The Imperative of Health

Public Health and the Regulated Body

Deborah Lupton

• Publisher: SAGE Publications Ltd
• Year: 1995
• Print ISBN: 9780803979369, 9780803979352
• eBook ISBN: 9781446238080
• Edition: 1
• Topic: Social Sciences
• Subtopic: Sociology
• Index: Social Sciences

In this reappraisal of public health and health promotion in contemporary societies, Deborah Lupton explores public health and health promotion using contemporary sociocultural and political theory, particularly that building on Foucault?s writings on subjectivity, embodiment and power relations. The author examines the implications of the new social theories for the study of health promotion and health communication to analyze the symbolic nature of public health practices, and explores their underlying meanings and assumptions.

1

Governing the Masses: the Emergence of the Public Health Movement

It is difficult fully to understand the rationale and logic of contemporary institutions such as public health without some awareness of their historical underpinnings. Armstrong (1993: 405) has identified four major regimes of public health over the past two centuries: quarantine, followed by sanitary science, the regime of interpersonal hygiene and lastly the ‘new’ public health. As he observes, all of these regimes deal with drawing boundaries and circumscribing spaces: between geographical places, between the body and the external environment, between one body and another body. The quarantine regime was dominant up to the mid-nineteenth century, when the public health movement began to focus on environmental conditions. During the nineteenth century, new forms of surveillance of populations were developed in the fields of public hygiene and mental health, along with state policies and programmes. A concern with personal hygiene arose from developments in bacteriology in the late nineteenth century, leading to an emphasis on education around the proper deportment of the body. The ‘new’ public health movement emerged in the 1970s, refocusing attention on the social and environmental conditions of health patterns, with an interest in radical change. In this chapter the first three ‘regimes’ of public health are discussed, while Chapter 2 goes on to examine public health and health promotion in the late twentieth century.

Traditional historians of public health have tended to describe a narrative of progression. For these historians, the advent of the public health or sanitarian movement in the nineteenth century, particularly as it emerged in Britain and continental Europe under the dynamic interventions of the great reformers (almost invariably all white, bourgeois men), was the beginning of a ‘modern’, rationalized approach to protecting and preserving the public’s health. The standard narrative of such histories begins by discussing the filth, squalor, ignorance and superstitious beliefs that prevailed before the nineteenth century and recounts the progressive introduction of the sanitarians’ ideas into hygienic conduct as a continuing fight against general apathy, ignorance and dirt. The discovery of the microbe in the late nineteenth century is hailed as the watershed for a ‘scientific’ public health, enabling public health reformers to strengthen their arguments for a web of governmental regulations around public and private hygiene (for an example of such a history, see Duffy, 1990). Other histories of public health have taken a social history perspective, adopting a somewhat more critical stance in highlighting the inequities inherent in the nineteenth- and early twentieth-century public health movements’ treatment of groups such as women, immigrants, non-whites, the working class and the poor (for example, Rogers, 1992). Those adopting a social constructionist approach have located their histories in the broader socio-cultural context, seeking to explore the symbolic and ideological dimension of public health practices (Brandt, 1985; Corbin, 1986; Herzlich and Pierret, 1987; Davenport-Hines, 1990). The advent of HIV/AIDS in the early 1980s, with its evocation of ages-old meanings around disease and epidemics, has had a particularly stimulating effect on the writing of histories of public health from the social history and social constructionist perspectives (see, for example, several of the essays collected in Fee and Fox, 1988, 1992).

A further, more radical historical approach has built upon the work of Michel Foucault in his genealogical analyses of medicine and public health. Genealogy is a term used by Foucault to describe his method of tracing the emergence of discourses, bodies of knowledge and power relations over time, to write a ‘history of the present’. In genealogy, lateral connections are as important as causal or development connections (Grosz, 1989: xviii). Genealogy seeks to show that previous discourses and practices have their own logic and are internally coherent, even if they are radically different from present day practices and logic. As such, it demonstrates the contingent nature of the present. According to Foucault (1984b: 80) the genealogist ‘needs history to dispel the chimeras of the origin’, to demonstrate the fragmentary and heterogeneous nature of knowledges. Genealogy is also a means by which to trace the inscription upon the human body of events, to describe ‘the articulation of the body and history’ (1984b: 83). In doing so, Foucault was concerned to emphasize the discontinuity and non-linear nature of social change, to focus on local knowledges, or ‘discreet and apparently insignificant truths’ (1984b: 77). These include human emotions and abstract concepts such as morals, ideals, liberty, sentiments, love, conscience, instincts and how they emerge and re-emerge in different roles or are absent at certain moments.

The histories written by social constructionists and Foucault and his followers have demonstrated that a close analysis of the emergence and development of the public health movement reveals not a steady progression from primitive, ‘unenlightened’ thought to ‘modern’ ideas and practices, but a series of eras characterized by regressions and political struggles. Their histories have shown that while it is standard to describe the ‘old’ public health and the ‘new’ public health as related but very different traditions, much of the discourses and practices of the ‘old’ public health movement can be currently seen in the ‘new’ public health. They have also revealed that for centuries the institutions of medicine and public health have been central in constituting the ‘normalizing gaze’ as part of mass observation and social regulation. This chapter primarily draws upon the insights of such histories to discuss the key problems identified and constructed by public health and the strategies of surveillance and regulation developed to govern these problems. The history and philosophy of the public health and social hygiene movements as they emerged in the eighteenth century in western societies are reviewed, with a particular focus on Britain and continental Europe as the ‘birthplaces’ of the public health/sanitary movement. The discussion begins with medieval attempts to respond to epidemics, moving onto the Enlightenment and the emergence of the social hygiene movement, then to the implications of the discovery of the microbe for public health practice. The chapter focuses in particular on the ways in which the bodies of individuals have been constructed and regulated via the discourses and practices of public health in its various forms, centring on the constitution of such problems as dirt, miasma, odour, sexuality, reproduction, childhood and the family as matters requiring the attention and expertise of public health reformers.

Public health before the Enlightenment

Two kinds of public health measures dominated western societies until the late eighteenth century: emergency measures dealing with outbreaks of epidemic disease, and everyday regulations dealing with municipal nuisances such as waste disposal. Illness during this era was characterized by three primary dimensions: ‘numbers, impotence and death, and exclusion’ (Herzlich and Pierret, 1987: 3). Epidemic disease such as the plague created intense activity and extreme measures, which subsided after the threat had passed, while endemic diseases were taken-for-granted. When epidemics broke out, they were dealt with by invoking such measures as quarantines, sequestration and cordons sanitaires, and temporary institutions such as boards of health were set up to manage the crisis (La Berge, 1992: 10). From the Middle Ages onwards, more permanent public health measures were instituted, governing street cleaning, sewage disposal, the free-flowing of water courses, the zoning of industries, and hygiene in meat, fish and fruit markets (Palmer, 1993: 66).

The recurrence of plague in Europe throughout the fourteenth and fifteenth centuries engendered a concern with its control, with the high death rates inspiring the introduction of new measures to counter its spread. Of the European countries, Italy was in the forefront of establishing a system of epidemic control, having set up in the fourteenth and fifteenth centuries permanent magistracies charged with overseeing moral and physical hygiene in the major cities (Cipolla, 1992: 1). The Italians introduced new techniques of isolating the sick and those who had come into contact with them, establishing special isolation hospitals, requiring that the dead’s clothing and effects be burnt and imposing restrictions on travel and trade with infected areas. Travellers were required to present a bill of health stating that they did not carry infection before they were allowed to enter a city or a port (Herzlich and Pierret, 1987: 14). Some Italian cities set up ‘books of the dead’ to record mortalities and follow the course of epidemics (Park, 1992: 87). In the northern and central cities of Italy the health magistracies also concerned themselves with wider regulatory measures such as the quality of food sold, sanitary conditions in houses of the poor, prostitution, sewage, the activities of medical workers and the issuing of health passes (Cipolla, 1992: 2).

The word ‘quarantine’, still in common use today, originates from the Italian for ‘forty days’, as that was the length of time deemed necessary to isolate the ill. Quarantine was the first public health strategy used to police boundaries. This strategy was developed from the contagionist understanding of disease; that is, the belief that illness could be spread from body to body, and that the ill and the infectious should therefore be isolated from others to control the spread of epidemics. Under this notion, ‘illness somehow resided in places, as it was places that had to be kept separate’, while human bodies were seen as the vectors between places of infection and places of purity (Armstrong, 1993: 395). The contagionist model relied upon the identification of stigmatized groups as the dangerous Other, the site of contagion. For example, in medieval times lepers were separated from others, and were publicly denounced and expelled from cities or confined to hospitals outside the city walls. They were deprived of all property and forced to live on public charity (Herzlich and Pierret, 1987: 5; Park, 1992: 87). During the fourteenth century, Jews in particular were singled out as spreading plague, and were subsequently persecuted and killed in large numbers (Frankenberg, 1992: 74–5).

Two other central theories of disease causation underlay public health measures for several centuries; the miasmic and the humoral theories. From the time of the ancient Greeks and Romans, it was believed that the environment, in combination with individuals’ constitutions, were influential in affecting people’s state of health. The humoral theory of disease incorporated an understanding of the healthy body as maintaining a balance of the four humours, blood, phlegm, black bile and yellow bile, four elements, earth, air, fire and water, and four qualities, hot, cold, wet and dry. Both one’s diet and the climate one lived in were deemed important to one’s state of health (Nutton, 1992: 23). The longevity of the humoral theory of disease is demonstrated by its recurrence in lay and medical explanations of ways to maintain good health in the sixteenth and seventeenth centuries. During this time it was believed that ‘the different qualities vital for life had to be kept in a good balance. The body must not be allowed to become too hot or cold, too wet or dry (fevers and colds would result)’ (Porter, 1992: 95). It was further believed that the six ‘non-naturals’ – diet, evacuations, exercise, air, sleep and the passions – should be regulated by individuals to ensure good health (Porter, 1992: 99; Risse, 1992: 171). In the seventeenth and eighteenth centuries a series of books, manuals and pamphlets building on the humoral model were published, encouraging individuals to adopt a regimen directed at strengthening the body’s constitution and giving advice on the types of food it was best to consume, the frequency of exercise that should be taken and so on. Such publications urged their readers to adopt a sober, rational approach to their lifestyle, privileging asceticism as the route to good health. They were directed at literate, wealthy, ‘well-disposed’ people who were expected to spread this knowledge among the less well-privileged (Turner, 1992; Risse, 1992: 187).

The miasma theory of disease was prevalent in Europe from ancient times right up until the discovery of microbes. This was the notion that ‘bad air’ – air that was damp, odorous or polluted – in itself caused disease. It was believed that the sticky miasmal atoms lodged in bodies, wood, fabrics, clothing and merchandise and could be absorbed through the skin or by inhalation and could therefore pass from person to person or animal to person through contact (Corbin, 1986: 63; Cipolla, 1992: 4). The theory was thus similar to the contagionist model, but was more specifically related to substances of contagion that could be identified by the senses: dirt and odour. The miasmas issuing from diseased, dead and decomposing bodies were considered especially dangerous, capable of causing such conditions as gangrene, syphilis, scurvy and pestilential fevers by breaking down the equilibrium of the living body (Corbin, 1986: 17). The miasma theory, in conjunction with the contagionist and humoral models, was able to account for a wide variety of disease. The chain of infection was believed to be the sequence of dirt leading to smells leading to miasma leading to pestilence. For example, it was noted that plague epidemics often broke out in the hot summer months, and this was explained by the fact that the heat intensified the bad odours associated with miasmas. Little attention was given to another phenomenon of this season: the increase in the number of rats and the fleas they carried (Cipolla, 1992: 5).

Because of the belief that smell was an indicator of the contagious nature of air, odour has been a particularly important dimension of beliefs about the causes of diseases and ways of preventing against epidemics. It was believed that confinement in spaces that smelt malodorous, such as ships, jails, hospitals and latrines, was especially dangerous (Palmer, 1993: 66). During an outbreak of the ‘Black Death’ (as the plague was called at that time) in 1348, the Italian town of Pistoia regulated the depth of burials ‘“to avoid a foul stink” … and banned the tanning of hides within the city walls “so that stink and putrefaction should not harm the people”’. In 1522, the city of Venice ordered the compulsory hospitalization of people with syphilis found begging in the town because of the concern that their ‘great stench’ could bring the plague (Palmer, 1993: 65). In sixteenth-century England it was strongly believed that the countryside was far healthier an environment to live in than urban areas, partly because of the abundance of fresh air and lack of overcrowding. Tobias Venner, an English physician, wrote in 1628 in his treatise on healthy living that marshy or damp air produced nearly all ‘the diseases of the braine and sinews, as Crampes, Palsies etc. with paines in the joynts; and to speake all in a word, a general torpidity both of minde and body’ (quoted in Wear, 1992: 133–4). Methods of disinfection used aromatic substances to ‘purify’ the air and rid bodies or materials of the miasmic atoms (Corbin, 1986: 623). The sense of smell was employed to determine whether an environment was healthy or unhealthy, and people used sweet odours to combat the ill effects of bad air, carrying fragrant flowers or herbs around with them or using fumigation in dwellings, ships and hospitals (Corbin, 1986: 64–5; Wear, 1992: 137). As late as the eighteenth century in France, individuals would douse themselves liberally with perfume in the belief that doing so would protect themselves by purifying the surrounding air (Corbin, 1986: 63).

While factors such as the climate, diet and odours were believed to play an important part in causing disease, the ultimate cause was deemed to be God’s will: disease was God’s punishment for the sins of humankind (Herzlich and Pierret, 1987: 103; Porter, 1992: 96). A supernatural understanding of how disease was engendered thus overlay the other models, and provided an explanation when other rationales failed. It also allowed the expression of overtly moralistic statements concerning the relative sinfulness of individuals and certain social groups such as the poor (Tesh, 1988: 18–19); a tendency that has pervaded public health discourses for centuries.

Public health during the Enlightenment

The age of the Enlightenment, emerging around the end of the seventeenth century and lasting until the late eighteenth century, was a transitional era characterized by a reaction against unquestioning religious and superstitious belief, and a strong optimism in the ability of humans to control their destiny to their own convenience. It was believed that nature was patterned and predictable, and that its laws could be discovered using human insight. The uncovering of truth using rational thought, scientific method, experiment and calculation was believed to be the key to human progress. The public health movement (more often referred to at that time as the social medicine or social hygiene movement) as it developed in eighteenth-century Europe adopted many of the concerns and approaches of Enlightenment thought, including an emphasis on progress, rational reform, education, social order, humanitarianism and scientific method (La Berge, 1992: 11). It was believed that there were underlying laws of nature governing disease and epidemics that could be revealed through scientific inquiry and the gathering of empirical data (1992: 12). Once such laws were established, then disease could be controlled, removed and prevented by deliberate and rational action (Risse, 1992: 172).

This was also the time in which the concerns and strategies of governmentality became a central feature of the state’s relationship with its citizens. The concept and apparatus of governmentality sprang from the Enlightenment ideal of the rationalization and ordering of society. Foucault (1991: 87–8) argues that governmentality first emerged as a general issue in the sixteenth century, associated with a number of social and economic phenomena: the breakdown of the feudal system and the development of administrative states in its place which were based upon rationality and legitimate rule, and the questions of spirituality and self posed by the Reformation. According to Foucault, by the eighteenth century, due to the emergence of the problem of the growth of the population, the notion of governmentality expanded beyond the aegis of the state (1991: 98–9).

The concept of ‘social medicine’ originated in the eighteenth century in association with a trend towards paternalism involving greater state intervention and regulation of citizens at the level of the population (Turner, 1990: 5). The ideology of statism, or the notion that it was the responsibility of the state to provide for public health through administrative, legislative, and institutional means, dominated the social medicine movement. It was believed that good health was a natural right of all citizens and as a result, if states’ duty was to protect their citizens’ rights, then public health was the duty of the state and a proper area for intervention and control (La Berge, 1992: 16). The movement was also influenced by scientism, or the notion that science was the key to progress, and hygienism, an ideology combining medicalization and moralization directed at preventing and containing the feared social disorder looming as a result of industrialization and urbanization. To achieve the goals of social medicine, its practitioners realized that they needed to increase their authority to gain legitimization, and to work towards professionalization and the development of the movement as a science (1992: 2). The proponents of the social medicine movement saw health reform as interlinked and broad, ranging from poverty, prostitution, venereal disease, infant abandonment and mortality and housing (Jones, 1986: 11–12; La Berge, 1992: 4). It was considered important to avoid the emergency approach to containing disease that characterized the Middle Ages by moving to a preventive model, using administrative procedures.

The goals of public health were predicated upon the rise of the modern European states during the seventeenth and eighteenth centuries, allowing the institution of effective political and bureaucratic organizations with national scope (Risse, 1992: 171–2). Enlightenment medicine began to regard health as ‘a positive tenet which could be attained, preserved, and even recovered with the aid of a proper life style, public and personal hygiene, and the aid of medicine’ (Risse, 1992: 195). By the early eighteenth century, the attention of public health reformers moved to endemic disease, devoting particular attention to occupational hygiene (La Berge, 1992: 18). This change in emphasis can be linked to the public health movement’s concern with ensuring the health of the labour force in the context of rapid industrialization and urbanization. The goal of the public’s health became an essential objective of political power. In concert with the economic imperatives of the emergent capitalist system, the health of the population became of central importance, especially that of the poor (Dean, 1991; Risse, 1992). It was in the interests of the modern European state to ensure that its citizens were healthy so as to promote productivity: to move beyond a concern with individuals and small groups to regulate health at the level of the population as a whole. Where Italy led the way for the management of public health in th...

Table of contents

• Cover Page
• Title page
• Copyright
• Contents
• Acknowledgements
• Introduction
• 1 Governing the Masses: the Emergence of the Public Health Movement
• 2 Technologies of Health: Contemporary Health Promotion and Public Health
• 3 Taming Uncertainty: Risk Discourse and Diagnostic Testing
• 4 Communicating Health: the Mass Media and Advertising in Health Promotion
• 5 Bodies, Pleasures and the Practices of the Self
• Conclusion
• References
• Index