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Guest Editorial
Re-imagining Preventive Health
Theoretical Perspectives
Christine Beasley
School of History and Politics, University of Adelaide, SA
Megan Warin
Department of Anthropology, Durham University, United Kingdom
Article Text
This Special Edition of Health Sociology Review arose in the first instance out of the work of a 'Research Cluster' within the University of Adelaide, South Australia. The Research Cluster was organised around a common concern amongst researchers regarding Preventive Health. The aim was to develop a broad research grouping with interdisciplinary interests which would, in particular, provide an opportunity to draw together scientists and social scientists. The intention of the Preventive Health Research Cluster was specifically to move beyond a narrow biomedical understanding of health.
Many researchers had particular health issues they wished to focus on (such as obesity), but a smaller sub-grouping sought funding to investigate the possible limits of theoretical frameworks employed in the field of Preventive Health, on the basis that the discussions undertaken concerning this field all too often presumed certain frameworks and understandings that at the least required clarification and analysis. The sub-grouping gained funding under the rubric of 'Social, Cultural and Economic Influences on Health' and organised public lectures followed by a colloquium on the subject of 'Re-imagining Preventive Health: Theoretical Perspectives'. The colloquium was held in February 2007 and involved University of Adelaide researchers from a number of disciplinary/institutional locations, including General Practice, Public Health, Politics, Psychology and Philosophy, as well as Gender Studies in the Social Sciences.
The colloquium formed part of a broader initiative of the Preventive Healthcare Research Cluster that aimed to develop new thinking on theory in Preventive Health. The initiative was designed to consider theories shaping the field today, and to critique and re-imagine these theories, in order to provide the grounding for robust debate and to advance a more developed theoretical base for that field. In short, the sub-grouping - and the colloquium which its members organised - started from the position that while many Public Health experts remain unconvinced by the relevance of theorising, these experts nevertheless employ frameworks which may be more or less implicit in that they are precisely not recognised as involving theoretical presumptions (Kickbusch 2006:561; Dean and McQueen 1996:7,9). This context, far from producing an absence of theorising within Public Health, tends to result in a flourishing of particular sorts of theoretical approaches. Yet, the dominance of certain ways of thinking such as atomistic individualism (with its asocial prescriptive agendas regarding individual health disconnected from material social conditions) and unreflective empiricism (a theory that rejects the need for theory, Jones and Walker 1997: 58-60), remains relatively invisible and under-examined. The result is what Green refers to as the ‘theory practice gap' in public health (Green 2000:125). To the degree that such presumptions remain relatively implicit they are likely to remain less than transparent, undeveloped (Dunn 2006:572) and, most problematically of all, less amenable to discussion, critique and possible reassessment.
In this setting, contributions to the colloquium (and to this Special Edition of Health Sociology Review) were marked by an inclination to perceive theory as intrinsic to Preventive Health, whether acknowledged explicitly or not, and thus to refuse any notion of Preventive Health as a self-evident, commonsense field of endeavour. Rather than constituting this field as an objective arena of knowledge 'external to us' (Sayer 1992:41), the implication is that health is a social product, and consequently is suffused by interpretative contestation and by its conditions of production, including existing power relations. While debates over the notion of social capital provide an obvious instance of the conceptual and socially situated character of what is deemed healthy (Moore et al 2006: 729), the same is said of issues which might appear more simply biomedical such as workplace injuries and so-called 'lifestyle' concerns such as obesity. Preventive Health does not, in this understanding, exist at a distance from sociality but is imbedded in it. Such a stance is clearly at a critical distance from a self-evident/objective account of Preventive Health (often aligned with a strongly biomedical orientation), yet this stance continues to be located at the margins of mainstream debate about health matters (Bambra et al 2005:187). Public Health generally, and Preventive Health within that rubric, has evolved from a biomedical framework and for the most part contemporary socio-political thinking remains thinly integrated into the theoretical foundations of health and its promotion (see, for example, Parker and Harper 2006). Indeed, some commentators would go so far as to argue that there is in fact little existent theoretical work which might provide the means to invoke and reflect upon the social relational aspects of health (Potvin et al 2005:591; Macintyre et al 2002).
Whether one sees contemporary socio-political theorising as poorly integrated into analysis of Preventive Health or Preventive Health as simply lacking much in the way of a theoretical foundation, the point here is that the interpretive social dimensions of the field appear presently underdeveloped. We, the guest editors of this edition, thus specifically invited papers seeking to engage in critical debate concerning current theoretical frameworks for understanding preventive and interventionist elements in health. Our concern was to move away from popular theoretical assumptions and to offer theoretical innovations in the arenas of Population and Public Health. It was expected that contributors would extend existing theoretical paradigms and/or concepts, consider their limits, challenge them, or even step beyond them and offer new directions/models. There was no expectation that the perspectives developed by the contributors would present a singular viewpoint or that such theory-building would result in a one all-encompassing mode of analysis (Szreter & Woolcock 2004:704). Rather we saw the rich theoretical project informing Preventive Health as broad, complex, drawing upon many disciplines and involving diverse conceptual possibilities. The contributions to this volume are indeed testimony to this assessment.
Despite the breadth of the collection, inevitably a collection like this one has certain contours. All of the contributors are Australian-based, bar one exception and even this contributor was located in Australia until recently. While the Special Edition of Health Sociology Review is dominated by directions and subject matter which have been the material of international debate, nevertheless the clustering of contributors may also enable a focus on particular issues that have formed the locus of contestation within a specific cultural context. This might generate potential comparative insights for readers located in other contexts. Additionally, it is relevant to note-even if an obvious point-that the contributors do not and could not provide an exhaustive coverage of all critical theoretical endeavours in Preventive Health. There are some important absences in the collection: in particular, attention to Indigenous issues. Clearly, there are significant debates concerning Indigenous health in Australia (see, for example, Langton 2007 for a recent commentary in the Griffith Review). Many of these point to entrenched racism, misguided academic discourse, and glaring policy failures. In this Special Edition, Bacchi's paper on the gap between what we know about the social determinants of health, and what we do about them, may well be relevant to interrogating the research/policy nexus within Indigenous health.
There are certain thematic regularities in this Special Edition of Health Sociology Review, arising no doubt from the call to engage in critical debate in order to re-imagine and reinvigorate theorising in Preventive Health. Critical engagements in the field have drawn attention to its inherently social constitution-both in the sense of it being necessarily an interpretive terrain and in the sense of its implication in existing power relations. Such engagements have more specifically registered a critique of that sociality: 'a critique of modernity' (Potvin et al 2005:591). Not surprisingly, certain theoretical consistencies appear in this critique. Leading theoretical frameworks reoccur, such as Michel Foucault's account of the operations of power in modernity, Ulrich Beck's analysis of the risk society, the notion of social capital in the work of writers like Robert Putnam, and the broad concept of the 'social determinants' of health. The latter evokes axes of power associated with socio-economic status, gender, and ethnicity amongst others, as well as questions about hierarchical relations between unequal actors in health systems and the role of 'lay' voices in offering challenges to the exclusive authority of 'expert' knowledges (Popay 2006), enabling a return to Foucault's concerns regarding regimes of power/knowledge. Such agendas and topics are well established in international debate concerning Preventive Health, but here they are extended and/or re-appraised and sometimes subjected to reassessment, rather than being taken as given. In this way the Special Edition offers a critical lens upon existing critical agendas with the intention of substantively furthering the development of theoretical frameworks in the field.
For instance, while Kickbusch suggests some limits to Foucault's concept of medicalisation in light of the impact of the market (Kickbusch 2008:561), Foucault's work is nevertheless re-examined in innovative ways in this Special Edition of Health Sociology Review by several contributors. Coveney's focus on Foucault's later work concerning governmentality and Diprose's coupling of Foucault with other theoretical paradigms offer two possible modes of enquiry, amongst others in the volume. These papers (and many others) examine embodied everyday lives (shaped by multiple and intersecting power relations such as sexuality, consumption, gender and class), and the complex practices involved in knowledge construction as well as in strategies of resistance and pleasure.
Outline of the Special Edition
A brief description of the contents of the collection indicates that the list of theoretical contributions (if not exhaustive) is undoubtedly wide-ranging. While the papers may be distinguished and ordered in a variety of ways, perhaps the most obvious distinction may be found between the first four papers and the last three. The first four, by Broom, Diprose, Beasley, and Bacchi, all in different ways question the enterprise of Public Health. The first three of these are especially concerned to question the risk orientation of Preventive Health - to offer a critical perspective on the field as a form of governance by prevention/pre-emption. Broom establishes a strong foundation for the volume by demonstrating how risk creates inadvertent blind spots in our contemporary paradigms. Her analysis of preventing smoking-related harm demonstrates how underdeveloped analytical reflection has led to inadequate recognition of class and gender factors in relation to smoking, and in consequence unintentionally fostered the reproduction of health inequalities. Diprose builds upon this analysis through her examination of the 2006 ‘quit smoking' campaign in Australia. Drawing on philosophies of the body (specifically Foucault's biopolitics and Merleau-Ponty's phenomenology), Diprose argues that there is a new emerging paradigm of pre-emptive risk in public health discourses (analogous to biosecurity and anti-terrorism measures) that has implications for diminishing the creative and resistant possibilities of embodied social life.
Beasley also considers the questionable impact of a risk orientation in Preventive Health, but in this case with regard to sexuality. Beasley's work initially suggests some qualification of Foucault's claims concerning the proliferation of sexualising discourses in modernity. She argues that heterosexuality within Preventive Health, and in Gender/Sexuality thinking which informs it, is largely absent as a potential source of pleasure and over-determined as a source of repressive domination. In consequence preventive sexual health projects are unable to frame hetero-sex beyond the defensive language of risk avoidance. Re-imagining sexuality and sexual health frameworks, she asserts, involves developing new modes of thinking which do not discount pleasure and its creative potentialities and offer ways of constituting an 'ethical erotics'.
These perspectives on risk put forward by Broom, Diprose and Beasley enable consideration of what risk problematically prioritises, what it may inadvertently privilege and what is absent from its purview. The analysis of this risk orientation has implications for the whole arena of Public Health. The fourth paper by Bacchi offers another take on the framing of Public Health and is concerned with the structures of governance. This paper attends to funding arrangements, the narrowing of complex plural knowledges, and unacknowledged institutional regulatory processes. Bacchi critiques the ways in which the knowledge gap between research (what we know) and policy (what we do) is articulated, suggesting that research management has now aligned itself to a delimited research agenda which veils a particular set of assumptions with the supposedly value-free language of efficiency and realistic goals to produce a certain kind of ‘fit' between research problems, questions and expected outcomes. This 'fit' amounts to the curtailment of intellectual diversity and debate.
The latter three papers by Meyer et al, Warin et al and Coveney, have a somewhat different orientation. All concentrate upon detailed analysis of existing critical vocabularies in the Preventive Health field, with a focus upon trust, consumption and governmentality respectively. These writers aim to provide a more rigorous and expansive understanding of widely used terminologies in the critical literature. Meyer et al examine dominant theories of trust in health systems from Giddens and Luhmann, and suggest that a more comprehensive model (enabling recognition of significant social factors and the complex, multidimensional webs that activate trust) is required in Public Health research. Importantly, this paper also problematises the argument that trust is quantifiable; asking: ‘can we ever really measure and bring into view the linkages between knowledge and ignorance'? In many ways, this question points to wider positions and arguments raised by the Special Edition of Health Sociology Review as a whole: ‘to value those things that cannot be measured; to recognise that not everything that can be counted counts and that not everything that counts can be counted' (Sillitoe 2007).
While Broom and Diprose refer to the topic of smoking, Warin et al and Coveney offer careful assessments of the issue of obesity. Using ethnographic techniques of participant observation Warin et al critique the ways in which consumption has been taken-for-granted in obesity discourses and policy initiatives, suggesting that commodification of bodies, spaces and health are not simply part and parcel of the negative effects of a 'consumer society', but fundamentally concerned with the paradoxes and possibilities of consumption. An ethnographic approach to a Public Health issue allows us to rethink and redefine key questions of the ‘obesity problem', particularly as they relate to contexts of gender and class. Coveney's timely paper illustrates how childhood has become a major point of engagement in the war on fat, and the ways fatness in children has allowed for the availability of different subjectivities or subject positions in which children are framed as sick, slothful and dangerous, or innocent helpless victims (and extending to new subject positions for parents, industries, and organisations). Such governing of the girth is positioned within Rose's characterisations of new forms of government (Rose 1996), which emphasise networks of governance and pluralisation of ‘social' technologies.
In short, all the contributors to this Special Edition of Health Sociology Review are committed to re-imagining theoretical perspectives in Preventive Health. We recognise that no single discipline has a monopoly, and that both biological and social science perspectives are important to unpacking the complexity of patterns and experiences of health and disease. We hope that the papers in this volume will continue to challenge and extend our existing stock of social and political theories of health and prevention, and contribute to new theoretical directions.
Acknowledgements
The editors would like to thank the anonymous reviewers who generously assisted in reviewing manuscripts for this Special Edition of Health Sociology Review, and the hard work of the HSR editorial team. We would also like to thank participants of the Preventive Health Research Cluster at the University of Adelaide and Professor Ilona Kickbusch for their stimulating intellectual engagement. Anne Hayes deserves special mention for her instrumental role in organising the original forum from which the idea for this Special Edition arose.
Endnotes
1. The on-going members of this sub-grouping were Carol Bacchi, Chris Beasley, Annette Braunack-Mayer, Teresa Burgess, Anne Hayes (administrative coordinator), and Vivienne Moore.
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