The politics of health promotion

Case studies from Denmark and England

Peter Triantafillou, Naja Vucina

• Publisher: Manchester University Press
• Year: 2018
• ISBN:
  9781526130853
• Edition: 1
• Topic: Medicina
• Subtopic: Política de salud

This book examines the quest to promote the health and vigour of individuals and populations in Denmark and England. Based on a detailed account of obesity control and mental recovery programs, the book shows that these interventions are supported by a form of optimistic vitalism that seems to have no political limitations.

1

Critical studies of the politics of public health promotion

Over the years, public health promotion has received critical attention from a wide range of academic scholars and disciplinary approaches. Much of the critique has evolved within the medical community, in which debates have taken place over the lacking (evidence of the) efficacy of specific clinical interventions and procedures (Minkler, 1999; Jackson, Waters, and Taskforce, 2005; Brownson, Baker, Leet, Gillespie, and True, 2011), and not least the tendency of medical interventions to focus rather narrowly on individuals deemed at risk, rather than focusing on the underlying causes affecting the entire population (G. Rose, 2001). While often highly critical of the state of contemporary health promotion interventions, it is usually an internal critique that only rarely touches upon the social and political dynamics shaping public health interventions. However, public health promotion has also received attention from social science scholars that explicitly addresses the social and political norms, forces, and consequences of the contemporary quest for public health promotion.

This chapter has two overall purposes: to provide an overview of existing critical social science studies of health promotion and to outline an analytical framework that will be used in the remainder of this book. Firstly, we review and discuss the merits and the limitations of the most influential political science, political economy, and sociological analyses seeking to critically address the contemporary politics of health. Secondly, we account for the Foucauldian-inspired analytical framework used in the empirical analyses of this book. This implies accounting for existing studies in the area of public health, discussing the analytical framework’s potential and limitations, and accounting for the ways in which we adopt key analytical principles and concepts from Foucault’s work in order to analyse power–knowledge relations and unquestioned norms in the contemporary politics of health.

Critical studies of public health politics

This section reviews and discusses the potential and limitations of three general approaches for conducting critical analysis of health promotion, namely health policy process analysis, political economy, and sociological critique. The review and discussion are limited to works that deal more or less explicitly with health promotion rather than health politics in general. That is, we are interested in social science studies critically interrogating the emphasis that contemporary health politics attributes to individual lifestyle and empowerment of citizens and communities with a view towards improving the health and vigour of populations.

Policy process analysis

The aim of health policy process analysis has been formulated like this: ‘to understand past policy failures and successes and to plan for future policy implementation’ (Walt et al., 2008, p. 308). This may be a rather narrow definition, as some studies argue that we also need to focus on the agenda-setting and policy-formulation stages of the health policy process (T. Oliver, 2006). At any rate, based on a range of political science and public administration theories and methodologies, these studies deal with the diverse administrative, organizational, and political dynamics shaping the formulation and implementation of health policies.

Some have lamented the limited use of explicit theories in understanding and analysing health policy processes (Breton and de Leeuw, 2011). Others have pointed to the scant attention paid to politics and power in these studies (Bambra, Fox, and Scott-Samuel, 2005). Notwithstanding these discouraging assessments, we do find policy process analyses that pay attention to the kind of power relations embedded in health policies and how those power relations impinge on the target group of these policies: namely patients and citizens at large. Some have addressed the ways in which public management reforms in the health sectors from the 1980s onwards tried, with more or less success, to break with the (medical) professional authority structures found in public health institutions and services in order to hold doctors accountable for their actions (Moran, 1999; Salter, 2007). These public management reforms have arguably changed and possibly equalized doctor–patient relationships, which are increasingly characterized as a provider–consumer relationship (Hugman, 1994).

We also find critical analyses of the policy processes revolving around health promotion. The general thrust of these studies is to point to implementation failures and – in some cases – the factors or forces leading to this failure. Conversely, only very few studies pay attention to the role that agenda-setting and policy formulation play in health promotion processes (Bryant, 2002). Curiously, it is as if policy process analysts have largely ignored the political forces and conflicts engaged in setting the health agenda and formulating health promotion policies. Instead a common argument in some of the early studies was that health promotion programmes employed so far simply do not meet their goals, i.e. the programmes employed have yet to fully empower citizens and communities and, thereby, enable them to live a healthier life (Beattie, 1991; Farrant, 1991; Parish, 1995). Accordingly, the prevalence of, for example, cardiovascular diseases and type 2 diabetes is still increasing, particularly among economically disadvantaged groups. More recently, several studies have pointed to the many difficulties in empowering not only individual citizens but also local communities, which are envisaged to work in support of health promotion (Neale, Littlejohns, Hawe, and Sutherland, 2008; Baggott, 2011, pp. 367–370, 408–412; Harting and Assema, 2011; Short, Phillips, Nugus, Dugdale, and Greenfield, 2015). Such implementation deficits or even outright failures are due to a variety of factors, such as lack of an adequate programme theory, conflicting notions of success between implementation actors, and narrow vested interests among politicians and private businesses that override local community interests and needs.

In sum, political process analysis holds a strong potential for critically addressing the agenda-setting, formulation, and implementation of health promotion policies. However, the bulk of analyses have targeted only the implementation stage. Here they have pointed to the many administrative and political barriers to effective implementation. These insights are important to our understanding of why health promotion programmes often do not deliver what they promise. However, they are not very helpful in understanding why these policies were adopted in the first place. The role of knowledge, media attention, and political interests and strategies feeding into health promotion deserve much more attention than previously given. Finally, and more generally, even if the role of knowledge, media attention, and political interests were analysed, we find it an unnecessary limitation that such analysis is almost invariably couched in terms of given actors pursuing given interests. Of course, we do find policy process approaches going beyond the traditional narrow focus on actors with given interests, but they do so by drawing on political economy, ideology, sociological, and post-structuralist studies. Thus, we now turn to these latter approaches to discuss the insights they have provided and may further contribute.

Political economy and ideology studies

This section discusses the merits of approaches that focus on the ways in which socioeconomic structures connect with the design of public health interventions and institutions to produce and/or reproduce inequality in terms of income and health.

Firstly, we may note that we find a very large literature that provides evidence of inequality in the health status of populations – both within and between states (e.g. Townsend, Davidson, and Whitehead, 1988; Fein, 1995; Leon and Walt, 2000). They are critical in the sense that they locate these inequalities in differences in income, living conditions, and material opportunities in general. Low life expectancy and high incidence of diseases, even the so-called lifestyle diseases, are regarded less as the result of the randomly distributed choice of citizens or variations in individual genetic dispositions, and more as the outcome of systematic differences in the material circumstances of individuals and groups. Accordingly, in order to effectively improve health for those most prone to diseases and having low life expectancy, states should target the poor and ultimately distribute income and resources more equally. Yet if these studies are adamant that the root cause of inequality in health is inequality in income and material means, they usually have little to say about why these resources are divided so unevenly and how that links up with the provision of medical services.

Inspired more or less directly by Marxist theory, political economy approaches have tried to answer the question of why resources are so unevenly distributed within and between states so as to produce huge health differences. In a series of works, Vicente Navarro has argued that capitalist economies systematically produce economic inequalities both within states and between (the developed and developing) states (Navarro, 1976, 2002a, 2007). While capitalism may contribute to increasing general wealth, the working classes in both developed and – in particular – in developing countries will tend to become poorer. From this follows that working classes will have to work harder, will not be able to afford proper food, and will have reduced access to medical services, ultimately causing their health to deteriorate. Others have pointed out that the organization and provision of health care in capitalist societies systematically ignores occupational and social production of health and disease (Doyal and Pennell, 1979).

Recently, political economy theory approaches have been used to question the ability of health promotion interventions to secure the health of the poor and labouring classes and thereby reduce the inequality of health conditions (e.g. Dennis, 2015). A particularly good example of this literature is The Health of Nations: Towards a New Political Economy (Mooney, 2012), in which Mooney analyses how power is exercised both in health-care systems and in society more generally. In doing so, Mooney reveals how too many vested interests hinder efficient and equitable policies to promote healthy populations, while too little is done to address the social determinants of health. Neoliberal ideology is here taken as the main culprit for the prevalence of poor health and (social) inequality in life expectancy despite increasing resources invested in public health interventions. Along the same lines, a study of the Canadian Active Living programme argued that the quest for health promotion and empowerment in reality worked to conceal power imbalances between government officials and the community and to justify the rapid retreat of the welfare state from social responsibility for fitness and health (Bercovitz, 1998).

While we sympathize with the general ambition of problematizing the power mechanisms at stake in health promotion, we think that the political economy and ideology approaches suffer from two interrelated problems. Firstly, they seem to assume that if only the health of all citizens was elevated to a level displayed by the wealthy segments of the population, then everything would be good. However, even if we share the concern over the poor health of many citizens, in particular those with low education and low income, then it is highly problematic to assume that every person agrees to adhere to nationally given health norms. Secondly, because political economy approaches assume that all citizens desire a high and uniform level of health, then the absence of this must be due to power relations blocking poorer groups from achieving better health outcomes. Accordingly, the political economy and ideology approach focuses only on repressive forms of power, i.e. those forms of power that thwarts citizens’ desires and needs. Thereby, they not only disregard the fact that some citizens – be they poor or rich – actually prefer a so-called unhealthy lifestyle. They also neglect the indirect or soft forms of power that work through citizens freely subjecting themselves to wider norms of good health. To ignore these freedom-based forms of power is problematic, as health promotion primarily, though not exclusively, relies on just these forms of power.

Sociological critique of health promotion

Ever since Émile Durkheim’s famous study of suicide (Durkheim, 1968 [1897]), the influence of modern social relations on the health of individual citizens has received attention from sociologists. Variations in the health status of a population within a given state have been attributed to differences in material conditions, positioning in predominant cultural and social structures, and to the role of biomedical knowledge and authority. Today there is a very substantial body of sociological literature – both theoretical and empirical – testifying to the importance of material and social conditions, such as income level and distribution, level of education, and access to medical services, for the level and variation of citizens’ health status (e.g. Macintyre, 1986; D. Gordon, 1999; Mitchell, Dorling, and Shaw, 2000). In line with political economy approaches, these sociological studies regard differences in material conditions and economic income as crucial in shaping the possibilities that people have for leading a healthy life.

Another strand of sociological health studies have focused on the importance of trust. Trust, or rather the lack of it, between citizens in a community or between citizens and (health) authorities may contribute to poor health (Kawachi and Kennedy, 2002; Wilkinson, 2005). In particular, the last decade or two have seen the emergence of sociological research pointing to the importance of social capital for health. While some of this literature rather uncritically endorses the building of social capital as a way to promote health, we also find sociological studies critically examining how health programmes built around the notion of social capital are saturated with power relations and at times ignore material forces crucial to health outcomes (Navarro, 2002b; Wakefield and Poland, 2005). Thus, several studies of the role of socio-psychological factors for health acknowledge that low trust or social capital in certain communities often is the result of unequal distribution of material resources. Accordingly, the strictly material and many of the socio-psychological studies are highly critical of health policies that ignore the material factors impinging on citizens’ health status.

A large body of sociological literature has pointed to the importance of medical knowledge and authority in shaping the relationship between doctor and patient and, more generally, the possibilities that citizens have to lead a healthy life. Several works have emerged since the 1970s criticizing the medicalization of social phenomena and, by implication, the attempt to treat social problems with medical means (Illich, 1976; see also Clarke, Shim, Mamo, Fosket, and Fishman, 2003; Conrad, 2007). Likewise, other scholars have criticized the authority exercised by the medical profession over ordinary citizens (Trostle, 1988). A somewhat different take on medical knowledge is the attempt to understand its role in formation of subjectivity. In particular, Armstrong’s A New History of Identity: A Sociology of Medical Knowledge provides an insightful analysis of the ways in which medical knowledge and practices have contributed to the emergence of the modern human being over the last 150 years in Western, industrialized countries (Armstrong, 2002). The book provides an important historical backdrop to the current politics of health promotion by accounting for shifting medical understandings and political strategies for dealing with illness and health.

The notion that citizens’ health is shaped by material, cultural, and epistemic forces and relations has also fed into sociological studies of health promotion. A general argument has been that health promotion often fails to alleviate inequality in the health of citizens, at least if it relies narrowly on biomedical expertise (Braveman, Egerter, and Williams, 2011). In fact, health promotion based on a narrow medical approach focusing on individual behaviour may perpetuate structural (social and cultural) inequalities (Bunton, Nettleton, and Burrows, 1995; M. Kelly and Charlton, 1995). According to critical sociologists, the intake of fatty foods, alcohol, tobacco, and the lack of regular physical exercise is regarded in most health promotion programmes as risky behaviour (Frohlich, Corin, and Potvin, 2001). However, what appears to be an individual choice is really a behaviour structured by social contexts and relations that induce poor people to conduct themselves in ways that are likely to lead to poor health. Thus, it has been argued that health promotion often contributes to making the individual increasingly responsible for her or his illness, including its prevention and cure (Lindbladh, Lyttkens, Hanson, and Östergren, 1998; Beck and Beck-Gernsheim, 2002). Similarly, it may contribute to the neglect of the societal or structural causes contributing to poor health. Based on this critique, a number of academics have suggested that health promotion should be designed in ways that empower communities and enhance their capacities to take care of the health of local citizens (Minkler, 2005). This may take place not through traditional medical expertise but through various forms of health education, social work, and delegation of resources to local communities.

These sociological analyses of health politics and health promotion are highly insightful in understanding why we often see wide disparities in the h...