographics. The five basic tenets of neoliberal rationality as outlined above: minimal government intervention, market fundamentalism, risk management,

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individual responsibility and inevitable inequality as a consequence of choice, provide the basis of a framework for understanding how neoliberalism works to facilitate present-day health promotion discourse and health consciousness. I will now speak to each of these tenets as they relate to contemporary health promotion in the Western world. Central to the political posturing of neoliberalism is the idea of minimal government intervention. This can be seen as a key explanation in the failure to implement the strategies and actualize the goals of the Ottawa Charter for Health Promotion. Rather than invest in the prerequisites of good health, such as income, shelter and food, as urged to by the contributors of the Charter, the framework for health promotion was quickly reverted back to the individualized lifestyle approach as advocated in the Lalonde Report. In this way, what were once seen as social problems, a failure of the state even (Galvin 2002), has come to be seen as a personal failure requiring personal accountability. Unemployment, poverty, lack of education, all major established social determinants of health, are rendered as poor personal choices made by freely choosing citizens. Health promotion policy and practice has appeared to largely ignore these fundamentals of health. Though talks of social determinants are often tossed around in government documents and speeches, it is questionable to what extent such talks actually move beyond that of rhetoric such as was seen with the Ottawa Charter. Instead, the health promotion policies which tend to receive the greatest amount of endorsement are those which suggest that all will be well if individuals simply exercised 30 minutes a day and ate more fruits and vegetables. This discourse prevails at the same time when increasing homelessness and affordable housing have become nationwide problems (Hulchanski 2002, Moore and Skaburskis 2004) and social and economic conditions have deteriorated for many citizens. The objective here is not to dispute the real benefits that physical activity and nutrition has on ones health. Rather, the intent is to demonstrate how such self-regulating, individualized practices become championed over other forms of well-established knowledge such as the social determinants of health. In this shift away from state intervention, citizens are not left alone to completely fend for themselves in achieving health and wellbeing. A massive array of expert knowledge, in which Foucault argues is integral to the formation of particular subjectivities (Lupton 1999), is made available to citizens providing them with lists of dos and donts and other guidelines to healthy living. The corporatization and the commodification of health also facilitates this process, thus assisting citizens in becoming consumers and enterprising individuals (Galvin 2002, p. 117); two virtues of neoliberalism that speak to the principle of market fundamentalism. While the state takes a step back from directly intervening in social and economic affairs, it simultaneously gives way for the creation of new markets in domains where they may not have previously existed (Dean 2008). This is evident as we consider the rise of the health industry and its expansive reach in all areas which pertain to the body, mind and spirit. Rather than the state focusing on the determinants of health, experts and corporations alike are encouraged to offer their goods and services through the free market, whereby, it is expected that the responsible, health conscious, neoliberal citizen will buy into them. It is hard to ignore the supremacy of the free market in neoliberal states over matters pertaining to health promotion. Whereas the capitalist state prior to the 1980s health promotion movement may have encouraged self-indulgence and a spur

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of cheap and unhealthy foods and other products, modern-day capitalistic neoliberal states in Western societies are increasingly encouraging a new type of self-indulgence. That is, one which better corresponds with the image of the healthy citizen. Grocery store isles are now littered with low-sodium, reduced-fat, calorie-wise and health check symbols on food items. Coupled with running shoes, athletic clothes, sports bras, health books, fitness magazines, exercise DVDs, diet pills, sport drinks, energy bars and machines which build, bend and bulk-up the body as just a small sample of what the health industry has to offer, Health consumerism greatly abounds. There is no limit to the reach of the free market and its entrepreneurial role in the health industry. Thus, the healthy and wise citizen is taught that insurance against health risks is based upon consumption of both the dominant ideals of what it means to be healthy and the goods and services which reinforces them. Risk management, is another one of the five tenets of neoliberal rationality as stated by Ericson et al. (2000). From a Foucaultian perspective, modern-day risk are directed at the regulation of the body (Lupton 1999, p. 90). This is evident in modern-day health promotion strategies as individuals bodies are targeted as the site of intervention and regulation as oppose to overarching social systems. According to the Merriam-Websters Online Dictionary, a risk can be defined as the possibility of loss or injury. In terms of health promotion, we can understand this loss or injury as the possibility of morbidity or premature mortality. It is the imminence of such harm, the potentiality for life threatening chronic diseases that legitimizes health promotion strategies. As such, the particular strength and effectiveness of deploying risks as a neoliberal tool, a technology of government indeed, is the impending harm that it implies, thus stimulating a sense of panic, a sense of urgency, and a sense that action must be taken now. Not only is it expected that prudent and responsible individuals will embrace the goods and services offered by the flourishing health industry as part of their reasonable service to themselves, but as well, as part of their duty of citizenship to the state. With this in mind, it becomes evident as to how individual responsibility works as a tenet of the neoliberal state. This principle of personal responsibility is not only a matter of economic efficiency, but it is also highly value-laden and situated as a code of ethics, an obligatory duty of citizenship. Ideally, personal responsibility is intended to relieve a great amount of burden off the state as social issues become personal issues. Yet, the rendering of such personal issues, such as health-related lifestyle behaviours, into moralistic issues in the air of secularism, has been highly effectual in supporting this new breed of health consciousness and self-regulating subjects. The issue of personal choice, and the freedom to choose, is another key tenet of neoliberal rationality. In fact, the very foundation of neoliberalism stands upon the premise of liberty and freedom. It is these rudiments of rational government which are transferred over to citizens in efforts to empower them to become self-governing, enterprising individuals (Petersen and Bunton 1997, Schee 2008). Thus, within this political, economic and social climate, matters pertaining to inequalities in health become an inevitable outcome as a consequence of freedom of choice. Just as there are those who take heed to health promotion messages promulgated through expert knowledge, there will also always be those who choose to navigate along their own way, failing to attend to the loud cries broadly disseminated by health promoters of what it means to be healthy. In this way, responsibility for the differences in health and illness are again removed from the conscience of governing bodies and placed

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onto health conscious individuals who are made to be accountable for their own actions and circumstances. Of course, the issue of choice here can be seen as more of a facade as it is understood that a number of oppressive social and structural forces mediate the choices in which one is able to make. It is evident that the manner in which contemporary health promotion is employed within Western neoliberal societies both reflects and reinforces this prevailing political ideology. The neoliberal agenda of restructuring governmental techniques so as to minimize state intervention, secure competitive markets, while at the same time evading risks and establishing a social body comprised of knowledgeable, prudent, health conscious citizens, while also accepting the inevitability of inequality as a side effect of the freedom of choice, is symbolic of the healthy society. As can be seen, and is thus worth reiterating, health promotion works not by way of making social structural changes which impede upon population health, but instead by inciting the desire within individuals to choose to follow the imperatives set out by governing health bodies, and thus change their own lifestyles accordingly. However, I contend that this notion of choice based upon the liberties of neoliberalism, is more illusory than it is a true act of volition. The consequences for those who fail to conform to the prescribed mandate as to what constitutes a healthy lifestyle are real. Such include among other things, public disdain and reproach for being a part of societal problems rather than a part of the solution, gazes of repulsion due to ones failure to manifest the symbolic metaphors of neoliberal citizenship, such as the self-governing individual or the capitalistic hard work ethic, embodied in the taut, refined and fit body, and admonitions from both health experts and loved ones alike. Health promotion messages such as be active, eat healthy and lose weight, are boisterously propagated throughout Western neoliberal societies as the panacea to modern day health concerns of chronic diseases. Under this logic, it is individuals who are placed at the centre of health promotion strategies, as opposed to overarching social systems that also determine health outcomes. They are seen as being both the cause and the solution to potential health problems and thus are made to be accountable for their own health. However, when exercising ones autonomy and freedom, it is expected that the responsible citizen will allow his or her lifestyle to be guided under the auspices of knowledgeable experts and normative prescriptions of what it means to be healthy. This requires attending to ones own health in ways which have been socially approved and politically sanctioned. In this manner, it can be understood how health promotion and health practices are not merely the result of objective reasoning, but rather as contingent on aggregates of social, cultural, political and economic conditions. Highlighting the role of neoliberalism in this set of contingencies provides insight as to how this rationality has contributed to shaping the way contemporary Western societies have come to understand what it means to be healthy.

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