I find that when I learn a theoretical concept, especially one I like, I start to see it everywhere. Anyone who’s any significant amount of time with me knows that a seemingly benign ad or sign can set me off on a rant, and that I can usually be found half-an-hour later pacing and muttering about one book or another. The nice thing about having this blog is I can write these rants down instead of (okay, often in addition to) blabbering to my friends and family. I snapped a picture of this dispenser in line at the Toronto Airport because it gives me an excuse to write about one of my favorite ideas: biomedicalization.
The sign says (in French and English, Canada being bilingual and all) “Your health is in your hands” to encourage people to use the sanitizer. The message the sign sends is that you are responsible for your own medical well-being, especially if the tools for disease-prevention are freely and publicly available. If you get sick, the logic goes, and did not avail yourself of the hand sanitizer made conveniently accessible by the State, then you have no one to blame but yourself. This isn’t how we’ve always talked about illness.
As an example to ground the discussion of changing medical discourses, I’ll use the plague at Thebes in Sophocles’s Oedipus Rex. In the pre-medicalized discourse of the play, the plague is inflicted on the city as punishment for the incestuous pairing of Oedipus and Queen Jocasta. Tiresias, the blind seer, compelled by Oedipus to point out the person responsible, says “I charge thee, hold/To thy late edict, and from this day forth/Speak not to me, nor yet to these, for thou/For thou art the accursed plague-spot of the land.” The king is the cause of disease within the city, the site of its origin, and it will only relent when Oedipus realizes his crimes and exiles himself. Of course, we know exiling monarchs is a relatively poor public health policy. Medicalization is the discursive shift whereby we explain diseases according to pathogens external to the diseased. Plagues, in this way of thinking, aren’t caused by incest or moral corruption of any sort, they’re caused by contagious microbes. Expel all the mother-fuckers you want, but no one is going to get any healthier.
In their paper “Biomedicalization: Technoscientific Transformations of Health, Illness and U.S. Biomedicine” – which spellcheck assures me contains no recognized words – Adele E. Clarke, Janet K. Shim, Laura Mamo, Jennifer Ruth Fosket and Jennifer R. Fishman outline the turn from a medicalized to biomedicalized discourse. Medicalization involves de-moralizing illness, a movement from “badness to sickness.” (10) The causes of a medicalized plague aren’t anyone’s fault; outbreaks of sickness are unfortunate happenings that can be addressed with science. The painful excess of passive voice in the second part of that sentence is important; in medicalized discourse, illness is not inflicted by agents, but upon them.
Biomedicalization has five pillars as described in the piece: the Biomedical TechnoService Complex, a focus on risk and surveillance, technoscientization of biomedicine, transformations of information and the production and distribution of knowledges, and the transformation of bodies and identities. I want to focus here on the second, the focus on risk and surveillance, because, as the authors state, this is a central point in the discursive switch. They write of “health as a moral obligation” as possibly the most radical shift in biomedicine. This is the re-moralization of illness, going from medicalized “sickness” back to an improved idea of “badness.” The herd of authors write,
“[H]ealth becomes an individual goal, a social and moral responsibility, and a site for routine biomedical intervention. Increasingly what is being articulated is the individual moral responsibility to be and remain healthy or to properly manage one’s chronic illness(es), rather than merely attempt to recover from illness or disease when they ‘strike.’ In the biomedicalization era, the focus is no longer on illness, disability, and disease as matters of fate, but on health as a matter ongoing moral self-transformation.” (12)
Within biomedical discourse, one’s health is once again in one’s hands. This is all tied to Foucault’s idea of biopolitics, in which the State regulates and surveils individual bodies as members of populations. If disease is due to unclean bodies, then we must all keep ourselves clean, lest we make ourselves ill. The plague is once again our fault. This time, the Thebans are responsible for not taking measures that would have prevented the disease’s spread in the first place; Oedipus should have used the hand sanitizer when he had the chance. The pollution is internal, a moral failing takes place before the physical failure of infection. In the biomedical discourse, one is responsible for the condition of one’s defenses. Even as the authors stress that the two are not necessarily exclusive, medicalization provides the cures that make biomedicalization possible. If all illness is explainable and curable (or at least containable), then there quickly becomes no good excuse for not making use of these technologies and knowledges to keep oneself “healthy.”
Here I want to shift gears a little and examine the way biomedicine is gendered. One of the most common invocations of health risk and surveillance is best expressed by this Cathy panel that really could be from any number of individual strips. For Cathy, eating chocolate is an immoral act, a lapse in willpower, a crime against her own body. The tension causes, as seen in the picture, a hysterically ambivalent response on Cathy’s part. The influence of Foucault becomes clear when we think about the surveillance occuring. No one else is watching Cathy, no one else knows what she’s eating, but she has internalized the observer’s eye. This anxiety about food’s health effects has expanded in recent years, but it is still a gendered idea. There aren’t a lot of men running around yelling “Chocolate! Aack!” or at least not many representations of it. Women’s bodies are specially targeted for transformation through this surveillance: cosmetic surgery is biomedicine par excellence and is still primarily aimed at women. With so much money to be made off diet books and liposuction, it would be economically inefficient not to find a profitable discourse. Of course, this isn’t to say that medicalization was not profitable or gendered – you can ask the ghost of Rosemary Kennedy, who was lobotomized at the age of 23 for “mood swings.” But the key here is that biomedicine involves the regulation of populations, not just of diseased individuals. Sickness is no longer an individual problem, but a national problem. I don’t think it’s insignificant that the hand-sanitizing dispenser above was part of the airport security checkpoint, a site of particularly invasive State surveillance.
Lest I imply that biomedicalization is only gendered as it applies to women, I’ve got another example from north of the border. This is a pack of du Maurier cigarettes, a Canadian brand I picked up duty-free at the same airport. The small text reads, “Cigarettes may cause sexual impotence due to decreased blood flow to the penis. This can prevent you from having an erection.” Impotence among men, despite (or because of) the profits to be made off Viagra and other erectile dysfunction drugs, has never been fully medicalized. “Real men” don’t have impotence problems in the first place. When biomedicalized, smoking becomes a health choice, and therefore a moralized decision. The consequences are deserved: if you don’t want to be impotent, don’t smoke. The ad, of course, assumes the smoker is male, as I imagine the limp cigarette imagery and threats to erections wouldn’t have the same desired deterring effects on female consumers. It’s also worth mentioning that this is a health warning not from the cigarette manufacturer, but from the Canadian State. Impotence is not merely an unfortunate side-effect that can be cured with proper medication, for the smoker it’s the result of a failure to maintain one’s own health. In effect, I’m being told that if I smoke these cigarettes and can’t get it up, it’s my own damn fault. In the same way that biomedicine uses ideas of proper female bodies (skinny, wrinkle-less, buxom) to sell surgeries and supplements, the discourse uses ideas of proper male bodies (erect on command) in this health warning.
We can see another hallmark of biomedicalization – the viewing of individuals as members of populations – in this warning. Empirically, tobacco use does not cause impotence in all men, but apparently it does in some. Who these men are and what the confounding variables in their lives might be I do not know, but the fact that some men are rendered impotent by smoking is enough to determine that it might affect “you” in the same way. As a part of the susceptible population, one is put automatically at risk by the very existence of a possible condition. This is the condition of being permanently “at risk” that Clarke et al describe, “It is no longer necessary to manifest symptoms to be considered ill or ‘at risk.’ With the ‘problematisation of the normal’ and the rise of ‘surveillance medicine,’ everyone is implicated in the process of eventually ‘becoming ill.’ Both individually and collectively, we inhabit tenuous and liminal spaces between illness and health, leading to the emergence of the ‘worried well,’ rendering us ready subjects for health-related discourses, commodities, services, procedures, and technologies. It is impossible not to be ‘at risk.'” (13) This is one of the central dangers of biomedicalization as a health discourse, it engenders a constant baseline of fear and anxiety about one’s own body. Am I doing enough to stay healthy? Am I eating the right foods? Am I taking all the right vitamins and pills? One could spend all day worrying about, and spending to protect, one’s health. And some do. The body is at war with itself. I find discourse analysis so important not because we shouldn’t be healthy, but because the way we talk about health changes, changing correspondingly what it means to be “healthy” in the first place. It would be nice to think of the State as just looking out for us, but biomedicine is disciplining and we must be attentive to the way it transforms and regulates (gendered) bodies.