INFORMED CONSUMERS, REGULATED SUBJECTS: PUBLIC HEALTH AND THE RISE AND FALL OF THE INTERVENTIONIST STATE

Keith Denny

A thesis submitted in conformity with the requirements for the degree of Master of Ans Department of Adult Education, Community Development and Counselling Psychology Ontario Institute for Studies in Education of the University of Toronto

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ACKNOWLEDGEMENT INTRODUCTION 1 The Retum of Public Health 1 The Context of the Study 4 Method of Analysis: Reading for the Ideological Themes 7 The Case Studies 10 CHAPTER ONE: ADULT EDUCATION, PUBLIC HEALTH AND CULTURAL MATEWISM i 8 Adult Education and the Adult Leamer 18 Adult Education and Ideology: Looking for a Theory of Culture in Marx, Gramsci and Freire 23 Gramsci's Theory of Hegemony: From "False Consciousness" to Antinomy 30 Education as ldeological Production in Gramsci and Freire 33 Ideology and Hegemony, Government and Discourse: Synthesising the Components of Cultural Materialism 39 Adding ~oucaulito the Mix Education, Public Heal th and the State CHAPTER TWO: FOR THE PROGRESS OF THE RACE: THE CANADIAN PUBLIC HEALTH MOVEMENT 1 880- 1920 Configuring the Nation Public Health and/% Cultural Production Public Health: "Philosophy of the Epoch" Public Health, the State, and Civil Society Shedding Light on Working Class Lives Ideologies of Sex, "Race" and CIass and Public Heahh Discourse CHAPTER TWREE: RECONFIGURING THE NATION: THE NEW PUBLIC HEALTH AND THE RISE OF HEALTH PROMOTION The Post-Interventionist State and the New Public Health Social Marketing and Health as Fetishised Commodity The "New" Health Promotion: "Empowerment" for Hedth The Turn to "Community" CHAPTER FOUR:CONSUMER HEALTH INFORMATION: THERAPY ON THE ELECTRONIC HIGHWAY Information: The New Magic Bullet Introducing Consumer Health Information The "Cult of Information" and a New Hegemonic Order Information and/as Democracy, Freedom and Wealth The Genealogy of Consumer Health Information 1: From Positivism to Cognitive Constructionism in Information Science The Genealogy of Consumer Health Information iI: The Rise of the Consumer in Health Care Consumer Health Information: The Ideological Effect Consumer Health Information and the Social Relations of Knowledge Production Heaith Information and the Private Sector The New Paradigm in Knowledge Production in Health: Evidence-Based Medicine Medical Authority and Autonomous Practice Evidence-Based Medicine, Knowledge and Structural Interests in Health Care Evidence-Based Medicine and the "Cult of Information" Conclusion CONCLUSION Public Health and Hegemony Towards a Post-Libcral Public Health? BIBLIOGRAPHY Informed Consumers, Regulated Subjects: Public Health and the Rise and Fall of the Interventionist State

Muter of Arts, 1999 Keith Thomas Demy Graduate Department of Education Ontario Institute for Studies in Education / University of Toronto

ABSTRACT

The question ai the heart of this thesis is where. if anywhere. should we locate public health in an analysis of post welfare state, neo-liberal processes of political legitimation? The thesis explores the relationship between the practices and discourse of public health - and in particulûr those strategies broadly falling within what is now called "health promotion" - and the sustainability and reproduction of hegemonic govemment in Canada. It does so through an examination, in three case studies, of the relationship of public health to the state. to ideological production. and to the capitalist mode of production. The thesis concludes that public health does have an identifiable role in the reproduction of hegemony. that it is implicated in the ideological sustainability of the capitalist mode of production. and that it can be located among an may of strategies that enable the state to "govern at a distance." ACKNOWLEDGEMENTS First of al1 to my thesis committee members, Roxana Ng and Budd Hall; to Roxana for helpful, critical and supportive chapter readings. for generous supervision of this thesis, and for helping me to make it make some sort of sense; to Budd also for helpful readings of the various parts that mdce up the whole; to Dons Denny for more than she will probably ever know, for the love of reading, for her inspinng, perceptive intelligence; to Kes Denny for sparking the thoughts that made me a socialist, for the confidence that cornes from knowing love is given unconditionally; to Eleanor and Wes Henderson for much love and support; and finally, to Jennifer Henderson, for making it al1 worth doing, for the love. for the laughter, for the friendship like no other 1 have ever known, and for profound imaginative and intellectual challenges,

HEARTFELT THANKS. INTRODUCTION

The Return Of Public Health

The objects of study in this project are the practices of what has been called "second wave public health", and the relation of public health to the Canadian state in a post-interventionist period. In particular, project the focusses on the field of health promotion, which has corne to dominate public health since the early 1970s.' To be more specific, the greater part of the thesis consists of an ideological critique - through an examination of both government and professional publications - of both health promotion and the emerging field of "consumer health information". The methodology of choice for this thesis, of which Ihave more to say below. is what Iam calling substantiated ideological critique. There are two complementary and interrelated themes that have deterrnined the specific area of research that this thesis pursues. The first is what 1 perceive as the problematic nature of individual psychologising about the "adult leamer" that tends to characterise much of the mainstream literature in Adult Education. In terms of its theoretical perspective the thesis constitutes a critique of the phenomenological assumptions of adult education that position the üdult learner in the world as an existential, epistemoiogically autonomous, and self-directed subject. This "cognitive viewpoint" may well locate the individual learner in a social space - perhaps even with the goal of social transformation - but it largely fails to address the ways in which individuals are constructeci as subjects. It assumes a reiatively unproblematic relation between the leamer, acquired knowledge of the world, and the learning process. In this thesis 1 eschew the focus on the simultaneously individual and universal "adult leamer", working instead from a broader, social theoretical perspective that has ai its centre a very different concept of the subject and knowledge (and thus of "information"). It is an approach that incorporates the concepts of "ideology" and "discourse" into a larger theoretical frarnework of cultural materialism. The second theme prompting the particular focus of this project arises out of rny own experiences as. successively. a hospital librarian, and, more recently, a community health worker in a community-based health information centre. From this experience ha! corne an awareness of a need for critical analyses of the largely unproblematised advocacy of both "information" provision in health promotion, and the corresponding construction of a "health consumer*'- a parallel being in rnany ways to the "adult leamer" - who uses information to make "appropriate" choices regarding health, well-being, and lifestylc. The research question central to this thesis can be framed in the following way: to what extent can health promotion be understood as being bbconstitutedüs [a] discrete phenomen[on] in the institutional contexts of ruling" (Smith 1990, 15) or as arising as one of a set of "problems in relation to the actual practice of govemment or management." (ibid, 15). That is to say, where may we situate health promotion in relation to the methods and practices of goveming individuals and populations'?

1 should make clear at this point, however, some of the ambivalence 1 experience in developing this extended critique of public health and health promotion. This takes the fom of two related and very significant caveats; the first to do with the progressive politics of public heülth and the second with my own location in the field of health promotion. In the pages that follow it may be less than apparent to the reader that I am a very long way from considering public health and health promotion to be the incarnation of regressive politics. And as 1 do not take the time to address this in chapters that follow this I need to make the point now so thit cm be borne in mind through the critique that makes up this project. The first caveat, then, is the acknowledgement that the public health movement of the late nineteenth and early twentieth century has a fine record of progressive achievements that succeeded in alleviating a great deal of human suffering. May of the actors involved in the movement were committed to bringing about progressive social change and improving the life circumstances of others. It is certainly not my intention to trade in simplicities by cüsting aspenions in this analysis on the often good intentions of those involved in such work. S imilarly . rnany contemporary health promoters are committed to stmggling for structural and social changes that really grapple with the issues that detennine health at the level of populations. The Ottawa Charter on health promotion is a genuine example of the progressive theme within the field. Nevertheless, if we are to maintain good faith in a field that we have chosen to be part of because we consider it to be a progressive one, it behooves us to never cease to retlect critically upon the potentially nrgutivc cff'ects that a positive movement can have, either in general, or in locations and to people who may be obscured from view unless we are really searching. So this thesis is not about the "goodness" or the "badness" of health promotion; i t is a cri tically engaged reflection upon possibl y unintentioned ideological effects that hopes to contribute to the future health of the field. My second caveat derives from the fact that I am a part of the field 1 set out to challenge in this thesis. This means, of course. that in some ways 1 am the object as well as the subject of the project: what 1 have to say 1 accept is about, and directed to, me as much as it is to others. In a sense, then, this work is an attempt to assume, as an observer, the identity of what Donna Haraway calls the "split and coniradictory self ... who can interrogate positionings and be accountable" ( 199 1, 193). Caught between the dilemma of a rejection of the idea of universal and "true" knowledge (that is to say, the idea of "objectivity") on one hand, and an almost equaliy unsatisfying concept of "authentic" knowledge derived from particular forms of identity on the other. Haraway has suggested the, by now well known, alternative "situated knowledge." That is to say that knowledge is always contingent on the - spatial, cultural, economic, and historical - location of the knower. At the same time this contingent knowledge is never "pure" or "true" in some non-ideological sense, because '"being' is much more problematic and contingent... we are not immediately present to ourselves" ( 192). We can only know what we know by virtue of who. what. and where we are in the world at any given point in Our lives; and we have to accept that what we know is in some sense a fiction, or ri narrative, that serves to make the world comprehensible to us. I am, therefore, asking what 1 hope are useful, but critical, questions about health promotion from a location within the field and 1 am making a very clcar distinction between criticisni and condemnation.

The Context Of The Study This thesis contains original research that is not currently seen in the literature on public health and health promotion. The review of this literature that follows is thematic rather than systernatic, and consequently selective rather than exhaustive.

There is a huge quantity of literature relating to health promotion practice. 1 am interested in the sociology of public health and health promotion from a cultural studies and political economy perspective, upon which a good deal less has been written

(Bunton, Nettleton & Burrows 1995, 2; Petersen and Lupton 1996, xi). I have reviewed the literature accordingly. There is a significant amount of literature that focusses on the emergence of the public health rnovement in Canada between 1880 and 1920 (e.g. Bilson 1984: Cassel 1994; Macdougall 1988; Oberlander 1984: Ostry 1994; Severs 1989) at which point public health priorities largely gave way to a resituating of energies within the institution of the hospital. Most of these authors represent the achievements of the public health rnovement as progressive. I would not challenge this, but as I have suggested 1 am also interested in other - primdy ideological - effects, intentional or otherwise, of the rnovement. As this penod, 1880- 1920. maps neatly on to that usually characterised as Canada's nation-building era, it seems ciear that there is scope for research that explores the hypothesis that this was more than a rnere coincidence.

Others (e.g. McClaren 1990; Valverde 199 1 ) have researched the association of other "progressive" movements of the time, such as early feminism. social purity activists, social workers, for rxarnple, with issues of "race" and gender in the construction of a white, Protestant Canada. Sem ( 1995) has explored the role of public health during the same period aï a response to anxieties created by the need for a healthy workforce dunng a period of intense industrialization. 1 explore the location of public health in this penod in relation to the intersection of industrialization, nation-building, and concems with racial purity . Public health concems, particularly represented by the emergence of health promotion, have reappeared with some force over the last three decades in Canada and other Western countries (Pedersen, O'Neill & Rootman 1994; Bunton, Nettleton &

Burrows 1995: Petersen & Lupton 1996). There is a demonstrable awareness within public healtli that an üpproach to health promotion that focusses on the individual and behaviour change crin lead to "victim-blaming," and that attention needs to be paid to broader "social determinants of health". The collection of essays in Health Promotion in Carzccdu (Pederson, O'Neill, & Rootman 1994), for example ernphasise the social deteminants of health and the importance of a community developrnent focus (see especially Badgley; Rootman & Raeburn; Hoffman). Similarly, Bunton and

MacDonald ( 19%) - although their focus is not limiied to Canada - provide an overview of the development of health promotion that illustrates the move from a narrow behaviour change mode1 to a perspective that incorpontes contributions from social psychology, sociology, and education. This trajectory toward a more sophisticated appreciation of social, political and ethical issues is reiterated by the authors included in Health Promotion - Concepts and Practice (Dines & Cribb, 1993) Nevertheless, in general social determinants seem to be interpreted within a particularly liberai-pluralist perspective. That is to say that they are considered relevant insofar as they detennine individual behaviour that is not conducive to good health - or wetlness.

In fact. as Grace ( 199 1 ) argues. the empowerment discourse of health promotion which produces the "consumer" of health does so in accordance witii the model of consumer capitalism. In Canada it is this very model of consumer empowerment that characterizes the neo-liberal economics that are fueling the move away from socialised heal th care. It is for this reason that I think Grace's argument makes particularly compelling the need for research that focusses on the use of social marketing as a practice in health promotion. though she does not actually address this particular practice. Health promotion constructs the idea of the consumer of health and then goes on to construct the concept of health needs for which it designs elaborately planned social marketing programs. complete with sophisticated evüluation procedures to measure behaviounl change. In the carefully managed environment of these prograrns Grüce sees the empowerment discourse of health promotion as controlling rather than empowering individuals. She does not pursue this line of argument, however, and we are left to look elsewhere for illustrations of the ways in which health promotion ideologically bolsters the hegemony of a market-based political economy. There are analyses of heal th promotion thüt atternpt a sociology of heül th promotion making use of Foucault's concepts of "techniques of the self" and "govemmentality". Such analyses are extremely fmitful and 1 will make use of them in the thesis. Two texts that are particularly useful for this perspective are those edited by

Bunton, Nettleton and Burrows ( 1995) and Petersen and Bunton ( 1997). However, these analyses are rarely rnapped ont0 a broader socio-economic context of why, for example, the rise of health promotion should coincide so closely with restnicturing in health care. The novel contribution of the present project is its exploration of public health using a Marxist-informed cultural materîalism to analyse the ideological content of its discourse whilst sirnultaneously situating this discourse in the context of its political economy. At the core of this study is the relationship between health, the neo- liberal state, and emerging forms of hegemonic government

Method Of Analysis: Reading For The ldeological Themes The methodology of this project consists of what 1 am calling a substantiated ideologicai critique. By this 1 mean that I reiid selected primary public health texts for the ideological themes contained wi thin them. My method incorporates techniques drawn from textual analysis, discourse analysis. and historical research. 1 cal1 my approach one of ideologicül critique because, although I focus my analysis upon texts, 1 do so in ways thüt di ffer from both textual analysis and discourse analysis. The selection of texts for this study is intentionally wide-ranging, so that 1 can substantiate claims thüt I make about the field of health promotion generally. This expansiveness is incompatible with - though it draws from - fornial textual analysis which requires close reading of a small number of texts. Roxana Ng, following Dorothy Smith ( 1990a; 1990b), characterises textual anaiysis in this way: Analyses of texts frequently treat them as givens: the purpose is to discover their meaning through different kinds of interpretive practices. Instead of treating the [text] as an independent document ihat can be subjected to multiple and competing interpretations, [textual] analysis treats it as part and parcel of a sociai organization ... (Ng 1995,36) What 1 take from textual analysis is the idea that texts are not independent entities but rather that they are inseparable from larger social contexts. However, rather than applying my analysis to one text I treat texts as entry points into a broader ideological domain. Choosing to focus on a small nurnber of health promotion documents, for example, would enable me to draw conclusions about the ideologicd content of those documents, but it would limit my ability to make generalisable statements about the field. 1 accept that by broadening my analysis in this way 1 lose a good deal of precision, and that making generalisations is a potentially overambitious, not to mention overly homogenising, project. Nevertheless, I do want to establish an argument about the relation of health promotion in general to forms of hegemonic govemment. On the other hand, although 1 have selected a broad array of texts as my priniary data, 1 do not attempt in this thesis a formal discourse analysis that charts the unity and totality of an expert discourse, or the mechanisms that produce such a discourse, in the way that is envisaged perhaps by Foucault (1972). My concem in the chapters that follow is not to carry out a "study of the rules, conventions, and procedures which legitimate and to some degress detemine a particular discursive practice" (Barsky

1993. 35) - though at two points, with regard to the discourses of social marketing in health promotion in chapter three and of evidence-based rnedicine in chapter four, I do describe the ways in which each discourse is legitimated and authorised. However, if 1 am not so much concerned in the present project with the niles, conventions and procedures of discourse. 1 crrtainly adopt a great deal from discourse analysis to the extent that "discourse analysis contextualises and formalises studies in content analysis and thus generates questions conceming the production, reproduction, function, and effect of basic units of discoune within given ideological configurations and sociohistorical moments" (Barsky 1993, 35). Elsewhere, discourse analysis has been characterised in the following manner: Discourse analysis is therefore composed of two main dimensions, textual and contextual. Textual dimensions are those which acount for the structures of discounes. while contextual dimensions relate to these structural descriptions to various properties of the social, political or cultural context in which they take place. The former is therefore concerned with such micro elements of discourse as the use of grammar, rhetorical devices (such as metaphor), syntax, sound forms and the overt meaning and content matter ... The latter examines rhe prodticfion und reception processes of discourse. with particufnr attention to the reproduction of ideology and hegenrony in such processes. and the links between discourse structures and social interaction nncl situations. The ernphasis is not so much upon the 'message' itself, but upon the elements and influences in the discourse process as a whole. (Lupton 1992, 145: emphasis added) To the extent that rny methodology can be characterised as "discourse analysis", my emphasis is primarily on what Lupton calls the "contextual". To the extent that a formal discourse analysis requires attentiveness to both the micro and the macro, 1 cannot claim to do so. In other words, the texts chosen as the primary data in this project are not themselves the objects of analysis so much as they are tools that enable me to engage in a critical sociology of public health and health promotion. My methodology borrows from the methods of historical research in the sense that 1 quote frorn texts not to comment on the texts themselves, but as evidence in support of claims 1 am making about more general processes of hegemonic reproduction. The texts that I draw upon are primarily government and professional publications for the period 1880 to 1920 and 1975 to the present. Specifically 1 read texts that are writtcn for a readership of public health and health promotion professionals. 1 reüd these texts to gain insight into the ways in which they can be said. in Dorothy Smith's vocabulary, to constitute "ideological practices" (Smith 1 990,4). For example, how do the representational practices of the literature not only produce tlie public health or health promotion professional as "expert". but in doing so how do they produce the concept "health" itself as a contingent ideological category? And how is health rehted to other ideological categories such as nation and "race". Where may we situate health promotion discourse ideologically in relation to the neo-liberal state, and to the globalising and restmcturing economy? How does this construction of authoritative expertise through the discourse of public health articulate norms and normative niles for conduct that are integral to techniques of government that serve to sustain hegemony in a post welfare state context? In addition to a an ideological critique substantiated through primary texts drawn from the literature of public health, health promotion and interrelated discourses, I also read secondary texts for both periods so that 1 can situate these discourses in a critical historical and contemporary social context. 1 have made extensive use of such secondary sources throughout the chapters that make up the three case studies of this thesis. The nature of the methodology that 1 am using in this thesis means that there is some blumng of the line that distinguishes how 1 make use of priniary and secondary sources. The former, as 1 have said, 1 cite as evidence to substantiate claims 1 make about the ideological effects of public health discourse. The latter. on the other hand. are cited in order to supplement or expand my own arguments regarding both these ideological effects and the structural. social, and historical contexts in which they occur. To avoid any confusion that might anse as to when 1 am treating a text as data for analysis, and when 1 am using a secondary source,

1 endeavor to rnake explicit rny citing of the latter in the instances in which 1 incorporate them. Addi tionally , I have cütegorised the bibliography of this thesis according to primary and secondary sources.

The Case Studies The thesis consists of four chapters. In the first 1 elaborate the theoretical perspective that guides the research and the methodology that 1 have just described. The second applies the theoretical analysis developed in chripter one to an ünalysis of public health in the period 1880- 1930. In the remaining two chapters the theory is iipplied to an examination of health promotion in chapter three and to the concept of "consumer health information" in chapter four. In chapter one 1 outline a theoretical perspective that allows me to make use both of the Marxist concept of "ideology" and the Foucauldian concept of "discourse".'

Over against the well-worn, lirnited and limiting concept of the "adult leamer", 1 trace the concept of ideology as an analytical category in Adult Education from Gramsci

( 197 1 ) (contrasting this briefly with the less articulated and less sophisticated version of the concept found in Freire). Making use in particular of Gramsci's concept of "hegemony", I chart the elaboraiion of the concept through the "cultural materialism" of

Raymond Williams ( 1977). Cultural materialism, as 1 explain, challenges the privileging of class, in Mwist theory, as a category of difference and a force for social change. We are exposed instead to a myriad of marken of difference that needs a theoretical frarnework that avoids the stasis of a return to a notion of pluralism (albeit a "postmodem" pluralism). 1 also review two key concepts from Foucault: "techniques of the self', and "discourse", with the aim of incotporating them into an elaborated concept of "hegemony".

1 go on in subsequent chapters to apply this perspective to a study of public health in Canada through three case studies. Ido this in order to test the hypothesis that pub1 ic health discourse in Canada has served ideologicall y in the interests of dominant groups and of capital accumulation by acting as one of the crucial building blocks of dominant hegrmony in two distinct and identifiable periods in Canadian history: the years 1880- 1920 (after which public health was largely superseded by a turn to institutionalised heal th care in the space of the hospital), and 1970 to the present. By taking both of these periods as case studies it has been possible to chart not only the differenccs and similarities between the concerns of public henlth in each of them, but also the wüys in which these differences and similarities may be related to the socio- economic and political contexts in which public health was and is situated.

As 1 have already indicated, my interest in this analysis is in situating public healih and health promotion discourses in relation to techniques of hegernonic sustainability: that is to say, the relation of such discourses to the maintenance of hegemonic order, particularly as hegemony is reconfigured in the era of the post-interventionist state. In the case studies that constitute the three central chapters of the thesis 1 carry out an ideological critique of public hecilth, using as evidence to substantiate rny daims discourse aimed at public health professionuls at different historical moments in order to situate the discourse in contexts characterized by distinct techniques of govemment: those associated with the "nation-building" period of Canadian history. the era of welfare state liberalism, and the emerging techniques of neo-liberdism. According to Nikolas Rose (Rose 1993). nineteenth century libenlism faced a series of problems relating to the govemment of individuals, markets and populations. It responded to these problems with a new rnodality of authority: "Expertise in the conduct of conduct - authority arising out of a clairn to tme and positive knowledge of humans, to neutrality and efficacy - came to provide a number of solutions which were of considerable importance in rendering liberalism operable" (284). In the context of wel fare state liberalism. according to Rose, "persons and activities were to be govemed fhrough society. that is to say, through acting upon them in relation to a socid nom, and constituting thcir experiences and evaluations in a social form" (285). These social noms are established by authoritative experts who are themselves at a remove from political power - indeed expert authority depends on such distance in order to be perceived as iiuthoritative: "Political rule would not itself set out the norms of individual conduct, but would install and empower a variety of 'professionals' who would, investing them with authority to iict as experts in the devices of social rule"

(285). In the post welfare-state neo-liberal world, govemment now "depends upon expertise in ii different way, and articulates experts differently into the apparatus of mle. It does not seek to govern througli 'society', but through the regulrited choices of individual citizens" (185). Neo-liberal government is increasingly characterised by.

a detaching of the centre from the various regulatory technologies that it sought, over the course of the twentieth century, to assemble into a single functioning network. and the adoption instead of a fom of govemment through shaping the powen and wills of autonomous entities. This has entailed the implantation of particular modes of calculation into agents, the supplanting of certain norms - such as those of service and dedication, by others such as those of cornpetition and customer dernand. (296)

A critical historical analysis of the period 1880 to 1920 highlights the relationships between the public health movement in Canada, the material requirements of capitalist development (in particular, for labour in a period of intense industrialisation) and the class-consolidation and race- and nation-building projects of the final decades of the nineteenth century and the early decades of the twentieth. The chapter provides the historical context that prefigures the themes that emerge in chapten three and four. My analysis of public health discoune in this chapter focusses on the ways in which the discourse itself produces the authoritative public health expert, and the ways in which "expertise in the conduct of conduct" that is based on "a claim to a true and positive knowledge of humans" is mmked by categories of "race". class and gender. The researc h for the c hapter covering the period 1 880- 1 920 consists primari ly of a review of ideological evidence derived from the Public Heulrh hunial (PHJ).

This journal was the organ of the public health movement. and as such it documents the principle concerns of its discourse. Other contemporary sources are reviewed, but the PHJ is the prirnary focus of the research. To summarize, the chapter consists of both a critical historicül analysis of the period 1880 to 1920 in Canadian history - a period of industrialisation, urbanisation. clws consolidation, and nation-building - and an ideological anülysis of public health discourse in the same period. The PHJ for the period under iinalysis is not indexed in a way that makes the articles easily accessible. The articles chosen for inclusion have therefore been selected on the bais of a physical examination of the available volumes of the journal housed in the library of the University of Toronto. The procedure used for selecting articles was one of elimination; that is, I am not including articles concemed with actual technical procedures of public health, such as those concerned with the techniques of sanitation, plumbing, building regulations. and sewerage, for example. Such articles constitute the bulk of published items in the journal for the period. Instead 1 am including in the analysis articles that focus on the social issues of the tirne and which are concerned pnmarily with the health of the population; with sex, prostitution, education, children, "race" and genetics, the "feeble-minded, immigration, native health, domestic work, the nation, and social justice. These are topics that correlate most closely with the concems of today's "health promotion", though of course the term was not used in late nineteenth century Canada. Chapter three consists of an analysis of the re-emergence of public health in the

1stquarter of the twentieth century. and in particular the tum to health promotion. My main concem in this chapter is to chart the relationship between this re-emergence and the economic restructuring that has characterised the same period. The period 1970- 1999 is cornmonly characterised as one of globalisation and restructuring. Since the early 1970~~the libcral democracies of the West have been characterised by restructuring, the dismantling of the welfare state structures estabiished after the Second

World War, and the emergence of what Harvey ( 1989) calls "flexible accumulation". These general trends have impcicted upon health care systems (in countries where they have to varying degrees been socialised) in the form of cuts in funding, rationalisation, restructuring, the creation of intemal markets, and in some cases, calls for privatisation. The same pcriod has witnessed the re-emergence of a focus on public health, and in particular, the rise of health promotion. By again focussing on the literature of public health - but now focussing on the literature of health promotion - the aim of this chüptrr, similar to chapter two, is to plot the concems of public health discourse in relation to these broader socio-economic circumstünces. 1 am particularly interested in exploring the ways in which health promotion may serve as an ideological support for a disengagement from a cornmitment to socialised health care. Again I am interested in the ways in which public health discourse addresses its readers, the ways in which it constructs health promoters as authoritative experts, and how it produces target audiences for health promotion. I am also interested in the ways in which health promotion discourse produces the concept of "health" itself as a norrn, and how this rnay relate to an economic context of downsizing and restructuring. This chapter focusses primarily on the practice and the methods of social marketing, and the tum to the concepts of "empowernient" and "cornrnunity" in health promotion. The research for this chapter utiiises both govemment and professional publications written by and for health promoters on the use of the practice of social marketing, and on the terms "empowerment" and 'bcommunity".These publications have been selected by searching under these headings in health and social science databases and through published bibliographies such as those mounted on Health Canada's web site. The purpose of the chapter is to establish the ideological role of public health in the creation of new hegemonic systerns, that is new ways of constituting practices of govemment. in the post welfare-state context. Chapter four, on consumer health information (CHI). focusses on the ways that its discourse addresses its expert readers in ways that differ from thc discourse of social marketing (though both focus on the health "consumer*').There are speci fic sirnilarities between CHI and social marketing as it is defined by health promoters (Mintz & Steele

19%; Sutton. Balch & Lefebvre 1995). The distinction is primarily that whereas marketing approaches use "information" in strategies designed to convince consumers of certain foms of behaviour, CHI practitioners are concerned to respond to the consumer's expressed or implicit health information needs. Social marketing is oriented to groups while the latter is more focused on individuals - albeit the generic individuals who make up the "general public". Specifïcally, 1 explore the ways in which the CHI movement resonates with emerging techniques of neo-liberal govemment that operate through the construction of "self-goveming" individuals. Like chapter three, this chapter also covers the period 1970 to the present: decades characterised by the rise of the consumer movement in health care and the accelerating ubiquity of discourses asserting the liberating and empowering qualities of "information" and the increasingly sophisticated technologies available for its storage. movement and retrieval. The research for the chapter addresses the genealogy of the tem "consumer health information" itself. To achieve this the analysis focusses on literature from both information science, and health promotion, as well as the limited, but growing, body of literature generated within the field of consumer health information itself, which in fact bridges both disciplines. The CHI movement bridges the disciplines of information science (a term that includes library science) and health promotion. I review the rise of the largely unproblematised categories of "infornation". "information need" and "information gap" in the information science literature, using a selection of influential authors widely cited in the literature of information science concerned with information need and use. These catcgories assume the existence of an "information consumer", who turns out to share similar (simultrineously)individual and universal characteristics, 1 think, with the "adult learner" seen in chapter one. This "information consumer", produced in the discourse of information science. also meshes nicely with the concept of the "health consumer" who populates contemporary discourse on health care. 1 explore the concept of the "health consumer" in more depth than in chapter three as a concept emerging alongside the various discourses about information. CHI is the point of convergence of the information consumer and the health consumer. Tuming to the small but expanding body of literature in CHI - obtained via searches of health, social science, and information science databases and published bibliographies - the chapter concludes with an examination of the extent to which this model (of a consumer of health with information needs and gaps) relies on a simplistic understanding of the knowledgelpower relationship, and the ways in which the concept of the "informed consumer" sustains, in ideological and practical terms, the encroachment of market oriented discourses in health and health care. The concluding section of this chapter situates CHI within the social relations of knowledge production about health through an examination of a "new" paradigrn in medical research and practice, Evidence-Based Medicine (EBM). The primary texts in this section have ken selected on the basis of a literature search of the medical literature using the terni evidence-based medicine. ' Throughout th is thesis 1 use the terms "public health" and "health promotion" interchangeably. 1 do this for simplicity's sake whilst acknowledging that they are not one and the same thing, pnmarily to maintain continuity between chapter two and chapters three and four. Public health is the broader field. and health promotion one of its strategies. In the period covered by chapters three and four - 1970 to the present - health promotion has become a dominant theme of public heal th in Canada. In the period covered by chapter two - 1880 to 1920 - fint wave public health health did not use the tenn "health promotion", but there are cenainly elements of this public health - concerns with the conduct of individuals, the impact of the environment on the health of the individual, and the definition of "health" itself in terms of "race". for example - that are in some ways continuous with today's health promotion.

As 1 elaborate in chapter one of the thesis, I do not understand "ideology" and "discourse" LS synonomous concepts, though 1 argue that they are in timately connected. I take my use of ideology from a Gramscian understanding of hegemony, in which ideology represen ts the epistemological context in which socio-political consensus is ensured. That is to say, it is the historically cumulative ordering of assumptions. values. beliefs, and "common sense" (Gramsci 197 1. 326-330) of a given socio-chronological moment. 1 understand discourses, on the other hand, to be systematised bodies of "knowlrdge". or "tnith claims" produced by "authoritative experts". As such. discourses are essential to the production, dissemination, and legitimacy of ideological forms. ADULT EDUCATION, PUBLIC HEALTH, AND CULTURAL

MATERIALISM

What must be explained is how it happens that in al1 periods there CO-existrnany systerns and currents of philosophical thought, how these currents are bom, how they are diffused, and why, in the process of diffusion thqfracture along certain lines and in certain directions. (Gramsci 1 97 1,327)

Adult Education And The Adult Learner Throughout the 1%Os, 1970s and 1980s there were various atternpts to synthesize a unifying theory for the field of adult education. Perhüps the most notable of these attempts is found in the efforts of Malcolm Knowles to develop a theory of "andragogy" (see for example, Knowles 1980; 1984). However, the search for unifying theory haalso included Patricia Cross' "Characteristics of Adults as

Learners" framework (Cross 198 1, 235-4 1 ), as well as various other efforts that can be characterized as "humanistic", "developmenial", and "behaviourist".' These various debates have been well rehearsed elsewhere and they are generally familiar enough to not warrant repetition here. 1 am not going to debate the rnerits of one contribution over the others, and neither am 1 going to enter into a discussion of the possibility, or the desirability, of constnicting a single theory for a field as diverse and eclectic as adult education. It is possible, in any event, that we are now beyond the search for "grand unifying theories" in the social sciences in the wake of the cultural phenornenon we now label "postmodemism". We may have seen. as Michael Welton argues, the collapse of the "andragogical consensus" (1991,22) in adult education. Nevertheless, despite the lack of a single unifying theory (even, in fact, of a single unifying focus: the learner? the educator? the process?), the field of adult education, particularly in areas such as human resource development, but also in the area central to this thesis, health education, has coalesced around a number of characteiizing principles. These principles have settled into the underlying assumptions of adult education, and acquired the status of prescriptive axioms. It is these normative principles that 1 want to examine in the first section of this chapter. These principles are founded on generally assumed characteristics of adult learners. Brookfield (l986,25), citing E.L. Simpson. suggests that there are two core characteristics of adult learners at the heart of various theories of adult education: that adult leamers exercise autonomous self-direction in their learning, and that adult leamers have acquired a bank of personal life experiences that can serve as a resource for leaming. The first of these two assumptions has, as Brookfield points oui, been largely discredited: there is little evidence to support the generalization that adults are particularly self-directed towards leuning. What we see here is not an empirically developed observation of how adults learn so much as a commonly held assumption that self-directedness is in fact one of a set of definitive characteristics of adulthood; adults must de facto be self-directed in their orientation towards leaming. In this chapter 1 will be developing at length a critique of the libenl perspective of the epistemologically autonomous and self-directed subject. The second characteristic of adult learners - that they have a bank of life experiences tliat they bnng to a leaming situation, whatever that situation is - is both more obviously acceptable than the first, and nt the same time, far more cornplex. It is true that we al1 have accumulated a store of experiences, and that we carry the baggage of Our individual histories w ith us wherever we go. However, the transparency of our experiences is not as obvious as it might seem. As subjects we are al1 constituted by processes that precede us and that are far larger than us, and our consciousness of Our experiences, our means of interpreting and understanding them is not wholly authored by us. 1 agree that Our individual experiences are a resource for learning, but it is far more productive to treat such experiences as opportunities for challenging and critical reflection rather than as the basis for an authentic knowledge of the world that simply has to be "facilitated" and given a voice. The processes by which we become the subjects we are and by which we acquire the filters through which we view, understand and interpret the world, our location in it and Our relations with oihers is the second major theme of this chapter. Beyond these two characteristics are others tliat Brookfield suggests "constitute a catechism familiar to educators and trainers of adults" ( l986,3 1 ). These chmcteristics can be summarised as follows: for adults leaming is a life-long process, in which different (but identifiable and predictable) transitional stages act as catalysts to learning. Leaming styles and needs are heterogeneous and differ, according to need, both beiween individuals and at different times in the life of a single individual. Despite such differences, in general adults leam what they do. and so prefer iearning to be problem-centred. to be relevant to their life situations and to have obvious applications. The general acceptance of these characteristics of adult learners has meant that adult educators, across various locations, have corne to undentand their role as facilitating leaming rather than teaching. In other words, process has become at least as important as content. From these conclusions there have been vanous attempts to derive inventories of good practice for adult educators, some of which have been summarised by Brookfield ( 1986, 34-39). These broad themes that have emerged in the theory and practice of adult education rest on the significance of the use of the word "adult" as an adjective. To what extent does the prefïx "adult" qualify "education"? This has proved to be an important question through al1 of the attempts to construct theories to guide the practice of adult education. Even Knowles (198 1.6 1-63), who has popularîzed the term "andragogy" to differentiate the education of adults from that of children, has conceded that the distinction is not as rigorous as he at first claimed. And yet, as 1 have suggested, adult education is guided by some very specific assumptions about the characteristics of adult learners that have attained the statu of common sense within the field. Given the preference for the varied and somewhat dl-inclusive tem "learning" over "education" in adult education, the latter is unavailable as the focus for theoretical elaboration. Learning can and does take place outside of the set of relationships we cal1 "education", and even in more forma1 and institutionalized settings adults are considered to acquire new knowledge by leming rather than education. Adult education theory then, has become leamer-centred, with the concept of the "adult" at its core regardless of the difficulties inherent in drawing boundaries between adult-specific theory and theories of educûtion related to children and youth. This leamer-centred theory in adult education is associated with "adulthood" as a normative state. From the perspective of adult education theory, adulthood "tends to be seen as a normative state based on the notions of 'maturity', 'autonomy', and 'rights', of which the right to choose predominates" (Lawson 1989. 13). In other words, the adult leamer in adult education theory is synonymous with the rational, autonomous subject of liberal philosophy. In the discourse of Adult Education. the adult leamer is constructed as both simultaneously individual and universal. abstract and particular.

The characteristics attributed to the adult learner apply to adult learners generaflv, yet at the same time the prescribed practices of adult educators are deliberately minimal to allow for the exercise of choice and self-directedness on the part of learners with particular needs. To be an "adult" is to be de facto an autonomous and rational subject and to exercise both autonomy and reason in individual choice. As a generalized category the adult learner is an abstract psychology. disengaged from cultural and social considerations which only acquire relevence at the level of the individual, where they are transformed into the relatively neutral category of transitional life-stages. This classically liberal autonomous, self-directing, rights-possessing subject is the residue that has been crystallized in the assumptions of mainstream adult education after the collapse of efforts to distill a unifying theory for the field. The field is now, according to Welton "occupied by an array of competing discourses" (199 1,22) that have replaced the "andragogical consensus" that had become a tenuous "dominant paradigm". It is unclear, however. to what extent these competing discourses challenge the characterization of the adult learner discussed above. Most discussions of cntical

thinking or critical educational practice have been limited to critique defined as "a cognitive process of reflection upon an individual's taken-for-granted assumptions, values or roles and [the proposal of] techniques for fostering individual reflectivity" (Welton 1991,29). Welton, on the other hand, sets out to present the arguments for a cntical theory of adult education that incorporates a Marxist social analysis through a Habermasian critique of individualistic inodels of learning (29). Without such a theory, he suggests, "we will never know how even the individualist ideals we posit - the fulfillment of the individual, Our cornmitment to 'autonomous' self-directed learning - are systematically blocked and constrained" (23).

Welton suggests that "we are just in the struggling stages of reconstructing the study of adult education from a critical theoretical perspective" (22), and it is as a contribution to this process that 1 wish to characterize the present project. 1, like Welton, will begin with Marx. But in keeping with what I agree is a need for a diversity of theoretical approaches - reflected perhaps in the assertion that "the concept, and the related practice, of adult education is not unitary, and any attempt to provide overall definitions does a gross injustice to the field" (Lawson 1989, 17) - the trajectory of rny exegesis will depart frorn his. I am not, for the moment, interested in disputing the pros and cons of Habermasian theory. Instead 1 will be suggesting that another Marxist perspective can help us to gain insight into the practices and processes of adult education in ail of its seemingly infinite variety. Accordingly, in the remaining sections of this chapter I outline the principles of cultural materialism as a mode of analysis, before explaining how 1 apply this methodology in subsequent chapters to the forms of adult education found in public health and health promotion. Adult Education And Ideology: Looking For A Theory Of Culture In Marx, Gramsci, And Freire The work of both Antonio Gramsci and Paulo Freire, as contributions to the field of critical pedagogy, "represent attempts to theonze and operationalize challenges to oppressive social formations" (Ellsworth 1989,298). Each author asserts that education has a vital role to play in bringing about social change because it is capable of generating an engagement with, and a questioning of, dominant ideologicd assumptions, or what Mechtild Hart ( 1985, 122) ciills "self-perpetuating mechanisms which prevent thematizations of certain needs and interests". Pursuing this theme, the premise of this section is that from the perspective of a critical appraisal of the focus on the simultaneously individual and universal "adult learner" within Adult Education, it is helpful to incorporate, and to some extent rehabilitate, the concept of "ideology". To establish a usable definition of "ideology" I begin with Marx because, as

Weedon (i989, 27) suggests, he was amongst the first theorists to break with the assumptions of nineteenth century liberalism. Marx reverses the Cartesian concept of self-authored individual subjectivity - founded on the dualist separation of mind and body central to liberal theory - and argues thüt human consciousness is actually determined by social relations, which are themselves the product of physical human activity. Gramcsi's concept of "hegzmony" simultaneously follows and departs from

Marx, and I will argue diat hegemony theory hinges on ;in elaborated understanding of ideology. Similarly, 1 will suggest that an understanding of the limiting functions of dominant ideologies is implicit in the pedagogy advocated by Freire. It might be useful at this point to expand upon my usage of the term "ideology". "~deology"~usually refers, in contemporary popular usage, to a set of political views or opinions; socialist or conservative, for example. When it is used in this way, the implication is often pejorative; that is to Say, it is often used to differentiate a point of view, or a set of values, as "common sense" real world practicality in contrast to the positions and points of view of others who are driven by ideological purposes and political agendas. From this perspective, it is possible to define degrees of ideological determinism in that the more "extreme" a political position is said to be, particularly if it is considered left of centre, the more ideological it is. This assumes, of course, that there exists an epistemological centre ground, determined by impartial judgement, good sense, and compromise. Furthemore, this centre ground is usually believed to be enshrined in the rule of codified law, based on philosophies of individual rights and freedoms, and actualized in contemporary liberal democracies. It is these assumptions that undenvrite a good deal of mainstream adult education theory that focusses on the individual adult leamer. Learning , from this perspective, should be non-pol itical and the purpose of theory is to develop pedagogical techniques and classroom strategies. The same set of assumptions is shared within the related fields of health promotion and health education, as is exemplified by the employment of social marketing techniques to bring about behaviour change; this forms one of the central themes of chapter three. Debate within mainstream education, whether to promote health or more broadly, is fundamentally about the most effective ways in which to promote the learning of a specific body of knowledge - the hamful effects of cigarettes, or the recommended minimum daily consumption of servings of vegetables. for example. Pedagogicai theory that seeks to address political issues - and which denies the possibility of politically neutral education - remains marginalized. As Welton argues, 'The prevalent tendency in contemporary educational discourse is to restrict the meaning of critical to processes of validating arguments" in the approach that seeks to stimulate what is known as "critical thinking" (1991,24). The dominant theme in adult education debates, according to Welton, is a concern to "identify critique with a cognitive process of reflection upon an individual's taken-for-granted assumptions, values or roles and then to propose techniques for fostering individual self-reflectivity" ( 1991,29). Another popular use of the term "ideology", though perhaps less common than that just outlined, undentands it to refer to "false consciousness", or the deliberate masking and distortion of exploitative social and economic structures and relations. This is a familiar misreading of Marx, the origins of which, in Marx, 1 will return to below. What this interpretation of the terni shares with the one discussed above is the cissumption that the realm of the ideological has a sort of fictional relation to a non- ideological reality. The difference is that whereas, in the former, the ideological is a self-consciously constructed fiction of political extremists, for advocates of "false- consciousness", ideology is the instrumental means by which exploited classes are prevented from perceiving their exploited status. This approach to ideology - as false consciousness - was taken up by the theorists of the Second International in the context of a broader economically determinist Marxist "science" and, as Memngton (1 978,

142-145) argues, it ossified into a theoretically stunted dogma. 1 am not using the term "ideology" to describe a consciously held set of political values that veer from a common sense nom, and 1 do not use the terni to suggest something that is inherently pejorative. Instead, I am suggesting that ideology is an unavoidable characteristic of human subjectivity and of al1 forrns of social intercourse. 1 am using the term "ideology", in other words, in a way that denies its fictional relationship to a non-ideological realiiy. The assumptions, values, beliefs, practices, and behaviours that constitute the nom that I have already characterized as "common sense" - and which are usually portrayed as politically neutral, impartial and practical - are actually socially produced, and in tum socially reproductive. They are, in fact, what Bordieu calls "dispositions", or "structured structures predisposed to function as stmcturing structures, that is as principles of the generation and stnicturing of practices and representations" (1977,72). In other words, contrary to its most popular usage, "ideology is not an optional extra, deliberately adopted by self-conscious individuals. but the very condition of our experience of the world, unconscious precisely in that it is unquestioned, taken for granted" (Belsey l980,5). This is not to suggest that human consciousness is shiiped by one prevailing ideology. On the contrary, there will be a range of competing ideologies representing the interests of different social groups. However, sorne ideologies attain dominance and successfully impose their meaning of the world (current "common scnse" regarding deficit cutting, a less interventionist state, flexible labour markets, and globalization is an ideal exarnple) while others remain niarginal. In order to understand why this should be so, 1 want to go back and trace the development of the concept of ideology from its Marxist origins. 1 have already suggested that there is confusion regarding Marx's theory of ideology that has led to an overly simplistic interpretation of the concept to mean "false consciousness". This confusion is due to the fact "that the concept of ideology [in Marx] is not clearly defined; it must be theoreiically worked out from what little Marx wrote of it" (Larrain 1979.36). The attempt to tease such a theory out of Mm's work is complicated by the fact that at different points in his theorizing on this subject, Marx, in his attempt to incorporate elements of Hegelian idealism into his own historical materialisrn, can appear to give different emphases to idealism and materialisrn at different times. Essentially, Marx's concept of ideology is premised on his assertion that consciousness is deterrnined, in the final instance, by physical experience of the world. The role of ideology is to mediate this experience; that is, to make sense of the the world for human consciousness. This is Marx's point of departure from Hegel's idealism which presumes that the realm of social and economic relations is produced by human consciousness. In other words, for Hegelians, unequal and exploitative relations between human beings are the result of wrong ideas, whilst for Mm, it is those very relations that produce ideas that serve to legitirnate and reproduce them. In the Preface to A Critique of Political Economy Marx asserts "It is not the consciousness of men that detemmines their being, but on the contrary, their social being that determines their consciousness" ( 1977,389). Nevertheless, Marx clearly understands the relationship between an embodied experience of the world and consciousness of that experience as one that is dialectical, such that "circumstances make men just as much as men make circumstances" (Marx & Engels 1947,29). He argues that consciousness is socidly produced: it emerges in the context of the essential nature social intercourse to human survival, and it in turn makes that intercourse possible. In other words, the physical deficiencies of human beings relative to other animal species have made collective action essential to species survival. This collective action ha,over millenia, led to the evolution of elaborate means of communication, and the equally elaborate socialization of human infants in order that they be able to make sense of such communication. It is through a social, shared, consciousness of the world that human beings are able to rnake meiining of their experiences, and to literally make sense to each other. This meaning is ordered and made comprehensible through the means of communication that evolve to make collective action possible. That is to Say, language, which develops in order to communicate human experiences, in tum structures what it is possible to communicate about those experiences, and the meaning that it is possible to make of them.' This social construction of meaning and consciousness is ideological, which is to say two things: first, that the assumptions, values, ideas and concepts that structure social consciousness at different historical points and in different locations are detemined through a dialectic relation with the actual physical, material circumstances in which human beings are located - the visceral experience of environment; second, that the characteristics of a social consciousness are invisible to those whose epistemology is shaped by it, and who "do not understand the forces that actually guide their thinking, but imagine it to be wholly govemed by logic and intellectual influences" (Kolakowski 1978, 154). Humans must produce in order to survive, and they must act collectively in order to produce effectively. The way in which collective action leads to production - that is. the way in which humans organize their material production - will be reflected in the nature of the forrn of social organization and will detemine the environment in which other social activities evolve. The necessity for collective action by no means precludes conflict, tensions, exploitation, intra-group violence and subjugation, contingent and unstable alliances, and hierarchical social formations. in fact, in the struggle for survival over scarcity that has characterised human history these features have become typical of collective human experience. Just as the way in which humans have organized their matenai production has changed through time (for example, from slave economies to feudal ta capitalist) so the changing material relations between humans and between humans and their physical environment have altered, and been altered by, the simuliuneouslv shifting social consciousness through which humans make sense of their world. At any point, the prevailing features of social consciousness - dominant ideas, values. morals, assumptions - will be generally, though never exclusively, favourable to the interests of dominant groups who benefit more than others from existing means of organizing production. Obviously, then, there are members of a group for whom the worldview established by the forrn taken by social consciousness at a particular moment can appear to be contrary to their best interests. They participate in social formations and a mode of production that exploit them for the benefit of others apparently because they are blinded to their real interests by ideology. This is what Marx means when he defines ideology as "false-consciousness" - a term that 1 discuss further below. Ideology mediates an understanding of the world so that so called "real" social relations are disguised. For example, In the money relation, in the developed system of exchange, the ties of personal dependence [of feudalism] are in fact exploded and individuals seem independent. The abstraction, or idea, however, is nothing more than the theoretical expression of those material relations which are their lord and master. (Marx 1973, 164) In order to help explain the relationship between an ideological social consciousness and the physical experience of ontology, Marx developed the spatial metaphor of the base and its superstructure. The material circumstances of production detennine the relations of production, which in their turn shape social, political, and cultural spheres. However, the topography of this metaphor as a tool for clarification is somewhat self-defeating. It implies too strictly that the relationship between the form of organization of production and social consciousness is one in which the latter is excessively deterrnined by the former. We have already seen that Marx saw the relationship as more dialectic than unidirectional, and that collective action, the bais for socially organized production, is itself dependent upon the evolution of a shared and communicable understanding of experience. The development of consciousness, according to Marx, is more cornplex than his own base-superstructure metaphor implies. Consciousness emerges at the v isceral interface between a highly developed central nervous system and the physical experience of worldly embodiment. For Marx, as he demonstrates in the Theses on Feuerbach, the evidence that consciousness is mutually bound to embodied expenence is found in the fact that human beings are creatures of "practice", that is "practical-critical" acivity: "AH social life is essentially practical. All rnysteries which lead theory to mysticism find their rational solution in human practice and in the comprehension of this practice" ( 1977, 157). Marx's use of the term "practice" here is synonomous with the tenn "praxis" as it is used by Gramsci and Freire discussed below. As it is used by Marx, "practice is not activity opposed to consciousness, but it is conscious activity; otherwise it would be only a blind activity"

(Larrain 1979, 4 1).

Larrain ( 1979,52) provides a very useful summary of Marx's contradictory dilemma in opting for the metaphor of base and superstructure. He locates the point of contradiction in a distinction between the political structures of state apparatuses and the superstructure of ideas: For Marx, the political superstructure presents a remarkable unity; only one state arises directly out of the base and, in tum, makes that base work in the interests of the ruling class. If one considers the whole of social consciousness as a superstructure, the unity disappears. It is not like the political superstructure, in which only one state apparatus and one juridical organization exist which are functional for the reproduction of the system. In the ideational superstructure one may find conflicting theories and ideas, some of them not in the least functional to the system. True, the ruling ideas are the ideas of the ruling class so that. in the main the forms of social consciouisness correspond to the system of domination. Yet the importance of disruptive ideas cannot be underestimated. (emphasis added) This way of characterizing the weaknesses of the base and superstructure metaphor provides an extremely useful clarification of Marx's somewhat muddled position. It illustrates the complexity of the relation between base and superstructure. and it provides a useful segue into Gramsci's theory of hegemony. Pursuing the Gramscian thread of hegemony from Marx's work on social consciousness leads us further away from the economically reductionist tendency to reduce ideas to mere epiphenomena that has characterized a good deal of twentieih century Marxism (Merrington 1977, 142-3).

Gramsci's Theory Of Hegemony: From "False Consciousness" To Antinomy Gramsci's concept of hegemony" represents a significant development in ideology theory. It avoids overly reductionist theorizing by emphasizing the dialectical relationship between the material and ideological social consciousness. Gramsci argues that in advanced capitalist societies, what Marx calls superstructures have developed an autonomous existence in relation to the economic base. Although dominant ideological frameworks tend toward the reproduction of prevailing forms of social organization and consequently favour the interests of dominant social groups, they cannot be regarded as no more than epiphenomena of the social organization of production. For theonsts of education, hegemony theory is of particular interest because of the emphasis that Gramsci places on the role of education in both the reproduction of dominant ideologies and in the formulation of disruptive ideas. Gramsci's recognition of the problematic nature of the base-superstructure metaphor is similar to that identified by Larrain quoted above. Rather than use the terrn "ideological superstructure", Gramsci instead distinguishes beiween political socieîy, which consists of those apparatuses of the state the function of which is primarily coercive (the police, military, judiciary), and civil socie~,which consists of sites of ideological production, such as education, media, the professions. Political society, which has a fairly unambiguous relation to social relations of production (organized, for example, to defend the principle of private property) ensures the survival of dominant social groups through coercion. Civil society, on the other hand, ensures dominance by the ideological organization of consent to prevailing social relations and practices; the idea of private property as an unassailable individual right. for example, becomes an uncontested taken-for-granted in social consciousness. When consent to social relations and practices is organized efficiently, the privilege of social groups that benefit from them üt the expense of others appears natural and legitimate. In other words, domination takes two forms: hegemony and force, corresponding to civil and political society respectively: 'These two levels correspond on the one hand to the function of "hegemony" which the dominant group exercises throughout society and on the other to that of "direct domination" or command exercised through the State and "juridical" governement" (Gramsci 197 1, 12). Any system of domination that relies exclusively, or even primarily, on force will be tenuous and short-lived. By far the most secure form of domination is ihrough hegemony. Jessop provides us with a concise definition of liegemony: Hegemony involves taking systematic account of popular interests and demands... to maintain support and alliances in an inherently unstable and fragile system of political relations ... and organising this support for the attainment of national goals which serve the fundamental long-term interests of the dominant class. It also involves intellectual and moral leadership through constituting a collective will, a 'national-popular' outlook, a common worldview which is adequate to the needs of social and economic reproduction. (Jessop 1990: 5 1) Hegemony is achieved when potentially damaging social antagonisms are successfully mediated by ideology in the everyday practices of civil society. Hegemony will be maintained as long as social consciousness incorporates the assumptions, values and ideas that underpin prevailing foms of social organization. Ideology functions to ensure the organization of consent through the various spheres of civil society: "hegemony [through ideology] is the 'motor' of cornmon sense, defining reality and organizing consent to ruling clXs ideas of tnith" (O'Brien 1984, 89). "Common sense" for Gramsci can only ever be ideologically constructed. Gramsci does not use the phrase "common sense" in the way that it is generally used in everyday English to describe a very practical and useful application of intuitive

or empirical knowledge. This he descri bes as "good sense" ( 197 1,326). Instead, by "common sense", Gramsci means "the diffuse, unco-ordinated features of a generic form of thought common to a particular period and a particular popular environmeni"

( 197 1,330). In other words, by b'common sense" Gramsci means what we might cal1 the mentality, or the shared worldview of a given historical period. However, societies are far from static entities, and hegemony, even when well established, is never absolute. Societies will be characterised by tensions, conflicts, and disputes even when fundamental vaiues appear to be held in common. Hegemony, therefore, is never uncontested, and it will often exist as crust of uneasy tensions and alliances concealing a stew of cornpeting worldviews, or counter-hegemonies. The sphere of education consists of multiple sites where these tensions between hegemony and counter-hegemony are particularly acute. As a key component of civil society, education is instrumental in the reproduction of dominant ideologies, yet it is also, because it deals explicitly in the realm of ideas, a space readily capable of questioning those same ideologies: "Education is especially vital to elaborate the axioms of practices of "common sense", yet in doing this it creates the criticd "good sense" which challenges accepted definitions" (O'Brien 1984,89). These "challenges to accepted definitions" are the same "disruptive ideas" that Larrain identifies in Marx's ideational superstructure, and they emphasise the fact tliat the relationship between consciousness and the social organization of production is two-way. The structural logic of the base-superstructure metaphor is that a particular base will lcad to a hornogenous superstructure in which a11 subjects detemined by the same mode of production think identically within a monolithic epistemology. Under such circumstances there can be no role for politics or for education. But once we allow that the uniformity of social consciousness can be disturbed by the cracks that open up when experience of the world sits uneasily with dominant representations of those experiences, we are also acknowledging that a critical interrogation of this incongruity can lead to political change. Education can be the site at which such interrogation is encouraged just as much as it cm be the site at which dominant representations of social organization can be reinforced and reproduced. It is at this point that Paulo Freire's pedagogical theories are relevant to the theory of ideology.

Education As ldeological Production In Gramsci and Friere

Whereas Gramsci wuconcemed to elnborüte an analysis of power that incorporated, as i will discuss beiow, a role for education, Freire is much more concerned to outline specific pedagogical processes. Although he does not offer an explicit analysis of ideology, Freire's concept of banking education, which serves to "domesticate", or to "intemalize the oppressor" (1970, 64), demonstrates that he has something in mind that is compatable with the way in which 1 am using the term. Mayo claims that Freire "focuses on the ideological means whereby those in power (the oppressors) exert their control over those whom they exploit (the oppressed)" (1993, 1 1). The term "banking education" is used by Freire to describe the process by which the teacher sirnply "deposits" knowledge into passive student vessels. This form of education, in Gramscian terms, is an ideological technology of civil society that serves to organize consent, even if Freire casts it in a somewhat overly instrumentalist light: "In reality, the role of systematic education, in the repressive society from which it stems! and on which it acts as an agent of social control, is to preserve that society" (Freire 1975,4). Education maintains and performs an ideological role in an already repressive society.

There is, according to Freire, nothing redeemable in banking education. As an alternative he proposes "problem-posing education" as an instrument of counter- hegemonic liberation. Freire's assertion of the political role of education in deepening the fissures between dominant representations of "reality", and lived experiences that are incompatible with those representations, is similar to Gramsci's claim of a revolutionary role for education. The most significant difference between the two is that for Gramsci conventional, or "banking", pedagogy is capable of stimulating critical reflection, whilst Freire denies this possibility. In my earlier review Marx's theory of ideology, I highlighted two concepts as being of particular relevance: "consciousness", and "praxis". These iwo concepts are also central to the work of both Gramsci and Freire. Gramsci followed Marx in insisting upon the dialectical relationship between consciousness and lived experience of the world. Marx was not always clear about the nature of this relationship and has subsequently been used to justi fy economically deteminist explanations of social consciousness. Gramsci, on the other hand, rejects the unidirectional implications of the topography of Marx's spatial metaphor of base and superstructure. Marx claimed to have tumed Hegel on his head by reversing the Hegelian ordering of the relationship between the realm of ideas and the material world. Gramsci appears to pull ideology theory back towards Hegel by asserting that ideas can shape the matenal world. By asserting the materiality of the ideological, Gramsci is challenging the very distinction between materialism and idealism, rather in the way that Foucault does, as I describe later in this chapter, by insisting on the materiality of discourse. From the perspective of those who work in education, including health educators, this is a significant step in the the development of ideology theory as it makes explicit the suggestion that education is political action. Civil society, where formal education takes place, becomes the arena in which it is possible to work for (or against) social change. This is n major shift in Marxist theorizing of social change as it points the importance of a cultural politics as well as economic stmggle, and it raises the political profile of actors other than the organized proletariat. Gramsci sees a specific role for intellectuals in both the reproduction of dominant values, assumptions, and standards, and in the generation and dissemination of new ideas. He identifies, in fact, two varieties of intellectual: "traditional" and "organic". Traditional intellectuals are those who "owe their standing essentially to class relations, either historic or conternporary" (Morgan 1987,303). The role of traditional intellectuals is to act as ideological workers in the ongoing project to reinforce and reproduce prevailing hegemonic conventions. The term traditional intellectuals is not limited to university based intellectuais. it also includes professional "experts" of al1 stripes, in medicine, lnw, psychiatry, commerce, industry, and culture. Organic intellectuals form a stratum in each social group whether dominant (in which case they are also "traditional") or marginal. In the ongoing shifting equilibriurn and alliances between different social groups in the perpetual toiling to assert hegernony, organic intellectuals are responsible for producing new ideas that reflect their position in the overail framework of social organization. When such ideas become part of the structure of hegemony, "organic" intellectuals become "traditional". The tension between organic and traditional is one that is very real in the area of public health and health promotion. It is this tension and conflict that will be thematic in the subsequent chapters of this thesis. Central to Gramsci's exploration of the relationship between consciousness and lived experience is the concept of "praxis": "Without having understood this relationship it seems that one cannot understand the philosophy of praxis, its position in cornparison with idealism and mechanical materialism" (Gramsci 197 1.448). The importance of praxis follows logically from the broadening of the realm in which political action is possible to encornpass the cultural (particularly sites of education) as well the economic. According to Paul Armstrong ( l988, 256). "Gramsci's emphasis on the subjective rather than the objective in social change suggests that he saw this operating through conscious praxis." Praxis is a specifically human characteristic, and it refers in general tenns to the capacity of human beings for self-reflective activities that cm create and change the historical human world and themselves. It is through this capacity for self-reflective action that human beings retain the agency to bring about change, even in the context of their own subjectivity being ideologically produced through social consciousness. Praxis might not bring humans any closer to the

"Truth", or to the "Real", but it can produce the sort of critical interrogation that questions the normative pressures of these very categories: "the philosophy of praxis affims that every "tmth" believed to be etemal and absolute has had practical origins and has represented a "provisional" value" (Gramsci 197 1.406).

Freire uses the concept of "consciousness" in a sense similar to its use by Marx and Gnmsci, "when 1 speak about men or women. 1 am referring to historically situated human beings, not to abstract ideas. 1 am referring to people whose consciousness is intimately liked to their real social lives" (Freire 1975,s). Freire's use of the concept "conscientization" reflects the belief that human beings have the capacity to reflect consciously upon the world, to develop new understandings of it, and to change it on the basis of those new understandings. Conscientization is "the deepening of the attitude of awareness characteristic of al1 awareness" (Freire 1970, 90). By "emergence", Freire means emergence from a submersion in ideology in order to intervene actively in political processes to bring about social change. Consciousness is capable of self-reflective activity, and of seeing beyond an ideologically constructed version of reality, "real consciousness implies the possibility of perceiving the 'untested feasability' which lies beyond the lirnit-situations" (Freire 1970,94). The concepts of "generative themes", "limit situations", "limit acts", and "untested feasability", that are central to the pedagogy advocated by Freire, illustrate his refusa1 to separate pedagogy from politics. These terms are essential to an understanding of his critical pedagogy and to the ways in which he sees this engaging critically with dominant ideologies. Taking a closer look ai these tenns will also help us to understand how Freire understands the terrns bbconsciousness"and "praxis". Freire uses the term "thernes" to refer to the ideas, values, and concepts of any historical epoch (1 970, 82). The "universe of themes" corresponds to what Marx calls the ideaiional superstructure, and just as Larnin suggests that for Marx the latter contains dismptive ideas, so for Freire, "antagonisrn deepens between thernes which are the expression of reality" ( IWO, 82). This antagonism contains the potential for the generation of what Gramsci might cal1 counter-hegemony. The task of critical pedagogy is drawing out the features of a new hegemony, or what Freire calls "generative themes". Generative themes are lines of interrogation that push at the points of contradiction between the lived experience of oppressed people and dominant ideological representations of that experience. The concepts of "limit- situations" and "limit acts" focus on this exploration of the contradictions concealed by ideology (Mayo 1993, 16). The goal of a pedagogy of the oppressed is to develop an awareness of the ways in which ideology distorts reality, by demonstrating that what appear to be absolute and universal truths, obvious and natural, are really products of a process of "rnythicization". Critical pedagogy can demonstrate that oppressive social relations, far form being natural, are socially constructed "lirnit-situations". The falling away of the ideological scales that renders these limit-situations visible is the basis for the development of "limit-acts", or strategies for overcoming limit-situations (Freire 1970,83). A critical interrogation of "comrnon sense" itself, and the taken-for-granted assumptions, beliefs, and values of which it consists, requires an openess the the idea that social organization can be unlike what is familiar. This uncertain realm of change is what Freire calls the "untested feasability".

Freire's use of the term "praxis" is also similar to that of Marx and Gramsci: a unity of reflection and action. For Freire, action without reflection becomes "activism", and without action, theory becomes "verbalism"; both are pejorative terms. Praxis represents context-specific activity that leads to an increasingly sophisticated awareness of the nature of social relations and to conceive of strategies to change them:

People will be truly critical if they live in the plenitude of the praxis, that is, if their action encompasses a critical reflection which increasingly organises their thinking and thus leads them to move from a purely naive knowledge of reality to a higher level, one which enables them to perceive the causes of reality. (Freire 1970, 1 12) Freire regards human beings as creatures of praxis: that is to say, the capacity for creative activity that produces and changes the world is what marks humans out from other animal species. In this he is again following Marx. Both Freire and Gramsci understand ideology as an epistemological mediator that shapes the way in which human beings are conscious of their world. They both also argue that ideology can operate to sustain social relations that benefit dominant groups. However, neither suggests that ideas are solely determined by the economic base. Each argues that sites of cultural production, such as education, have an autonomous role in the production of ideas and in the struggle for political change through praxis. Despite these (not insignifiant) similarities, on closer analysis Gramsci and Freire have in mind a different mode1 of the relationship between the subject and ideology. Freire sees ideology primarily as a fom of false consciousness, or a distorting mystification of "real" social relations. Political activity, in the form of critical pedagogy, in the sites of cultural production is crucial for Freire so that the oppressed cm expose their "background awareness", or that w hich they already knew but was hidden from them by ideology (Freire 1970,96). Gramsci. on the other hand. seems to reject the assertion that ideology is simply false ideas or false consciousness about an objective reality. For him, the role of education is not to pull aside the obfuscating curtains of ideology so much as it is to lead to the construction of new ideologies that reflect the lived experiences of those who do not belong to dominant social groups. In effect Gramsci's modei of the relationship between the subject and ideology suggests that there is no such thing aï the non- ideological subject: "To the extent chat ideologies are historically necessary, they have a validity which is "psychological"; they "organise" human masses, and create the terrain on which men move. acquire consciousness of their position, struggle, etc." (Gramsci

197 1. 377). We cannot, therefore, dismiss ideology as an implicitly pejorative concept. as it is, in füct, an integral part of the process through which a human being becomes a "subject"

ldeology And Hegemony, Government And Discourse: Synthesising The Components Of Cultural Materialism In the previous section of this chapter, I attempted to move from Marx's economically determinist expianation of the relationship between mind and matter in which the material determines consciousness, to a Gramscian reassertion of the dialectic in this relationship. Gramsci rejects the idea that material activity precedcs and determines social consciousness, and instead insists on the simultaneous and indivisible connection of material existence and social consciousness. Gramsci's rethinking of the marxist explanation of the relationship between mind and matter and his incorporation of the concept of ideology into the broader one of hegemony redefines the tenns on which it is possible to think about the interplay of the material and the cultural. Indeed, it allows us to perceive the materiality of the cultural sphere that the conventional Mamist position risks dismissing as mere epiphemomena. In this section of the chapter I want to survey the ernergence and development of "cultural materîalism", a rnethodology which is built on the Grarnscian concept of hegemony, and it is the approach that 1 apply in the case studies that make up the three subsequent chapters. 1 will begin with Raymond Williams who coined the temi "cultural materialism" (1 977,5) and that he describes as "a theory of the specificities of material cultural production within historical materialism ... a Marxist theory ... part of what 1 at least see as the central thinking of Marxism" (5-6). Next 1 review the extent to which cultural materialism as a methodology has ceased to regard class as the primary focus of a politics of difference. Rather than repeating the by now familiar cataloguing of the myriad shifts away from class as a central category and attempting the impossible task of listing al1 of the consequent and proliferating subdivisions. 1 briefly state how I understand class as a dynamic category interwoven with other identifiers of difference. 1 then move on to two concepts from Foucault that are particularly useful for cultural materialist methodology (regardless of how "unfoucauldian" my use of these tums out to be): "discourse" and the "govemment of the self". 1 then want to make a distinction between the concept of "discourse" and that of "ideology" as I understand them as complernentary rather than synonornous tems. 1 do this by reassessing the concept of "ideology" in light of the post-structunilist contributions of Ernesto Laclau. Williams argues that the decisive historical and theoretical intervention represented by Mmism is the rejection of what Marx called "idealist historiography", and in that sense of the theoretical procedures of the Enlightenment. History wunot seen as the overcoming of ignorance and superstition by knowledge and reason. What tthat account and perspective excluded was material history, the history of labour, industry as the "open book of the human faculties". (Williams 1977, 18) According to Williams, Marx's insight offered the possibility of overcoming the great Enlightenment divide between "society" and "nature", "and of discoverhg new constitutive relationships between 'society' and 'economy"'; in short, "it was a recovery of the wholeness of history" (Williams 1977, 19). In other words, the vital contribution of Marx is the challenge to viewing human history as the linear progression of reason, or history as the advancement of enlightened ideas, ideas that in turn produce social. economic and political change. The challenge ihat Marx poses is characterised by his insistence on humanity's physical position in the world, and the practical activities consequent to this, as a driving force of history, and as 1 have already suggested, the cauldron in which consciousness itself is produced. For Williams, the tendency in Marxist thought towards an economically determinist reading of history is a disastrous flaw. It repeats both the assumption of progressive linear development and the separation of "culture" from material social life that had characterised "idealist historiography". We can see shades of Gramsci, 1 think, in Williams' rueful observation that "instead of making cultural history material, which was the next radical move, it was made dependent, secondary, bsuperstnictural': a realm of 'mere' ideas, beliefs, arts, customs, determined by the material history" (1977, 19). Economic determinism ultimately became a theoretical cul-de-sac in which Marxism spent a good deal of the first two thirds of the twentieth century, unable or unwilling to explore the possibilities of cultural analyses: "the full possibilities of the concept of culture as a constitutive social process, creating specific and different

'ways of life', which could have been rernarkably deepened by the emphasis on a material social process, were for a long time missed, and were often in practice superseded by an abstracting unilinear universalism" (1977, 19, emphasis added). Marx's initial assault on idealism's abstract concept of consciousness depends upon the assertion that it is methodologically futile to separate consciousness and thought from material social processes. For Marx, it is precisely this separation that makes consciousness ideological. It is ironic. then, that in the heat of polemic the Marxist position has asserted its own separation of consciousness and the matenal in the "elaboration of the familiar two-stage model, in which there isfirst material social life and then, at some temporal or spatial distance, consciousness and 'its' products"

(Williams 1977, 6 1). This materialist separation is ernphasized by a distinction between ideology and that which is not ideology, i.e. "science". Science represents "real" as opposed to ideological knowledge, and orthodox Marxism has coalesced around its self-definition as "scientific" and therefore objective and non-ideological. But the separation of the material and consciousness constructed by this orthodox Marxist position fails absolutely to appreciate that consciousness, thought and imagination are themselves social material activities: "'thinking' and 'imagining' are from the beginning social processes [that] become accessible only in unarguably physical and material ways: in voices, in sounds made by instruments, in penned or printed writing, in arranged pigments on canvas or plaster, in worked marble or stone" (1 977,62). However, not only are the components of culture that are written off by orthodox Marxism as abstract phantasms actually manifested in physical and material ways, but the realm of the "cultural" is also capable of material effects. In other words, Williams, like Gramsci, asserts what is for orthodox Marxism a theoretical heresy: that b'culture" is far more than a reflective superstructure, and that its relation to the economic is much more complex and interactive. In short, we are once more insisting on restoring dialectics to historical materialism. Williams argues that at the core of "culture" as a "constitutive" social process is language, which he defines, following Marx and Engels. as "practical consciousness" (1977, 37). Williams wants to avoid the pitfalls of both idealism, which views language as preceding al1 other activities, and the objectivist materialist position that insists that language is simply a reflection of "reality". Rather, language "as practical consciousness is saturated by and saturates al1 social activity" (1977, 37). Instead of preceding and making possible social activities, or succeeding and reflecting hem, language is, from the very beginning, interwoven with other social activities in a continuous, active, and changing social process. Social consciousness emerges and is shaped in the material signs (that is the language) created by a group in the course of its social intercourse necessitated by the collective activites it needs to pursue for its survival: "Signification, the social creation of meanings through the use of formal signs, is then a practical material activity; it is indeed, literall y a means of production. h is a specific form of that practical consciousness which is inseparable from al1 social material activity" (1977, 38). For Williams, Gramsci's concept of hegemony has an immediate relevance for a cultural materialist methodology (Williams 1977, 108). The importance of hegemony lies in the fact that it goes beyond the concepts of "culture" and "ideology". It "goes beyond 'culture', as previously defined, in its insistence on relating the 'whole social process' to specific distributions of power and influence" (108). and it goes beyond ideology by insisting on "the whole lived social process as practically organized by specific and dominant meanings and values" (109). In other words, "hegemony" introduces a recognition of domination and subordination into a context that still has to be recognized as a whole social process. Hegemony is more than ideology understood as a mechanical fom of control through manipulation or indoctrination. Rather it is a lived system of meanings and values that constitute reality for the majority of the memben of a society in ways that appear to be mutually and reciprocally confirming.

Hegemony is also essential to a cultural materialist methodology because what it seeks to describe is not a structure or a system but a process. Hegemonic analyses seek out the complex myriad of experiences, relationships and activities, which are themselves in a continuous state of flux, of which any given historical social moment consists. Flux is continuous because hegemony is never static, it is in perpetual need of renewal, support and reproduction. It is these hegemonic processes in to which it is possible to intevene with cultural matenalist analyses. In summary then, Williams insists that the production of signs and signifying systems (and therefore of ideology and discounes) is itself a materiai activity with material effects. Rather than arguing that the material or economic base produces effects such as culture or ideology as ephemeral aspects of its superstructure, Williams - and the cultural materialist methodology he advocates - argues that ideology and the discourses generated by social institutions are themselves located in material practices that have material effects that are capable of affecting the economic structures of the base. 1 commenced this section with the assertion that I wanted to move beyond the potential for overly economically determinist analytical approaches in Marx by adopting

Williams' cultural materialism. 1 also want to pursue the logic of cultural materialism in another of its challenges to conventional Marxist theory: the privileging of class as the motor of social change. More specifically, 1 am interested in a more complicated understanding of class than the narrowly determined and static category that relies on a fixed location in an economic structure. Class is a socio-economic category and not rnerely an economic one: "it is a process that indicates how people construct and alter their relations in terms of the productive and reproductive forces of society" (Ng 1993,

50). Perhaps the trinity has already become something of a cliche, but that does not alter the fact that clûss can not be properly understood - and therefore loses power as an analytical category - without reference

Adding Foucault To The Mix Before 1 conclude this section there are two issues 1 want to consider. The first is the utility of Foucault's theory and method for cultural materialism. The second allows me to conclude this section by returning to my earlier discussion of "ideology" as an analytical category. This discussion follows logically from the introduction of Foucault because the contemporary popularity of ~oucaul~,and the ubiquitity of a focus on b'di~c~~r~e",seems in many ways to have rendered ideological analyses anachronistic; ideology is somehow tainted by association with the "metanarrative" of Marxism. There are two concepts from Foucault that 1 am particularly interested in using:

"discourse" and "govemmentality". 1 am interested in them because as analytical tools, they seem to me to reflect an orientation that is similar in spirit to cultural matenalism as 1 have described it. I do not want to spend too much time on a description of the term

"discourse". It is widely used enough that we can assume a broad and relatively common understanding of it. "Govemrnent" as Foucault uses it is perhaps a less omnipresent feature of the scholarly landscape than is "discourse", but it is certainly being used to good effect in critical analyses of health promotion.

A discourse is an area of language-use that takes the form of a particular way of talking or writing, that is directed at a pgarticularobject, or range of objects, and that is characterized by a set of assurnptions that are specific to it: "discursive practices are characterized by the delimitation of a field of objects, the definition of a legitimate perspective for the agent of knowledge, and the fixing of noms for the elaboration of concepts and theories" (Foucault 1977, 199). We are surrounded by a multiplicity of discourses, some of which overlap, some of which contradict others, but each has its own focus, or as Foucault explains, "the term discourse cm be identified as the group of statements that belong to a single system of formation; thus 1 shall be able to speak of clinical discourse, economic discourse, the discourse of natural history, psychiatrie discourse" (Foucault 1972, 107). For the purposes of the present project, in subsequent chapters 1 will be identifying the discourses of public health and health promotion. But what is it that discourses do? How do they affect human behaviour? The answer for Foucault is that discoune is about much more than the production of words and language strategies. Just as 1 suggested earlier that Gramsci disrupts Marxist assumptions regarding a clean distinction between materialism and idealism, so for

Foucault an anaiysis of discourse is a materialist analysis, "discursive practices are not purely and simply ways of producing discourse. They are embodied in technical processes, in institutions. in pattems for general behaviour, in forms for transmission and diffusion, and in pedagogical forms which, at once, impose and maintain hem" (1977,200). Foucault is interested "less in the common mind than in the discourse of experts" (Kent 1986, 375). and it is in this way that the concept of discursive practices intersects with the second Foucauldian concept that 1 want to address, that of "government". Foucault's concept of "government" through "technologies of the self' seems to me to be very close to a Gramscian understanding of hegemony, the subject constitutes himself in an active fashion. by the practices of self, these practices are nevertheless not something invents by himself. They are patterns that he finds in his culture and which are proposed, suggested and imposed upon him, by his culture, his society and his social group. (Foucault 1988, 11)

As Foucault makes clear elsewhere ( l982), this form of government is dependent upon the establishment of normative patterns that are internalized by individuals who are then able to, in fact compelled to, exercise self-government. These normative patterns are constructed in discourse, but the power to construct and dictate social noms for individud behaviour "cannot be exercised without knowing the insides of people's minds, without explorhg their souls, without making [hem reveal their innermost secrets. It irnplies a knowledge of the conscience and an ability to direct it" (783). The need for this knowledge has led to the emergence of authoritative experts whose object of study and domain of knoweldge is human behaviour. From a Gramscian perspective we cm cal1 these "experts" traditional intellectuals. In other words, social norms are generated in the discourse of institutionalized experts who are authonzed by the state to speak on issues of human behaviour. These social norms are subsequently intemalized by individuais, on the bais of the authoritativeness of the expertise that produces them, and these individuals are thereby autonomously self-regulating. The penalty faced by individuals who fail to internalise such noms, and who therefore fail to police their own behaviour according to their dictates, is to be judged by experts in fields such as law, criminology, psychiatry or medicine. as deviant. As strategies of govemment, the institutionalized discourse of authoritative experts sanctioned by the state, and the self-government of individuals who act in accordance with internalised social norms, are compatable, I think. with hegemonic analyses that focus on the work of traditional intellectuals at vanous locations of civil society.

As 1 have already suggested, the contemporary popularity of Foucault, and in particular the widespread use of the concept of discourse has meant that "ideology" as a conceptual tool has fallen from favour sornewhat. Ideology lacks the currency of the linguistic turn of much contemporiry "postmodem" theory. What is more, in addition to suffering from the fact that it has just been around for a long time, ideology is viewed as something of an anachronism because of its historical affiliations with the

"metanarrative" of Marxism. Even though 1 have gone to sorne length in this chapter to argue the relevance of ideologicai analysis, 1 have already suggested that 1 will be using the concept of discourse in the case studies that make up the subsequent chapters of this thesis. 1 am going to conclude this section, therefore, by clarifying the distinction that 1 make between the two ternis and by reasserting that it is time to bt-ing back ideology to cultural analysis. Along with Ernesto Laclau (1997), whom 1 discuss in detail in chapter three, 1 want to suggest that the concept of ideology shouid be rehabilitated. This is because although ideology is inscribed in, and transmitted by, discourse it is in fact more than discourse. Ideological social consciousness represents the whole of an epistemological context in which socio-political consensus is ensured. That is to say, it is the historically cumulative ordering of al1 of the assumptions, values. beliefs, and bbcomrnonsense" of a given moment in time and place. 1 understand the concept of discourses, on the other hand, as forms of specific, operationalised ideologies. Discourses are part of the array by which ideological effects are created. By definition, as I have already suggested, discourse is limitec! to language, whereas ideological consciousness is formed in ways that include what is extra-discursive; music, clothing, architecture, visual arts, bodily functions, for exarnple. Not that each of these is not intirnately bound to discourses about them, but my point is that the effect of each on human consciousness is more than discourse. In other words, discourses are part of the microcircuitry of larger ideological technologies. Perhaps an analogy will be useful at this point. I hesitate to employ metaphors that ium to technologies, particularly computer technologies, to rxplain specifically human characteristics. However. for the purposes of explaining how 1 understand the differencr between ideology and discourse, 1 find such an analogy quite helpful. 1 am not equating the hurnan thought process to data-processing machines, for example, or claiming that computers are "intelligent", but 1 am suggesting a similarity, admittedly at the risk of ovenimplification, that hopefully makes my point quite clear. If we think, for the moment, of a human being as being analogous to a cornputer, 1 am suggesting that ideological consciousness is analogous to an operating system, while discourses are more like software applications. It is true that an openting system and an application program are two different foms of software and that both are written in the same binary language. Nevertheless, they perform very different functions. The operating system software represents the "ideologicai consciousness" of the computer, but without the codes inscribed in the form of program software, designed so that it is readable by the operating system, the computer will remain largely inactive. It is possible to push this analogy further, but 1 think I am better served at this point by reviewing briefiy this section before concluding the chapter by stating the ways in which 1 will be using a cultural materialist approach in the remaining chapters of this project. Building on my earlier arguments for developing a criticai theory of the branch of education ttiat employs hegemony theory based on a reading of Marx, Gramsci, and to sorne extent, Friere, in the current section 1 have argued further for a cultural Mamism such as that outlined by Raymond Williams. 1 have also incorporated the arguments of cultural theorists that challenge the centrality of class, determined by structure, as the privileged marker of difference by arguing for an expanded understanding of class not only as a dynamic relation, but one that is simultaneously interwoven with categories such as gender and class. I have also suggested that two concepts from Foucault: "discourse" and "govemment" will be methodologically useful for the cultural materialist analyses that make up the three case studies of the present project. I have concluded with a clarification of the distinction, as I perceive it, between "ideology" and "discourse" by suggesting that the latter is a technology of - though not necessarily contained by - the former. In the final section of this chapter 1 want to say more about the ways in which 1 will be applying the theory I have described and the methods that 1 will be using.

Education, Public Health, And The State The present project treats "adult education" as a broad and elastic category. In keeping with the Gramscian and cultural materialist theoretical approach elaborated in previous sections of this chapter, 1 am arguing that there are multiple sites of cultural production throughout civil society where adult learning tdces place. This learning either serves to consolidate dominant hegemony, or it creates (intentionally or otherwise) moments that can foster critical interrogations of it. It is very clear to me that public health - with its concem, amongst others, with the conduct of individuals and popiilations - is one such site. In this thesis I will not be occupied with a focus on what might be considered conventional leming or training spaces, the classroom or the training course for example, but the issue of the education of adults (including, as 1 explain below. the education of infantalized categories of adults) is central. This is in keeping with my theoretical perspective. and it broadens the scope of the field in ways that 1 think are useful and politically necessary. In this 1 am in aggreement with Lawson who argues "If we insist that research takes place only within tightly defined paramaters of 'adult education properly so called', is there not a danger of losing much of importance?" (1989, 17).

So. in what ways will the theoretical approach that 1 have outlined above be applied to a study of public health? In short. my concern will be to demonstrate the ways in which the discourses of the "authoritative experts" of public health serve broader ideological purposes in the maintenance of hegemony. Starting with the premise that a coherent thread running through the history of public health is the education of adults in "proper", that is to say "healthy", conduct, 1 set out to demonstrate how this serves the ideological needs of both late nineteenth century liberalism and late twentieth century neo-liberalism. Through a very concrete and demonstrable role in the configuring of ideologicd concepts such as "nation", "race", "the responsible consumer", and indeed of "health" itself, public health in both periods under consideration is an integril component of the machinery of hegemonic governance. Hegemony in any given period is always a more or less tenuously maintained political balance. The dominance of any constellation of ruling groups must always be attentive to the need for ongoing compromise chat allows for the incorporating of certain demands of subordinate and marginalised groups. Public herilth, at the end of the nineteenth century and in the final quarter of the twentieth, represents a balance of social forces in that it seems tu embody both the agenda of the state - driven by the exigencies of capitalist economics - and the political demands of the politically disadvantaged. In a very real Gramscian sense, therefore, it is a site of both hegemonic and counter-hegemonic production. A tension exists regarding the extent to which mling groups are able to accornodate and incorporate "demands from below" in a way that allows these demands to be managed in the interests of hegemonic sustainability rather than leading to the overtuming of the existing social order. Baggot suggests that the distinction between public health ai the end of the twentieth century and public health at the end of the nineteenth century is that for the former "most public health problerns have been associated wi th li festy le factors, whilst in Victorian times the main focus was on the physical environment" ( 1992, 194).

While 1 agree with this statement as far as it goes (and chapter three of this thesis will address the focus on lifestyle issues of contemporary health promotion) the second half of his statement leaves the story of nineteenth and early twentieth century public health only half told. It is in fact rather misleading. The public health movement in Canada at the tum of the twentieth century was most definitely concerned with what we would call, though they probably would not have, "lifestyle issues". A good deal of attention in public health was directed beyond the environmental concems of waste disposa1 engineering, sanitation, and water quality and towards the conduct of individuals.

Even when the focus was on the physical environment ii wüs often from the perspective of the consequences of the environment for conduct and behaviour. As Baggot points out, physical health was seen as a precondition of for social and spiritual progress (1992, 199). The issue of how to ensure appropriate conduct by individuals was a major preoccupation of the public health movement, as the following chapter will demonstrate. The very idea of subjecthood, in fact, can be seen to rest on concerns with conduct. There were those for whorn the only way to ensure appropriate conduct was through the construction of a regulated and surveilled environment: the working class. racial and ethnic others, and woven through both was the binding thread of gender. Those who could be expected to perform appropriate and exernplary conduct were those whose class and "race". once again interwoven with the complicating categories of gender. qualified them fully as self-regulating (though of course by the standards of established noms) Canadian subjects. In short, if we want to use

Knowle's ( 1980) terrninology, an andragogical approach was considered suitable for those individuals who matched the cri teria of the ii beral subject whilst pedagogical strategies were applied to an infantalized subject defined on the baîis of lower class status, non-European ethnicity, and gender. It is to a closer inspection of Iüte nineteenth century public health in Canada that 1 now wish to tum.

For reviews of these vanous atternpts to formulate general theories for adult education see Brookfield ( 1986, 25-39) and Cross ( 198 1, 220-34). ' For a history of the term. see Williams (1977, 55-71). For Marx's discussion of these ideas, see especially The Gennan Ideology (1947, 36-44), and the Preface to a critique of Politiccil Economy ( 1977).

' The term does not originate with Gramsci, but 1 am specifically discussing his use of it. For a more general history of the concept see Showstack ( 199 1 ).

"pparently, though at the time of writing 1 have not had the opportunity to verify this, recent citation studies reveal that Foucault is the most cited theorist in academic scholarship in the social sciences and hurnanities of the twentieth century. TWO FOR THE PROGRESS OF THE RACE1: THE CANADIAN PUBLIC HEALTH MOVEMENT 1880-1920

"Health is the prhary duty of life" (Wilde 1980, 329)

Configuring The Nation In this chapter an analysis of the public health movement in Canada in the late nineteenth and early twentieth centuries demonstrates what Raymond Williams calls the

"constitutive relationships between 'society ' and 'economy"' ( 1977, 19). That is to say, this chapter sets out to show that, rather than priviliging either the "social" or the "economic" as exclusively constituting the other, the relationship between them is demonstrably dialectical. In keeping with the cultural materialist theory outlined in the previous chapter, the analysis in this chapter, though Marxist, avoids the pitfalls of economic determinism by treating public health as part of a broader culture of liberalisrn that can be seen, in Williams' words, as "a constitutive social process" (19)' and not merely a chimeric epiphenomenon of the prevailing mode of production. Here, an ideological analysis of the Public Henlth Jo~tmal(PHa2, the organ of the Canadian public health movement, is used to examine the discourse of the "authoritative experts" of public health. Through this analysis of the discourse of experts 1 show how "culture" ûs a constitutive process operates through language. That is to say that it is through the exarnination of the institutional language, or discoune, of public health that we can demonstrate what Williams means when he asserts that signification, or the "social creation of meanings through formal signs" is "a practical material activity" (Williams 1977,38). We can see what it is that the discourse of public health produces and how this cultural production fits into what Gramsci calls "culture" more generally. From the perspective of the Gramscian concept of hegemony, and in particular the necessity of accomodating the industrial populations of the rapidly expanding cities within the social arrangements required for capital accumulation, this chapter is concemed primarily with the role played by public health discourse in the constitution of national subjects and the idea of "nation" infin de siecle Canada. This is not to suggest, of course, that public health played an exclusive role in such cultural production. Its discourse was a component of the much broader institutional array of ru ling practices that constituted the liberalism of the period (academic and professional disciplines, ideas of progress, and science, for example). Through the ideological categories of "nation", "health" and "gender/race7', the discourse of public health in effect produces the middle class Euro-Canadian subject of Victorian liberalism and simultaneously both defines and legitimises its moral and intellectual leadership over the rest of the population. The cultural rnaterialist approach cm illustrate the ways in which the public health movernent arises from a particular set of economic circumstances underwritten by the central necessity of capital accumulation, and it can also highlight the productive role of public health discourse in the construction of subjects belonging to a dominant class and the establishment and reproduction of that class's hegemony. In other words, public heülth provides the case study, and cultural materialism the analytical means, by which it is possible to describe how "gender, ethnic and class relations are inextricably linked to the formation of the Canadian state, if we see the state as the culmination and crystallisation of struggles over the dominant -in the case of Canada: capitalist - mode of production" (Ng 199 1,20). The central question posed by this chapter, then, is "what prompts the concern with public health which emerges in Canada in the years after 1880?', a period which begins with the creation of the Ontario Provincial Board of Health in 1882

(subsequently a rnodel for the rest of Canada) and culminates after the First World War with the establishment of a federal health department. The answer that 1 want to develop for this question is, in short, that issues of public health in the decades around the tum of the 20th century become a crucial element of "the ensemble of forms through which a class constitutes itself as the dominant force and imposes its will on the rest of society" (Laclau & Mouffe 1993,38). Specifically, 1 will argue that public health discourse becomes a significant mechanism in the consolidation of a white, Euro- Canadian middle class as "a 'class body' with its health, hygiene, descent, and race" (Foucault 1990, 124) as the primary elements of its self-definition. This is a self- definition, furthemore, with which members of the middle class distinguish themseives from others. The public health movement provides dominant social groups with both a forum for the articulation of anxieties of "racial degeneration" and the mechanisms for instituting a regime of "bio-power" (Foucault 1990, 140)"hrough which they are able to orchestrate responses to these anxieties.

Public Health AndAs Cultural Production Throughout 19 15 the Public Heolth Journal published a series of features on Canadian poets, which included a short biography and a selection of poems for each of the nine poets chosen. The series is, perhaps, something of an enigma. Why would a public health journal pay this son of attention to a group of poets? Clearly not as an entertaining diversion for its readers, for that does not explain the reason for choosing this particular group of probably little-known poets. Nor is the series simply about drawing attention to the existence of the poets and their work. Instead, it seems to be much more about providing teaders of the journal with instant cultural references that are specifically Canadian: each of the biographies depicts a life in ternis either heroic or tragic, or both, played out in Canadian contexts. The editors of the journal, feeling that "Canada is nch in native poetry, but most of us are not getting our share of the riches" (Public Health Journal 19 15, 18 l), published the series to make sure that its readers at least would have an increased awareness of this hitherto unappreciated richness of Canadian culture. Once again, why? The answer to this question lies in the socio- historic and discursive context into which the 19 15 volume of the Public Health Journal was published. And it is this context that 1 want to explore in this chapter. The educational. even instructional, nature of the series speaks to the fact that it is intended as a contribution to the development of a specifically Canadian identity: that is, a defining of what it means to be, and who is entitled to cail themselves, Canadian.

The implication is that the educated middle class readers of the PHJ should be informed about and appreciative of their country's literary heritage. And it is a very specific literary heritage, one which reflects the equally specific concept of Canadian identity that it is helping to construct. With one partial exception al1 of the featured poets are either British born or bom of British parents. The exception, Paulinc Johnson, serves to emphasise the foregrounding of "race" in the process of Canadian identity construction. Her father was "Head Chief of the Six Nations Indians, and a descendent of one of fifty noble families of Hiawatha's Confederation, founded four centuries ago.

Her mother was Emily S. Howells of Bristol, England". She is characterised as being, "of al1 Canadian poets ... the most distinctly a daughter of the soil, inasmuch as she inherited the blood of the great prirneval race so rapidly vanishing, and of the greater race that supplanted it" (PH 19 15,328). Like those individuals committed to the project of building the Canadian nation in the post confederation period - a project into which the PHJ poetry series crin be understood as a direct intervention - Canadian culture would be descended from European, preferably British, stock. The "new" nation would be great because it would be forged by an intellectually, physically, and morally superior ''Christian race". It is not immediately obvious. perhaps, that a public health journal would provide a means for communicating these raciatised notions of national identity, but in this chapter 1 will be arguing that, notwithstanding the undoubtedly positive achievements of the public health movement, public health discourse in Canada in the years between 1880 and 1920 was indeed implicated in the construction of ideological concepts such as "nation" and "race". The first section of what follows will constitute a critical histotical analysis of the period 1880- 1920. I want to begin by sketching the broader socioeconornic contexts of the public health movement, paying attention specifically to immigration, industrialization, urbanization. and the emergence of Canada's bourgeois and working classes. 1 will follow this with a discussion of the relation of the public health movement to the newly emerging national and provincial state apparatuses, exploring the contribution of the public health movement in ensuring the conditions for successful capi ta1 accumulation.

In the subsequent section 1 will tum to the iiterature of the public health movement for the purposes of ideological critique, an analytical approach that 1 describe in detail in the previous chapter. Focussing primarily, on theh

In the period under examination "the federal govemment [was] primarily concemed with public health as it related to immigration" (Ostry 1994, 294). However, the federal governrnent was also responsible for coordinating public health services for the First Nations. In fact, according to a contemporary source, "In 1904 the Department of the Interior and of Indian Affairs appointed for the first time a medical officer to organize and supervise the work of immigrant inspection, and the care of the heülth of the 100,000 or more Indians scattered throughout Canada in some 158 bands" (Bryce 19 10, 343). Puzzlingly, this is the first and last mention that is made of Canada's First Nations in the PHJ issues that 1 have scrutinised. 1 am at a loss to provide any explanation for the almost complete absence of Native Canadians from the discourse of public health. When Bryce referred to the appointment of a medical officer to supervise the health of "Indians scattered throughout Canada", he was in fact refemng to his own appointment as siich. Despi te the fact that Bryce was a remarkably prolific contributor to the PHJ, this is the only reference he makes to this responsibility. An explanation for this is suggested in a polemical pamphlet published by Bryce in 1922 after he had been squeezed out of his position as Chief Medical lnspector of Indian Affairs, and was thus freed of his civil servant's oath of contidentiality. This pamphlet catalogues his frustration and bewilderment over fifteen years with the federai govemment's refusal, having appointed him, to fund public health services to First Nations people or to listen to, let alone act upon, any of his recommendations (Bryce 1922). This was the case even though, as historians of the period have demonstrated, the health of First Nations had been devastated by contact with European settlers (Waldram, Hemng & Kue Young 1995,4344) and constituted "the greatest health disaster in nineteenth century

Canada" (Cassel 1994,281). One historian of public health in Canada has suggested that from the perspective of official policies of assimilation, the devastation wrought by diseases in First Nations communities simply illustrated that "the pnnciple of the survival of the fittest seemed to be working out in al1 its various ways in the new

Dominion" (Cassel 1 994,28 1 ).

Public Health: "Philosophy Of The Epoch'"

Although the period after the 1830s, intensifying after the 1 S50s, was one of increasing industrialization and urbanization in Canada, Palmer suggests that it was only, "during the 1880s [that] competitive capitalism consolidated much of Canada" (Palmer 1992, 1 17). complete with the ernergence of an identifiably new bourgeois class whose members "soon learned that the wny to secure advantage over business rivals was to heighten the extraction of surplus value from labour by cutting wages" (Palmer 1992, 120). In the years under discussion in this chapter, urban populations across Canada increased significantly (Urquhart 1965, 1-29), those of Quebec and Ontario, for example, almost doubled (Palmer 1992, 1 18). The bulk of these population increases were the consequence of increased demand for labour brought about by economic expansion, particularly in the indusirial sectors. The period also saw the extension of the railways and the "opening-up" of the West for population by the increasing numbers of immigrants arriving in Canada around the turn of the century, not al1 of whom were destined for the growing urban centres. By the 1880s the pressures of industrialization and hyper-exploitation had produced the militant, though uneven and faitering, mass working class responses that are indicative of both class awareness and organized discontent (Brown & Cook 1974,

108- 126; Palmer 1992, 1 17-208). Additionally , unlike earlier waves of immigration, which had primarily consisted of arrivais who were of British descent, the immigration at the close of the 19th century and the first years of the 20th was much more diverse and included many more people from southem and eastem Europe (Urquhart 1965, 1- 29). Thus, this was a period of identifiable anxieties for the dominant classes in Canada: first, the problerns of regulating the working class populations of the rapidly enlarging cities; second, the intensification after 1885 of policies designed to clear land in the west of Native Canadians to make the land available for new immigrants; and third, the increasing "foreignness" of those very immigrants and the necessity of ensuring their conforniity to Anglo-saxon norms (Brown & Cook 1974,54-74; McClaren 1990.47). These three intersecting and fundamentally racialised anxieties of the dominant class of Euro-Canadians constitute the material and ideological context for the emergence of the public heaIth movement. The public health movernent was in the vanguard of the "social professions" that emerged in the latter years of the nineteenth century and the earIy part of the twentieth - a period dominated by social and moral reformers that Valverde (1991) has characterized as "the age of light, soap, and water". Many of the leading figures in the

Canadian public health movenient were medical doctors, for it was they who in the closing decades of the 19th century recruited the new germ theories as legitimizing discourses in their campaign for recognition as the authoritative profession with a legitimate right to dominance in health care, tuming to public health as "another vehicle for extending the profession's standing in the community" (Cassel 1994,284). Looking back over thirty years of public health movement history in Canada, Dr. Peter H. Bryce comments that, "Ontario's Board of Health was born in 1882, the very year which marked the real birth of bacteriology" (Bryce 1910,290). Medical doctors were not the only activists in public health, as it will become clear in this chapter, but as (for the most part) educated, white, middle ciass men, they exemplified the racialised, gendered, and classed interests that characterized the movement. The middle class activists of the public health movement expressed, quite self-consciously, the missionary nature and moral imperative of their work, as the following passage i llustrates: It seems to me that humanity is ... divided into three great groups. First that lower strata, that great weltering mass of people whose lives are merely enlarged expressions of their two primary biological instincts of reproduction and self-preservation... It is from this group that Our social problems rnainly spring, as well as the dangers that threaten Our race and country. Another great group is that of the more or less selfish class ... occupied with their own ambitions and pleasures ... who refuse to see or believe that there are social problems which effect them. Between these two groups is the third great group ... who are the saviours of the others. (Shortt PHJ 1912.3 1 1) The correlation between germ theories of disease and the public health movement is hardly coincidental. Prior to the 1880s there had been little political will to commit the necessary resources for a permanent public health machinery but, "once the contagiousness of diseases which flourished among the poor was clearl y established, they were seen as a threat to members of the middle class and. therefore concern about slums increased" (Cassel 1994,282). In other words, for dominant classes in Canada, the germ theory of disease reposiiioned the working class from a class that merely consti tuted avai lable and disposable labour ("distasteful", "unmannered", and "uncouth" though they rnight be) to one that became ontologically dangerous as a source of contagion. It seems likely that prior to the intervention of bacteriology. concerns with cleanliness and hygiene were already emerging as signs of civilization and distinguishing marks of class (Goudsblom 1986, 162). which suggests a dual impetus for such concems: class distinction and fear of contagion. By the later decades of the 19th century. as the association between hygiene and disease became more widely accepted, a major shift in dominant values led to an obsession with cleanliness so intense that, "soap sales had soared, Victorians were consuming 260,000 tons of soap a year" (McClintock 1995,2 10). Germ theories implied thn, for their own safety, the wealthy would have to extend the civilizing notion of hygiene to the poor. By 1884, ris a result of intense lobbying of the provincial govemment, Ontario had passed a Public Health Act. which confined the permanent status of its Board of Health, and which made "it compulsory for local councils, under the direction of the provincial board to form permanent local boards and hire MHOs [medical officers of health]" (Ostry 1994,293). Ontario's act was rnodeled directly on the British act passed ten years earlier, and in turn became the model for the rest of Canada (Bryce 19 10 PHJ, 29 1). Just as "soap was credited with not only with bringing moral and economic salvation to Britain's great 'unwashed' but also with magically embodying the spiritual ingredient of the imperial mission itself" (McClintock 1990,211). so the

"sanitary idea" was imported into Canada from the imperial centre to perfom similar regulating and imperial functions.

Public Health, The State, And Civil Society Fear of the poor as contagious was one motivating factor behind the willingnrss to adopt a more active orientation to public health in Canada, but it is not alone enough to explain why the period between 1880 and 1920 was, in general. one of increasingly interventionist social policies by a state machinery developing at al1 three levels of Canadian government in areas such as ernployment, working conditions, child welfare, and housing as well as public health (Sem 1990,92). Neither does it begin to explain the complex relationship between the devclopment of state machinery, class interests and the institutionalization of expert authority in the emerging professions during this period. What this requires us to understand is the local role of the public health movement, within a broader context of expert authority, as a response to to the problem of govemment in the context of rapid industrialization and its consequent urbanization, and the production of Canadian subjects in a period of intense "nation-building". The public health movement, in fact, allows us to see how "expertise, as it became increasingly institutionalized in its professional form, became part of the process of goveming" (Johnson 1995,9). 1 want to focus on the ways in which the public health movement, made up of "experts" with state-sanctioned authority, worked to extend the reach of the state into the realm of everyday lives in order to secure the provision of a workforce fit for the needs of capital. and a citizenry fit to serve the needs of the nation. Clearly, what is being called into question here is the clarity of any distincion that we might want to assert between the state and civil society. and most specifically the often cited autonomy of professionals. The public health movement in the Canadian context clearly demonstrates that "the establishment of jurisdictions of professions like medicine, psychiatry, law and accountancy were al1 consequent on pmblems of govemment and as such were ... the product of govemment programmes and policies. Far from emerging autonomously in a period of separation between state and society, the professions were part of the process of state formation" (Johnson 1995, 1 I ). The history of the medical profession in Canada shows us that the granting of legisiative legitimacy to a particular form of medical knowledge was driven by social considerations at least as much as it was by the efficacy of particular therapeutic approaches. In tum, it was as a result of of lobbying by medical experts, still consolidating their professional dominance and social authority, that the variouis levels of the Canadian state introduced public health legislation such as Ontario's acts of 1882 and 19 12 (Cassel 1994, 283-84; Ostry 1994, 293-94) and the amendments to the federal Immigration Act in 1902, follwed by a new act in 1906 (Bilson 1982,401-3; Sem 1990, 104) and which ultimately produced a federal health department in 19 19. This interdependent relationship between professional experts and the machinery of the state in which the authority of the experts is sanctioned by the state, and the professionals in turn use their "expert" knowledge to influence state policy, hinges on more than some objective notion of "expertise". As 1 have suggested by referring to the history of the medical profession, the reasons why some forms of knowledge attain the status of institutionalized expertise and others do not are more social than technical; they are bound up with the structural interests of dominant social groups. This assertion. however, is not in keeping with a strictly Foucauldian use of the concept of "govemment". Foucault does not equate forms of govemment with the systemic and structural interests of dominant groups. Instead he explains govemment in terms of a much more ambiguous idea of historically specific problems in the management of individuals and populations (the rise of urban populations, for example) that require specific forms of government. But governments do not govem in a vacuum; the problem of government does not arise from disinterested sources. So, although we might agree with a Foucauldian definition of the state as "an ensemble of institutions. procedures, tactics, calculations, knowledges and technologies, which together comprise a particular form that govemment has taken; the outcome of goveming" (Johnson 1 995, 8) rather thun limi ting our definition to the political apparatuses of the state, the problem is that there is a Weberian turn in the Foucauldian concept of government that ultimately grants too much autonomy to the state. That is to say, the process of government seems to have its own intemal logic that is divoorced from issues of politicül economy. Not only are individuals erased from the socio- economic terrain - apart, that is from governed subjects - the very concept of interests, economic, class or otherwise, is absent from the analysis. The govemment of individuals and populations is simply a necessity and various techniques evolve to respond to this need. Although there is a great deal of real value in Foucault's concept of govemment, 1 do not think that this explmation of its appearance as a problem as "spontaneous" - that at a certain point in history the problem of govemment simply mises - is tenable. It is possible to reslove the riddle of the origins of the impetus for government through Gramsci's concept of "hegemony" (Gramsci 197 1,209-76). Gramsci argues that the capitalist state can best be understood as a concretization of the complex relations between competing social forces that produce a dominant class or alliance of social forces. Domination for Gramsci, as we have seen, takes two forms: force and hegernony. Hegemony involves taking systematic account of popular interests and demands... to maintain support and alliances in an inherently unstable and fragile system of political relations... and organising this support for the attainment of national goals which serve the fundamental long-tenn interests of the dominant class. It also involves intellectual and moral leadership through constituting a collective will, a 'national-popular*outlook, a common worldview which is adequate to the needs of social and economic reproduction. (Jessop 1990, 5 1 ) The apparatuses that Gramsci defines as the apparatuses of "political society" - the my,police, prisons, judiciary, and the civil service - comprise what we normally think of quite conventionally as the state, but the realin beyond these apparatuses, the space that Gramsci calls "civil society" is where hegemony is organized. We can characterize civil society in Foucauldian ternis as an "ensemble of institutions, procedures, tactics, calculations, knowledges, and technologies" (Johnson 1995, 8) that orchestrate the production of self-regulating, consenting subjects. Rather than understand political society and civil society as two entirely separate entities, it should be clear that, although they might each have a certain amount of relative autonomy, together they constitute particular forms of governing. It is in the interests of this form of govemment to emphasize a separation between the machinery of the state and civil society, the latter being the space occupied by independent professions: "because govemments depend on the neutrality of expertise in rendering social realities governable, the established professions have been, as far as possible, distanced from

spheres of political contention - the source of political autonomy" (Johnson 1995,22). ' In other words, we have retumed to the concept of govemment and its relation to expertise - institutionalized expertise, or the role of "intellectuals" in Gramsci's terminology, is essential to the organization of hegemony - but now with an appreciation for the ways in which the requirements of capital and the long-term interests of dominant social groups provide the impetus for govenment to arise as a political problem. Situating the institutionalization of expertise within a framework of hegemony allows us to clarify not only the relationship of professionais in the public health movement to emerging state apparatuses, but also - because hegemony rneans "taking systemic account of popular interests and demands", and "intellectual and moral leadership" - the social and political effects of the public health movement more broadly. As 1 have suggested, scrupulous attention to health and hygiene had already, by the 1880s. become identified as the primary duties of middle class subjects, exemplified by Lady Bracknell's assertion in Wilde's The Importance of Being

Earnest, with which 1 open this chapter. Discourse of health and hygiene become techiques for the assertion of a class entitlement to intellectual and moral leadership, for, in other words, "the self-affirmation of one [i.e. the middie] class" (Foucault t 990, 123). One of the consequences of the emergence of the public health movement and the extention of the discourses of health and hygiene to encompass the whole of society cm be understood as a contribution to "a political ordering of life, not through ann enslavement of others, but through an affirmation of self" (Foucault, 123). If intellectual and moral leadership are to be effective techniques of hegemony, in some ways expectations conceming the conduct of dominant groups have to be seen, publicly at least, to be higher than gendered, racialised and classed others, over whom dominant groups exercise moral superiority, hence the famously stifling "Victorian values". At the same time, however, the public health movement was not only motivated by the need for moral and intellectual leadership. It was also concemed with the health of the labour supply, as a national resource, at a crucial penod in Canadian econornic and national development, whilst simultaneously ensuring consent for existing relations of domination through fonns of social philanthropy, as this editorial demonstrates: We as a race must have physical soundness in order to survive. We are beginning to set as an ideal that of a sound body and a sound mind. We expect to get the maximum amount of service out of the race ... The man whose body is in perfect condition... is necessarily able to do better work ... Consequently it is our du', to see that men and women are not worked beyond their strength ... and that they have proper food ... and that their sanitary and other conditions of their homes are improved. (Public Health Journal 19 10,367, emphasis added) Similarly patemal sentiments and economic arguments are expressed by Bryce, though this time with the addition of gender and nationdism, It is not only necessary to understand the effect of disease upon national life and economic power, but it is necessary also to realize that only by preventing child labour and the employment in factories of mothers of families... by establishing some system of individual insurance against sickness... for the working people that we cm hope in any great degree to lessen the loss of life of our own people, more valuable to the state than can be a similar number of immigrants however good. (Bryce PHJ 19 10,344) The "social justice" element of the public health movement which is a thread running through public health discourse, ücted to legitimize both an increased interference in the lives of individuals, families and homes by the state, and relations of domination and exploitation. By the end of the First World War, public health is claimed to be an essential component of a tme democracy which is defined as, "socialism purged of its anarchy and other objectionable features" (Hastings PHJ 19 19,99). A year later another public health activist could assert, "just as 1 believe in compulsory education, 1 believe in compulsory health ... 1 believe in taxes for schools, and 1 believe also in taxes in health and morality ... If this is socialism, then 1 am an incipient socialist" (Almy PHJ 1920, 522).

1 am not suggesting that philanthropie motivation was in bad faith. The public health movement of the period was heterogeneous, intellectually at least, and it certainly included individuals who were committed to progressive social change in the narne of social justice. My concern is to examine the political effects of the public heaith movement in the context of prevailing socio-economic structures. Public health is especially powerfil as a site of hegemonic reproduction precisely because it is capable of reconciling certain demands of "incipient socialists" such as Almy with the agenda of the state. My assertion here, and in subsequent chapters, is that this form of compromise ultimately manages demands "from below" in the interests of mling groups whose dominance is thereby maintained. Nevertheless, the compromises made by ruling groups in the interests of hegemonic sustainability are real. The public health movement dunng this period, in other words, had real and beneficial consequences for the majority of the population, and was not simply a goveming discourse. Almy 's belief in compulsory health is illustrative of the conviction that unlike educated middle class subjects who might be relied upon to exemplify the personal virtues of attention to hygiene, cleanliness and good health. the masses in the cities were not capable of intemalizing such discipline and would have to be dragged to a higher level of "civilization" against their wishes and then constantly monitored "It is not enough to say that sunshine, fresh air, wholesome food and pure water are requisite to health. Man is apparently lazy and will make no effort to acquire opulence in the good things of nature if the opposite action is imrnediately easier and accompanied by present freedom from personal pain" (PublicHralth Jouninl 19 10,313). With regard to the urban working class 1 want to examine the ways that the public health movement focused on working class communities, specifically the home, to regulate behaviour and to render working class domestic life transparent to officiais.

Shedding Light On Working Class Lives MacDougall, a historian of medicine in Canada, informs us that after the passing of the

Public Health Act in Ontario in 1882 "by the end of the decade al1 three components of the sanitary idea - investigation, legislation, administration - were in place. Torontonians had become accustomed to investigations carried out by the health officer and his staff' (1988.86). Of course, as the Public Health Journal for the period illustrates, some Torontonims would have become much more accustomed to inspections than others. Whereas the middle class might have their commercial premises inspected, the working class, the poor. and identifiably "foreign" immigrants were exposed to an inspecting regime made up of sanitary engineen (Chapman PHJ 1891, 3), plumbing inspectors. public health inspectors (Arinunl Report of the

Medical Of/icerof Health 1 886. 2), public heal th nurses, neighbourhood (or social) workers (Clarke PHJ 19 16,498). and contagious diseases officers (Annual Report of the Medical Oficer of Healtli 1893,7). It was a regime that encompassed their workpiaces, their homes, and their schools. The schools were a target for relentless inspection because "our chiefest concern is with the children, the rising generation" (Roberts PHJ 19 12, 182), a concern which led some to advocate that, "in our public schools we ought to have qualified people to watch and study the children" (Yarros

PHJ 1920,6 10). Inspecting homes was vital because "most cases of social disorder originate in the home" (Schoales PHJ 19 16,470). In 1886, Toronto's Medical Officer for Health reported that "six policemen were placed at the disposal of the Board of Sanitary Inspectors... They proceeded to make a house to house inspection bringing to light the existence of many sanitary evils" (Annunl Report of the Medical Oflcer of Health 1886'2). Subsequent annual reports provide updates on such inspections complete with detailed tabulations street by street. These were inspections, furthemore, of areas of the city considered likely to harbour slum dwellings, or where household waste would have to be disposed of without the aid of amenities available to the middle class. Another dimension of the inspecting regime was an obsession with opening up the homes and the schools of the poor neighbourhoods. The literature is Iaced with demands for ventilation and sunlight as cure-al1 remedies for al1 manner of diseases: "good light and abundant sunshine are most important, both as aids to cheerfulness and as powerful sanitary agents... Sunshine and fresh-air are the most destructive of micro-organisms and diseases" (Schoales PHJ 19 15,47 1). Others also emphasized the acnial cleansing properties of ventilation and sunlight, "pure air and sunlight are first-class disinfectants, and as a vital necessity in every household. their importance cannot be overestimated" (Grant PHJ 19 16.74). Clearly, there were to be no corners of working class life that were not exposed to the authoritative gaze of the public health official. and no doors and windows not flung open to let in the bright sunshine that facilitated such close scrutiny. Once again, imposing this transparency upon the lives of the working class could not fail to produce economic, moral, and hegemonic dividends:

The raising of the whole physical tone of a community even a slight degree through pure air. sanitary homes, and hygienic surroundings increases effïciency in production to a degree which cannot be computed and can hardly be imagined ... Heightening of the joy of life which naturally fdlows an improvement in "physical" tone will change the whole mental outlook and moral tone of a community. (Brittain PHJ 1915,309) Sears, a historian looking back at the period under discussion, argues that, as with social policy in general, the surveilling function of public health "in this period was crucially organized around questions of gender. sexuülity and racelethnicity" (Sem 1995, 16). He points out that "[public health] problems in the domestic environment were to be attacked by regulating women's domestic labour" (1995, 17) primarily through home visits by women doctors and public health nurses, middle class women who were considered appropriate for teaching sanitary and domestic science to working class women. It was generally agreed within the public health movement that

- as the following passage suggests - women could be legitiinately recruited into the area of sanitary home inspection and that this might also have the not unappealing consequence of keeping them away from less appropriate professions: "this is a field in which more women can be usefully engaged, and to which we should gladly welcome them, even should some of them be obliged to forego the scalpel and the court in order to enter it" (Oldwright & Adams PHJ 1893,871). This focus on the domestic sphere and the necessity of policing women's labour and lifestyles is inextricably linked to the central fear of degeneration or. as i t was perhaps more dramaticall y labelled, "race suicide" - that is, the demise of the Euro-Canadian middle class as a consequence of the failure of that class's members to reproduce in sufficient numbers - that dominated the literature, and the minds of middle class activists, of the period. It is this issue of "race suicide", and in particular the ways in which it intersecis with prevailing gender politics. that 1 tum to in the following section. ldeologies Of Sex, "Race" And Class And Public Health Discourse

Clearly. "race" was a prominent concem in the public health literature of this period, and it is the interplay of class and gender in this notion of race that 1 want to focus on for the rest of this chapter. The components of this obsession with "race" that 1 want to discuss are as follows: the conviction that the conditions of modem urban living were causing "the race" to deterionte, secondly a somewhat ironic claim that the public health movement itself was contributing to "race" degeneration by contradicting the laws of natural selection, third a reiated belief that "race suicide" was king committed by worthy middle class stock who were reproducing less than the lower orders, and finally the issue of immigration.

The "race" under threat, it is assurned in the literature, is that of the white Anglo-saxon Protestant hailing from northem Europe, ideally Britain (perhaps via the United States), but nurtured through succeeding generations on Canadian soi1 and by the bracing northem climaie to produce a hardy, morally elevated, hard-working stock:

We in Canada - who with much reason clriim the Twentieth Century as especially ours, in the race of hurnan progress are in very truth "The heir of al1 the ages", and with our enormous temtory, our illimitable and underdeveloped resources, with our unique political organizations ... have the opportunity as never before of ... [placing]... man, "God's last creation" many steps higher in his advance toward the infinite. (Bryce PHJ 1910,394) The Euro-supremacist definition of a "Canadian race", however, specifically did not incîude French Canadians: rïlhirteen years ago I read some literature about the rapid reproduction of the French-Canadians... It was calculated that, at the same rate of fertility, in about a century , they would not only populate the whole of Canada, but would ovenun the whole of North America. The Yellow Peril was not in it with them ... [but. this not having occurred].. Nature has her compensations, and this is evidently proving a saving grace to a less prolific breed. (Barr PHJ 191 1,416) For one school of thought in the public health movernent the threat of urban industrial capitalism to "the race" w;is thought to be found most acutely in the environmental conditions of the cities, in poor housing, poor working conditions, wornen working, and the various vices commonly attributed to the urban dwelling poor - drunkenness, contagious diseases, insatiable sexual appetites and prostitution. Such a hell of degeneration were the poor urban neighbourhoods considered to be that a PHJ editorial could daim that, "Every time a baby dies the nation loses a prospective citizen, but in every slum child who lives the nation has a probable consumptive and a possible criminal" (Public Health Joiintnl 19 10,414). The same editorial goes on to assert:

If such conditions continue, what will be the fatc of hundreds of thousands of children who are born and raised in the congested centers? Minds are dwarfed and defonned; mental and moral degeneracy follows; disease plays havoc and is spread through the country; a great number of men and women inferior in minds and bodies are raised, instead of what should be a race of increasing efficiency. (416) Thus, we have fiirther motivation for the obsession noted earlier with slum clearance, and the ventilation and opening up of working class homes, and the regulation of the behaviour of the poor; the poor, in their environment have a propensity for degeneration which threatens the very fibre of the "race": "Bad housing conditions inevitably lead to drunkenness in parents, to delinquency in children, to disorderly conduct, to wife and family desertion, to immonlity in the growing population owing to lack of privacy, and consequent loss of modesty" (Shortt PHJ 1912,3 1 1 ).

Furthermore, this tendency towards degeneration, which. it was believed, only a perpetual vigilance by middle class public health activists working with and through govemment, could hope to avert, provided another incentive for middle class refomers to work towards improvements in working conditions which were also thought to be another potential source of moral, physical, and spiritual degradation. It was the working conditions of women that were believed to be particularly important from the perspective of "race". Ideally, working class women would not work at al1 but would tend to the business of raising children in an environment which was kept clean, ventilated and bright. Such an environment would provide a home for the working man that would disincline him towards drunkenness and family desertion, and thereby maintain his status ils a productive worker. On the other hand, economic and social necessity, characterized by the middle class as the "servant problem", created a somewhat contrridictory tension through which work before mariage, or before motherhood, for working class women was considered possible, even desirable. In fact, domestic service work was actively prornoted for young women as a means of keeping them üway from factory work. though simultaneous warnings to their potential employers sought to prevent their being overworked and their potential for being good mothen thus undçrmined. Acknowledging that 'wwe al1 do a fair amount of grumbling about our servants". Constance Hamilton advocates applying the new scientific management techniques to domestic work and wages to make the conditions of such employment less arbitrary in order to counter the appeal of the factories. Greater care taken in the organization of domestic work would have consequences beneficial to "the race": Are we doing our duty to the comrnunity or to the nation when we put such a strain on a young woman who may be a potential mother? Our duty to the race demands that we should govern the conditions of this young woman's work so that in later years she may have the chance of becoming the mother of a sound generation (Hamilton PHJ 19 13,30). For those in the public health movement who perceived dangers to "the race" prirnarily in tems of the detrimental effects of squaiid urban environrnenü on the poor, one of the greatest threats was the effect on the sexual morality of working class women, who might easily fa11 into prostitution, which by the second decade of the 20th century had replaced the fly as the single rnost virulent source of contagion in public health discourses. Working clas women were thought to incline towards looser morals and to have inherently more insatiable sexual appetites than well-bred women, about which I will have more to say below, and the living conditions of the turn of the century urban proletariat were believed to be conducive to accentuating this tendency: "Bad housing begets low ideals of living ... Bad housing sows the seeds of immorality, of betrayed womanhood and of fallen virtue" (Public Healrh Journal 19 1 1, 88). The figure of the prostitute provided another school of thought within the public health movement with a focus for its slide frorn environmental explanations for racial degeneration to others based on theones of heredity . These theories ultimatel y produced the eugenics movement (McClaren 1990, 13-28) which gained such lrgitimacy in public health circles that when the Canadian Public Health Association was formed in 19 10 one of its objectives was the "popularization of eugenics" (Pclblic

Hmlth Journcrl 19 10,460-6 1 ). This shift to eugenics meant less ernphasis on environmental issues, though 1 am not suggesting that the latter disappeared, nor that the debate between the advocates of nurture and nature was resolved. It is clear, however, that through the nineteen teens, advocates of eugenics positions acquired a higher profile in the Pitblic Herilrh Journal. and that increasingly concems of racial degeneration were expressed particularly in ternis of prostitution, venereal disease, and the ever-vague concept of "feeble-mindedness". The following passage illustrates a sort of transitional moment in the shift from environmental to eugenic concerns in its initial acknowledgment of the work of the public health movement followed by an important qualification: By secunng a healthy and satisfactory environment for your citizens you will do much to remove the antecedent conditions which tend to disease and distress, but it cannot be too strongly urged upon your notice that the attempt to secure the racial fitness of the nation by purely environmental refotms alone and the removal of the mother and the child from unhealthy surroundings will be in vain unless you have regard to the nature of the stock from which they spring. Nature is stronger than nurture. (Auden PHJ 19 1 1,210)

In fact. eugenecists argued frequently in the pages of the Public Hecilth Journal that the public health movement had actually contributed to racial degeneration by creating conditions which counteracted the laws of natural selection that would have kept the inhei-ently un fit from reproducing: "Those countries which have to a large extent suspended a selective death-rate. but are not wise enougli to establish a selective birth- rate are certain to decay, and go the way of al1 the ancient nations who disappeared and made way for more vigorous races" (Barr PHJ 19 1 1,416). The pages of the PHJ between 19 10 and 1920 are littered with such generalized fears of racial decay made by apologists for eugenics. but what 1 want to focus on here are the ways in which such fears are used to iiniculate more specific concerns about the racially polluting propensity of working class women, and "foreign" immigrant women. Central to the expression of these fears is the concept of "feebie-mindedness", which remains an undefined concept, sometimcs apparently associated with insanity, and at others more blatantly with criminaiity. morality and sobriety, but always with classed and raciiiliscd value judgments of Othered women. The elasticity of the terni "feeble-minded" enables its recruitrnent in both apocalyptic discussions of the breeding capacity of such women and the reproduction of inferior offspring, and slippage into accounts of the hell of contagious disease and destroyed farnilies wrought by feeble-minded prostitutes. This double usage is made possible because as it was assumed that "their pre-disposition to sexuül passions are generally recognized" (Downey PHJ 19 12. 126) there were only two paths that the life of the "feeble-minded" woman could take, unfit mother,

"revelling in the doubtful pleasures of large families" (Downey PHJ 19 12, 126). or venereal disease-spreading prostitute. Consequently two of the most crucial problems seen to require remedy from the standpoint of protecting "the race" were the breeding of the "unfit" and prostitution, and both problems could be solved by the application of two policies - segregation and sterilization - or at the very least preventing the "feeble- minded" from becoming mamed (Young PHJ 19 19,367). The relationship between

"feeble-mindedness" and prostitution becarne particularly circular: "the more you have to deal with these two scourges, the more you are convinced that they are one and the same. for the vast amount of prostitutes are feeble-minded" (Murphy PH3 1920,405).

In fiict, there was a growing assumption that the act of prostitution itself was just about sufficient for the diagnosis of "feeble-mindedness" and justification enough for submission to the actions necessary to eliminate the social evils consequent to it. Between 30 and 50% of al1 these unfortunates are mentally subnormal or disordered... Their mental state fits them only for menial and tiresome work at a very low wage ... [I]t is our task to protect society from them and to proteci them against themselves. This can only be done, as we know, by establishing training schools in connection with farms to to which these girls could be sent for permanent are. (Yarrow PHJ 1920,6 10) If one element of middle class fears of racial degeneration was articulated through discussions of the sexuality of working ciass and poor women. the other primary element focused on the sexuality of middle class women thernselves. This other element. counterposed to the uncontrolled reproduction of undesirables, was characterized as "race suicide" committed by the "sounder stock" who were thought to be Ming to reproduce in adequate numbers. This "race suicide" was blamed on the perception that middle class women were choosing less and less the option of motherhood, and instead opting to indulge their own selfish desires for leisure or work outside the home: though general calls were made for the middle class to increase the rate with which it reproduced, these calls were not aimed at regulating the behaviour of men with anything like the fervour with which middle class female subjects were targeted. Chief amongst those advocating remedies for this "race suicide" was the eugenecist Helen MacMurchy who clairned that, "the Canadian home and its children are the greatest asset of Canada". She went on to ask, "but are there enough of Canadian homes?" (MacMurchy PH3 19 10,305). The greatest threat to this Canadian home, and the reason for there not king enough of them is the, "selfish, unnatural, pleasure-loving, foolish mind. and heart and life", of women who do not perform their "race" and class duties of devoting themselves to living out an idealized concept of motherhood, "she has set vanity in her hem: and cobalt stocks or the automobile. or clothes or bridge or some other folly, robs her of the joys of motherhood, and the true riches of Cornelia's jewels" (MacMurchy PHJ 19 10,305). The possible contradictions between her own rhetoric and her life as a doctor and public health official notwithstanding, MacMurchy goes on to daim that "we should devote ourselves to the public and private service of the Home. The man and woman who make a home have rendered to their own generation and to posterity the greatest service of all" (19 10. 306). Others. though they acknowledged the potential for "racial dangers" in the increasingly common fact of middle class women in the sphere of work beyond the home. were less inclined than MacMurchy to advocate in favour of turning back the tide. Instead, accepting the new realities, they sought to extend the regulation of women to the workplace itself. If women could be kept from submitting to the obvious sexual and moral temptations of exposure to the world of work. she would. arguably, be in the ideal environment for borh a training that would suit her for a future as wife and mother and for finding the ideal husband in a man of business. Al1 in all. the business girl is a most encouraging phenomenon. For - temptations apart - both her character and her environmeni fit her to müke a wise marriage choice from high motives, and to be a good wife and mother. Upon her should be centred much of Our hope for the coming race. (Anon PHJ 1910,413) It seems that we have here a tension similar to the one suggested above in which although, ideülly, working class women were to be housewives and mothers in order to ensure an environment conducive to the efficient reproduction of healthy labour, their work outside the home was acceptable if it was in the context of the "servant problem", that is. servicing middle class homes, rather than factory work. For middle class women, wifely duty and motherhood were advocated more from the perspective of racial purity than economic necessity, but again, work outside the home could be tolerated if it could be regulated closely enough, both in ternis of time - before rnarriage and motherhood - and place - the office where they might meet prospective breeding partners. For the public health movement, in other words, concems with "race" (degeneration and purity) also pmvided the langage with which to articulate üttempts at policing the gender subjectivities of working class and rniddle class women. Thus Far I have focused on the public health issues of urban populations. 1 have considered the range of racirilised and sexualised anxieties, articulated through the public health movement, that arose as a consequence of the need for dornestic reproduction of labour in Canadian cities. However, another source of labour for capitalist economies. and one that was particularly signifiant in the Canadian context during the period under discussion. is immigration. Immigration, the responsibility of the federal governrnent. was, as we leam from the pages of the PHJ, a source of a good deal of anxiety for the public health movement because of the threat of racial pollution thnt was thought to be inherently potentiül within it. It is these anxieties that will form the focus of the final section of this chapter. Fears that racial degeneration might be accelerated by immigration seem to have focused on two issues, firstly that immigrants from "preferred" countries might have already become racially soiled by urban life in European countries, and secondly, that immigrants were increasingly from less "desirable" locations. 1 will deal with these two anxieties in tum, but first 1 want to comment on the fact that a specifically Canadian identity had been constructed so elaborately by this point, albeit of European origin, that immigration of any kind was considered a necessary evil at best. Bryce, for example, had advocated for public health measures to prevent the loss of life "of Our own people, more valuable to the state than can be any similar number of immigrants, however good" (Bryce PHJ 19 10,349, whilst others were even more emphatic: "every child bom on Canadian soi1 and raised to maturity is, in my opinion. worth to us as a nation, perhaps half a dozen of the average immigrants coming to us from foreign lands" (Pickard PHJ 1913,610). However. the requirements of the Canadian economy were such that large numbers of immigrants were needed, and acquired, by the end of the nineteenth century and into the twentieth. Sears (1990, 104) argues that the rnachinery of public health. administered by the federal state. had a role to play in the context of immigration policies designed to police entry into a "nationalized Canadian working class. Just as immigration itself became increaîingly important to the supply of labour for Canadian capital, so from the eariy days of the 20th century. health was to become a principal discourse through which the Canadian state attempted to operate a selective policy of controlled entry. In 1902, the 1872 Immigrütion Act was amended to introduce medical inspections at the point of entry into Canada and then in 1906, as Bilson - a historian of health and immigration - relates, a new act established a range of categories of person who could be excluded from the country including the "feeble-minded", "idiots", epileptics, and anyone with a "loathsome diseüse" (Bilson 1982,400). The underlying philosophy of such legislation wu that "Canadian laws should be restrictive and stringently enfomed as to admit only those who are physically and mentally sound, capable of developing and building up this great and glorious Dominion ... The conservation of the race is vastly more important than that of the Natural Resources"

(Bailey PHJ 19 1 2,439). Nevertheless, it was still claimed that "the majority of our national intemal problems will be found to have their root in the problem of the immigrant" (Lee PHJ 19 13, 134). and that "immigration is a subject of vital importance to every loyal citizen ... creating as it does complex problems - economic, social. moral and physical" (Bailey PHJ 19 12,433). Medical inspections appear to have been cursory at best and obviously depended on the individual discretion of inspectors who would be disposed to make their judgements using as Sem now argues, "a broad conception of public health ... defined as overall physical, mental, and moral well-king in the interest of usefulness to the nation" (1990,97). Some immigrants would be considered inherently more attractive than others, and subjected to considerably less scrutiny. For the most part, public health activists concurred with the prevailing wisdom of the day that "England, Wales, Scotland and

Ireland, [are] where we are naturally looking for our biggest supply of immigration"

(Page PHJ 19 12.26). or even a little more broüdly. "it is the United Kingdom. some of the European countries and the United States that Canada regards as most likely to fumish the class of aliens desired" (Bailey PHJ 19 12,439). Consequently. immigrants from these places were less rigorousl y inspected than others. These fears were not necessarily altering the fact that British immigrants were thought to be the most desirable. but they were arising from the growing concem that Britain was "dumping" its own undesirables on Canada, thereby ridding itself of iis own collection of urban degenerates, the unhealthy, the "feeble-minded", paupers, criminals, and prostitutes. These fears led, by 1904, to the establishment of a system whereby immigrants were examined before they left Britain and poiicies of actively encouraging the immigrütion of more desirable individuals. "Canadians have wisely framed their immigration laws ... and they have a systematic propaganda to induce the emigration of desired classes" (Bailey PHJ 19 12,439). As the nurnber of immigrants en tering Canada dwindled during the First World War, so the issue recedes from the pages of the Public Health Journal. Ultimately however, there was no resolution to this

"problem" of immigration, and the tension remained between the palpable need for additionai labour supplies and the racialised and class anxieties based on fears that, inspection and regulation notwithstanding, newcomers were diluting the quality of the Canadian population.

In the years after the First World War a Federal Department of Health was established to coordinate health care in Canada, but contrary to the expressed desires of activists in the public health movement, the direction pursued became increasingly focused on hospitals, technology, drugs, and surgery. the paraphemalia of a curative approach to hedth based on the scientific biomedical model. Why public health and the preventative approach to health should have receded from prominence when it did, and why, in the closing decades of the 20th century it is retuming in the context of the radical restnicturing of health care systems, are issues to be discussed in subsequent chapters. My purpose in this chapter has not been to reject the possibility of "well- intentioned" actors in the pubIic health movement at the turn of the 20th century; nor do I have any interest in denying the obviously beneficial effects which are reflected in the considerable achievements of the movement in the areas such as housing and infectious diseases. 1 have attcmpted rather, to undentand the public health movement, consisting as it did of both negative and positive aspects. This has meant looking not to the contributions of notable individuals, nor even to the specific improvements in the quality of urban life from the perspective of health and hygiene. but rather to the role played by public health discourse in the production of a white Euro-Canadian middle class, and in the establishment and reproduction of the hegemonic dominance of that class. In these terms. we can see that public health was intimately bound up with the labour requirements of 19th century capitalisrn, and the development of Ciinadian state apparatuses. Moreover. at the root of the movement was the intenvoven tapestry of racial, gender, class, and national anxieties of a dominant group still relatively insecure in its own subjectivity as it expanded its imperial frontiers, crowded increasing numbers of workers into the cities, and sought to regulate the entry of "aliens" into an increasingly "nationalised settler-society. ' 1 take this characterisation of the purpose of public health in the penod from Helen MacMurchy ( 19 10: 305).

Subsequently and currently, Canadian Journal of Public Health . Unless specified otherwise, al1 citations from articles published between 1880 and 1920 in this chapter are tdcen from the Public Health Journal. For clarity 1 have included the identifier PHJ in citations from the Public Health Journal. Citations for which no author is supplied are PHJ editorials. "oucault uses the term "biopower" to describe a political technology that emerges in the nineteenth century, consisting of discourses about sexuality, that "brought life and its mechanisms into the realrn of explicit calculations and made knowledge-power and agent of the transformation of human life" ( 1990, 143). Bio-power is exercised by various institutions and apparatuses, such as medical, legal, and administrative, whose functions, according to Foucault, are primarily regulatory in that they constitute a nomalizing regime. This normiilizing regime, furthemore, establishes and polices noms at both a macro and a micro level: "the disciplines of the body and the regulations of the population constituted the two poles around which the organization of power over life was deployed" (1 990, 139).

1 borrow this tenn from Gramsci (197 1.228) who uses it to describe central ideological themes of the hegemonic apparatus of the ruling group. Hegemonic leadership, as defined by Gramsci, goes beyond force based on corporate interests and extends to consent organized around moral and intellectual leadership. See chapter one for a fuller discussion of "ideology" and "hegemony". This is a generalization and, perhaps, an oversimplification, but the primary object of fear in the 1880s, at least as represented in the pages of the PHJ,as the germ theory of disease became more widely accepted, was the fly and its propensity to compt food; milk in particular. As the public health rnovement matured and the boundaries between it and other movements for social and moral reforrn became less distinct, and the roIe of of middle class women activists became increasingly proininent (Ehrenreich & English 1973; Valverde 1993) prostitution and venereal disease replace the fly and corrupied mil k as the central preoccupations of the movement. THREE RECONFIGURING THE NATION: THE NEW PUBLIC HEALTH AND THE RISE OF HEALTH PROMOTION

You are a bad and dangerous person and stand branded in the eyes of your fellow- cowtrymen with one of the most heinous known offences... [Hlad not the capital punishment for consumption been abolished, 1 should certainly inflict it now. Butler - Erewhon.

The Post-Interventionist State And The New Public Health In the previous chapter I attempted to chan the relationship between the public health movement and strategies of govemment in Canada during the penod 1880 to 1920, a period characterized as one of nation-bui lding and the consolidation of industrialized capitalism. Central to this discussion was a concern with the contribution of the public health movement to the construction of a specifically Canadian subject, and to the techniques by which the conduct of this subject, and also the conduct of those against whom this subject was defined, was to be miinaged. It is rny contention that the subject so constmcted turns out to be not only the famil iar subject of liberal discourse, but also the "adult" of adult education discourse. My concern in the present chapter is to revisit these issues in light of the return to an emphasis on public health, now in the form of health promotion, since the mid 1970s. If chapter two sought to explore the role of public health between 1880 and 1920 in the configuring of the Canadian nation both economically and ideologically, the present chapter attempts to chat the function of the "new" public health in what we rnight cd1 the "reconfiguring" of the nation economically and ideologically. Prominent in this discussion are the redefinition of the role of the state in the post-interventionist priod and the reconstruction of the "ideal" Canadian subject as a self-sufîicient, self- managing entity no longer in need of the so-called "disempowering," "interfering" state. In particular, it is with regard to the role of health promotion in the emergence of new neoliberal strategies of goveming that 1 explore the refrarning within the "new" public health of two dominant characteristics of public health 1880-1 920. We have seen how the public health movement, in its first Canadian incarnation, was implicated in the construction of specific classed. gendered. and racialised subject identities. It was middle-class adults, men and women, of European descent, toward whom the energies of public health's instruction in appropriate conduct were directed. This instruction in conduct was set within public health's concems with the degrading potential of the physical environment and was driven by racialised discourses of moral responsibiiity. Late twentieth century health promotion, as is the case with its broader liberal context, no longer articulates its agenda explicitly in terms of "race7'.' Since the 1980s the "new" public health has expanded the Victorian fear of the degrading influence of the environment beyond insanitary urban conditions, to include the social conditions such as education and poverty. However, within this context it remains, at its core, concemed with the instruction of individuals in personal conduct. What is more, this instruction remains couched in the language of moral responsiblitity. The overtly racialised nature of the discourse niay have disappeared, but "appropnate" behaviour is framed as a moral imperative. as that which is conducive to "wellness".

Another characteristic of first wave public health that we can see repeated in the contemporary version is its propensity to manage radical social critiques by refrarning their objects of analysis as technical problems of health. In the previous chapter, 1 described the ways in which elements of socialist critique were incorporated into a eugenicist public heal th discourse. In this chapter, 1 consider the extent to which heaith promotion achieves a similar institutionalisation of radical discourse by enfolding it within the dampening folds of "health". Health promotion, as it has emerged since the 1970~~cm be understood in terms of a more generd disenchantment with the medical mode1 of health dominant in the Canadian health care system for a century. Health promotion, dong with the consumer movement in health and advocates of complementary, or "alternative", therapies has seriously challenged the hegeinony of the dominant medical model. Between them these three rnovements present a common and a compelling, critique of the scientific medical model. Briefly, some of the key elements of such criticisms are that scientific medicine has an overly narrow biological focus. That is to Say, scientific medicine proceeds from the assumption that the determinants of health are pnmarily biological. This is a legacy of its association with science and the genn theories of illness ihat helped secure its dominance in the latter decades of the nineteenth century.

Associated with its scientism is scientific medicine's tendency to be reductive in its concerns with treating pathologies. It largely regards the body as a machine needing repair rather than an embodied sentient king. Therapeutically, scientific medicine seeks to "repair the machine" with "cuts and chemicals" (Armstrong & Armstrong 1996. 19): that is, its principle tools are drugs and surgery. It is limited in its vision to seeking cures for specific illnesses rather than maintaining a broader concept of good healtli that prevents them in the first place. Finally, a hallmark of scientific medicine is that it is centred on a relationship between an authoritative professional and a passive patient who is thoroughly stripped of agency. Over against this model, and in contrat to tliese features of it, the three movements that 1 have identified as challenging the scientific rnedical model - the consumer movement, health promotion, and the range of approaches to health labelled "alternative" - argue for a more wholistic approach to health and well-being. The health promotion movement challenges the conventional scientific model by arguing for an understanding of the social determinants health and illness over and above - or at lest as equal to - the biological. As always, there are dangers in homogenising the health promotion movement. The health promotion models that have evolved in Canada since the mid 1970s produce strategies and practices that can fa11 anywhere dong a spectrum that ranges from narrowly behaviourist approaches that focus on disease prevention, and healthy lifestyles with regard to individuals, to community-onented approaches that advocate concepts such as "capacity-building" and "empowennent". Green and Kreuter provide a usefully brief definition of health promotion that underpins the content of this chapter "Health promotion is the combination of educational and environmental supports for actions and conditions of living conducive to health" ( 199 1,4). In this chapter 1 will be exploring the tensions, contradictions and common themes in health promotion's dual lifestyle/personal behaviour and socioenvironmental approaches. Specifically, is there more than a coincidental relationship between the emergence of health promotion and the dismantling of the welfare state that has been characteristic of the same period? Thiny yean ago Jurgen Habermas (1970) wrote: "the permanent regulation of the economic process by means of state intervention arose as a defence mechanism against the dysfunctional tendencies, which threaten the system, that capitalism generates when left to itself" ( 10 1 ). His assertion was that these "dysfunctional tendencies" threatened the hegemonic legitimacy of existing power structures and relations of production and exchange. Hence the ideology of free exchange is replaced by a substitute program. The latter is oriented not to the social results of the institution of the market but to those of govemrnent action designed to compensate for the dysfunctions of free exchange. This policy combines the rlement of the bourgeois ideology of achievement... with a guaran teed minimum level of welfare, w hich offers secure employment and a stable incorne ... [it] guarantees social security and the chance for upward mobility. (102) Habermas is writing specifically here about post Second World War Western ~urope? where, by general social consensus, varying degrees of interventionist States had emerged aimed at achieving the ameliorating social planning that he describes. Whatever the red extent of this "welfare" state in Europe (and as 1 have suggested, Europe was not homogenous in this expriment) in terms of a successful and long-lasting redistribution of wealth, a core common element was a cornmitment to the idea of publicly funded health care services. Additionally, whatever the uneveness of the development of the different welfare States seen in Europe, the relatively unambiguous authority of the central govemment allowed at least for consistency within nations. In Canada however, the particular constellation of govemments, and in particular the tensions between provincial and federal levels, produced a hodgepdge welfare state that incorporated wide variations on themes across the country between provinces. One theme that developed in priictice over more than thirty years was the idea of universal access to health care.' The particular set of compromises that make up this thirty year history (see, for example Taylor, 1978) culminated in a health care system that varies widely between provinces and territones on five common themes, adherence to which has thus far been a prerequisite of federal funding.' Furthemore, health care in Canada has never been socialized in the way that it has in some European countries. Rather, the rnodel has been one of public funding for privately delivered services, services delivered primarily by doctors. In other words, the role of the state has ken to make available public monies that guarantee the payment of individuals within a fee-for-service model. My intention in this chapter, however, is not to measure the extent to which health care in Canada became or did not become socialized. 1 am also not occupied, for the present, with debates concerning medical dominance within Canada's health care system (although issues of professional expertise is a continuing theme, and 1 am interested in the practical political effects of critiques of medical dominance). I am more interested in charting the retreat from the commitment to public funding, for health care in particular - a commitment that was attained and maintained up into the 1980s. Certainly, if we compare the Canadian model of health care with that found in the United States, it is hard to deny that the Canadian system has resembled, and for now continues to resemble, much more closely the social democratic model found in Europe than it does the U.S.model. But for how much longer this will continue to be tnie is uncertain. The central assumption of this chapter is that the commitment to socially Funded health care as it exists in Canada is vulnerable at best. and that, along with counterparts in Europe (and New Zealand and Australia) Canada is twenty-five years into the ideological and actual dismantling of the interventionist state. Even as Habermas was writing the passage quoted at length above, the particular hegemonic configuration of which he wu writing - the "welfare state" - was entering an extended period of decline that has culminated in a new "common sense" in the late 1990s in Canada, as elswhere. This new "common sense" is that the welfare state is an indulgent anachronism: a wasteful culture of dependency that cm no longer be afforded. The quarter century since the mid 1970s has brought policies designed to dismantle the welfare state frameworks that were constructed through the 1950s and 1960s. The impact of this on the Health Care system in Canada is described by Pat and

Hugh Armstrong (1996,63-93). Since the early 1980s there has been less and less federal money available for health care, and a generally similar picture has ernerged in each of the provinces and territories - a picture of underfunded services, restmcturing, downsizing. long waiting times for care, shorter stays in ever shabbier institutions and a greater emphasis on home care. Pan of the "cornmon sense" that has emerged as part of what is increasingly described as the "crisis in Canadian health care" is that the health care system has been too much oriented towards institutional l y provided services aimed at curative, and not preventative, care. This is no doubt true, but the difficulty, it seems to me, is that this critique - one that is bound up with the critique of the medical mode1 and its dominance - hanot been sufficiently extrapolated from the increasing threat posed to publiciy funded health care itself by the neo-liberal program of deregulation, corporatization, and ultimately privatization. The result is a confusion of voices, al1 apparently demanding the same of health care reform - a more accountable, community-responsive, and health promotion oriented health care system - but with widely differing, though at present dangerously undifferentiated, purposes. The long term neo-libenl agenda, fint witnessed under the Conservative government elected in the U.K. in 1979', has been designed to bring about the "withenng away" of the welfare state, including socialized health insurance, and the chronic culture of dependency that it has been successfully portrayed as nounshing. However, the observation that we are witnessing the passing of the "welfare state" should not be equated with any suggestion that the state itself is becoming any less powerful. 1 am describing a changing role for the state rather than a dwindling of power, the minimalist state as ideology rather than practice. This changing role can be characterised as a shift away from post-war commitments to create social conditions chat meet the generd needs of the population, the amelioration of the worst effects of poverty, and a more equitable distribution of the fruits of economic growth. It is a shift towards the celebntion of the resourcefulness and the creative energies of the individual, and the generation of the social and political conditions that are said to be conducive to unleashing the enrrgies of individuals. It is a shift from the Keynsian rnodel to the neo-liberal state model characterised by massive deregulation, downsizing, and a return to the reification of the unhindered rnechanisms of the free market. This shift, according to Laclau and Mouffe, "has a clearly hegemonic character" ( 1985, 176) in that

It seeks a profound transformation in the tems of political discourse and the creation of a new "definition of reality", which under the cover of the defence of "individual liberty" would legitimise inequalities and restore the hierarchical relations which the struggles of the previous decades had destroyed (1 76). We are certainly not dealing with a Iess powetful state, or a state form that in any way has ceased to guarantee the sanctity of pnvate property and ensure the practical conditions for the accumulation of capital. 1 would still go so far as to Say that the assertion that "the executive of the modern state is but a cornmittee for managing the cornmon affairs of the whoie bourgeoisie" (Marx & Engels 1967) retins not a little validity. As Leo Panitch ( 1998) argues, Because the process of globalisation has initial1y taken place under the ideological aegis of the new right, operating under the conceptual optics of neoclassical economics, it has presented itself in ternis of reducing the role of the state in relation to both domestic and international markets. Obscured from view has been has been the active role of states in setting the new rules of the gme as well as in shifting the balance of class forces as part of the process of globalisation ( 1 3). In distinct contrast to the role played by the welfare state, neo-liberal states seek to remove obstacles to the free play of the market. This takes the fom~of activities such as eliminating legislation aimed rit environmenta! protection, measures to control the rate of inflation, free trade agreements, lirniting the powers of trade unions, reducing levels of corpurate taxation, and ensuring the supply of cheap and flexible labour through the reduction of social security. The ideological success of this shift in the role of govemment has depended, as Laclau and Mouffe point out, upon a new legitimacy for inequality that has occurred under the guise of the protection of individual liberty as a result of which "a series of subject positions which were accepted as legitimate differences [welfare recipient or union member, for example] in the hegemonic formation corresponding to the Welfare State are expelled from the field of social positivity and construed as negativity" (Laclau and Mouffe 1985, 176). In a reversal of the process of the development of the Welfare State - in which, as Habermas points out, "the ideology of free exchange is replaced by a substitute program ... designed to compensate for the dysfunctions of free exchange" (1 970, 102) - protection of unrestrained individualism has become the sine qlra non of the role of the state. This role has regained ideological supremacy over the state's role in the redistribution of wealth to arneliorate the dysfunctions of the free market. The question that now arises of course is that if the welfare state arose as a hegemonic response to the potentially dangerous (from the perspective of Capital) social and political unrest caused by the inequalities generated by untrarnmelled markets, what, from the perspective of hegemonic sustainability, takes its place? In part, we might say that there has ken a reconfiguration of "common sense" such that, ideologically, the welfare state has been successfully portrayed as a wasteful, dependency-inducing anachronism. The achievernent of this new hegemony has involved new fons of goveming focused on the entrepreneurid self, in which the terms of the market are extended to dl areas of the life of the individual. This fom of government has ken characterised by Stephen Gill as "disciplinary neo-libenlism" ( 1 995. 1). For Gill, disciplinary neo-liberalism is constituted by new information technologies that facilitate ever expanding fons of panoptic surveillance, and other technologies of "goveming at a distance" such as the production of behavioural noms in the discourse of "authoritative experts." It is within this amy of of goveming practices that 1 will explore the question that I pose in the introductory chapter as the core question of this thesis. That is to say that in response to the question, "where may we situate health promotion in relation to the methods and practices of governing individuals and populations?'. 1 look for answers in the "governing at a distance" strategies of disciplinary neo-liberaiism. If, as 1 propose, we take Gramsci's theory of hegernony seriously, we arrive at a particular way of characterising the nature of the state. Because hegemony is a fluid, shifting, and continuously renewed balance, so the state that refiects that balance of social forces will be an ongoing compromise in which the interests of dominant social forces - the "ruling class" to employ an unfashionable term - always need to accommodate, in manageable ways, the interests of subordinate groups. Gramsci characterises the state thus: the State is conceived as a continuous process of formation and superceding of unstable equilibria ... between the interests of the fundamental group and those of the subordinate groups-equilibria in which the interests of the dominant group prevail, but only up to a certain point, i.e. stopping short of narrow ly corporate economic interesi ( 197 1, 182). We shauld not be surprised then if we find coincidences between the social change discourse that has ernerged out of what have been cailed the "new social movements", including heaith promotion, over the last thirty years and a neo-liberal rhetoric that serves an agenda of restructuring, downsizing, and privatisation. This coincidence occurs around themes such as minimising bureaucracy, devolving power, enhancing individual freedorns, empowering communities at the local level. and an ethos of self- help. My point here is not at al1 to dismiss political programmes aimed at achieving social and political change that results in extended democracy and equality. 1 am suggesting that the very nature of hegemony means that such programmes always run the risk of haviog their discourse CO-optedby dominant interests. The danger of taking the discourse of the minimalist state at face value and interpreting the neo-liberal agenda as an opportunity to infuse health promotion principles into a restructured health care system is that, by Ming to comprehend the realities of globalising neo-liberalism - a cornprehension that requires sustained and careful historical structural analyses - health promotion advocates allow their discourse to be incorporated into an agenda that is quite antithetical to their stated principles. Canada's first foray into the language of health promotion is a neat illustration of this confusion of progressive health reform with the imperatives of a state in the process of backing away from its commitments to socially funded health care. In 1974 the report, A New Perspective on the Healtlz of Canadians (Lalonde I974), introduced the idea of health promotion into the Canadian context. This report represented a response by the Canadian state to crises in the health care system: the inability of scientific medicine to respond to increasingly prevalent chronic illnesses such as heart disease and cancer, and the related ballooning of costs associated with the provision of health care services. Briefly, the centrai argument of the report is that health is determined by more than available health care services; it is also detemined by the interaction of human biology, lifestyles, and environment. Its main thrust, however, was to emphasize the individual's responsibility for the state of her or his own health. As Labonte (1994) points out,

Seen generously, the report was an attempt to break free of the medical approach to health to retum to a more holistic perspective... Viewed less generously, the Report was an off-loading of responsibility for escalating health care costs from service providers (hospitals and doctors) and their insurance brokers (the state) to individuals and their unhealthy lifestyles. (74) The fact that the report can be read in both ways illustrates the point that 1 am making, that there is an ambiguous relationship between the language of progressive change in approaches to health, and the language of neo-liberal self-help. Although the health promotion perspective has become much more sophisticated since 1974, this ambivalence remains problematic. Although the health promotion movement has moved beyond a narrow "lifestyle/behaviouraI" approach by supplementing it with a "socioenviroiimental" model of health (Working Group on Integrated Health Systems

1998, l), "healthism" and consumerist discourse remain, problcmatically, defining characteristics of the field.6 The Lalonde Report has been held responsible for the emergence in the iate seventies of the health promotion practices of social marketing aimed at bringing about changes of behaviour in individuals. Although this approach has been challenged as one that leads to victim blaming, it is still widely used and advocated, as 1 will discuss in more detail in the following section which has social marketing in health promotion as its focus. Subsequent developments in health promotion theory and practice, whilst not at al1 abandoning the lifesty lehehavioural approach, have attempted, through the influence of newmarxism, feminism, social environmentalism, and other new social movements, to expand the horizons of the field to take into account what are called the broader social determinants of health. This has been best, and most farnously, exemplified in the Ottawa Charter on Health Promotion adopted in 1986, which has subsequently become something of a revered text in health promotion circles. Central to this "new" socioenvironmental health promotion are the concepts of "comrnunity" and "empowement", terms that will forrn the focus of the final section of this chapter. As with the previous chapter of this thesis, the primary methodology for this chapter is ideological critique. In the two sections that follow this, two and three, 1 will focus on social marketing and the concepts of "empowement" and "comrnunity" in health promotion respectively. The main texts for analysis in section two will be publications conceming social marketing produced by Health Canada's Health Promotion and Programs Branch, and available via the Health Canada web site. I will also begin an analysis in this section of a publication that 1 will pursue in greater detail in a subsequent section. The Role of Health Promotion Witkin Integrated Health

Systems (Working Group on Integrated Health Systems, 1998) was written as a position paper by the University of Toronto's Centre for Health Promotion. It is directed at the mandarins of Ontario's Ministry of Health, and it is designed as an intervention into their deliberations regarding the restructuring of Ontario's health care system. The hope is that restnicturing will result in a greater emphasis on health promotion across the health care system. Although the Ontario government's plans to move ahead with integrated health systems (Ontario Ministry of Health 1996) seem to have stalled for the moment, this document remains a useful snapshot of current state-of-the-art thinking in Canadian health promotion. It is in this light that 1 analyse it in this chapter. Before 1 go on to look more closely at social marketing as a health promotion strategy 1 want to reiterate the central point that 1 am making about health promotion. In the mid 1970s Alford identified three stnictural interests in health care in the U.S. (Alford 1975, 190-217). The first of these three were "dominant structural interests", represented in the U.S.at the time by those benefitting from the existing professional dominance model. The second set of structural interests Alford categorises as "challenging structural interests". These divide into two further categories: "Market refonners" and bureaucratic ceformers that Alford calls the "corporate rationalisers", both of which seek the reorganisation of heaith care according to the imperatives of a capitalist econorny. Repressed structural interests, on the other hand, are represented by "'equal health advocates' who seek free, accessible, high- quality health care which equalises treatrnent available to the well-to-do and the poor" (Alford 1975, 19 1). Alford characterises these structural interests as "repressed" because in the American context in which he was writing equal health advocates were marginalised both practically and ideologically. The Canadian context is obviously different from the U.S.,but even within a single-payer social insurance system it makes sense to talk about structural interests in Alford's terms: particularly in the context of contemporary corporatisation in health care. In fact, the corporatisation of health care indicates that the market reformers and corporate rationalisers are successfully restructuring Canada's health care system according to the imperatives of neo-liberal economics. My contention is that repressed structural interests in Canadian health care are being successfully managed in the interests of a ne-liberal agenda in part through an incorporation into this agenda of the discourse of the health promotion movement. This incorporation means that, in effect, the voices of advocates of repressed structural interests that are being heard are those that are conveniently CO- opted into a discourse that seeks to shift social responsibility for health care to the level of individuals and "communities". Equal health advocates who advocate for the retention and extenstion of socialised health care remain marginalised. Consequently, what appears now as the articulated voice of repressed structural interests eschews the language of equal access to a socially provided health care system, and focuses instead on an idea of health that can only be improved, outside of the context of health care services. by individuals and communities who take on the management of their health through being empowered to make appropriate choices. What we are witnessing in other words is "the process whereby demands made by the health movement for empowerment are recaptured and transformed ... and contribute to the construction of the individual as a 'health consumer"' (Grace 199 1,34 1). Social Marketing And Health As Fetishised Commodity 1 suggested in the previous section that the LaIonde Report, the document that really ushered in the age of health promotion in Canada and that achieved international prominence, has been regarded as the catalyst for the emergence of the practice of social marketing as a means of health communication. This is not to suggest that health communication campaigns began in the 1970s, or that the mass media (newspapers, magazines, film) had not been used to promote healthy activities and discourage unhealthy ones before LaIonde. But there is a perception, at least, within health promotion that "social marketing has been the most frequently used approach to health communication" (Working Group on Integrated Health Systems 1998, 19). The authors of The Role of Henlrh Promotion Within lntegrated Health Systems go on to insist that social marketing should remain an integral stntegy of a broad approach to health promotion. By a broad approach they mean that health promotion should incorporate both the li festy le/behavioural model and the socioenvironmental rnodel. It is in ihis context that they view social marketing "as an important cornponent of comprehensive, community-based progrums that are developed to enhance the health outcomes" of a population (Working Group on Integrated Health Systems, 20). The authors of this report are not alone in this recommendation, and an extensive literature has emerged since the mid 1970s describing the principles and practice of social marketing and urging its use in health promotion. Health Canada's Health Promotion and Programs Branch, a strong advocate of social marketing, provides a comprehensive bibliography to this liteiature on its web site'. The Health Promotion and Programs Branch has, in fact, developed its own Partnerships and Marketing Division, responsible for Health Canada's own social marketing projects, and the promotion of social marketing as a health communication strategy. Its web site not only provides a bibliography to social marketing literature, it makes the full text of selected publications freely available. It is from these publications, as exarnples of current thinking and practice within Canada's state health apparatus, that 1 have chosen the texts for analysis in this ~ection.~The primary publication available at the web site is entitled Social Marketing in Health Promotion. a 1994 compilation of papers previously published or delivered as conference presentations by Canadians presurnably regarded by Health Canada as signifiant contributors to the field of social marketing. The two other publications chosen for analysis are Social Marketing

Primer, Health Canada's "social marketing for beginners", and Guidelinesfor

Working with the Private Sector, selected precisely for its advocacy of partnerships between the public and the private sector. My aim in this section is to critically assess the effects of social marketing at different levels, al1 of which are related to the comrnod~jicationof any property, in this case "health", that is considered to be marketable. But I will begin with a brief explanation of what social marketing is usually taken to be. Social marketing represents the effort to employ strategies developed by corporations to maximise profits, in the selling of ideas and lifestyles considered to be conducive to the common good, but not necessarily attractive enough that people will adopt thein in the absence of a strenuous external influence. Marketing strategies have been developed by corporations in order to deliver the maximum quantities of their products to consumers by convincing consumers that the products will be useful to them, enhance their lifestyle, make them more attractive as individuals or present them with any number of other personal and social advantages. The Working Group on Integrated Health Systems suggests that "social marketing strategies are distinguished from other health communication strategies by their grounding in corponte advertising and consumer psychology theory" ( 1998, 19). Health Canada's Social Marketing

Primer describes social marketing as "very much like advertising in the business world. But instead of pushing a product, social marketers push ideas: they promote social change using the same kinds of techniques companies use to sel1 products and services" (Health Canada 1995, 1). The term "social marketing" is usually said to have originated in a 197 1 article "Social Marketing: An Approach to Planned Social Change" (Kotler and Zaltman). shortly before the publication of the Lalonde Report. The history of social marketing and health promotion have therefore ken closely entwined as they have developed since the mid 1970s: "rarely has there been such a high degree of enthusiasm for the integration of two fields which, though distinct, fit together so well" (Mintz i988, 1). Perhaps this fact helps io explain why, despite the extensive literature on social marketing and health promotion, there is very little material that provides a criticül perspective. In fact, I have only been able to locate one essay that takes a critical approach to social marketing in health promotion (Buchanan, Reddy and Hossain 1994), and this turns out to be a rather more insipid than insightful attack. The authors' main objections are based on the assertion that social marketing is not a new idea, that its focus on the individual is problematic, and a squeamishness at the perceived manipulation irnplied in the selling of ideas. However, these criticisms seem to beg the central questions regarding the discursive efects of social marketing. In any event, the advocates of social marketing have taken care that their (re)presentation of it seems rather to anticipate and sidestep the criticism of Buchanan et al. This is because, although very little opposition to the ideas of social marketing has appeared in print, its proponents appear to have encountered a good deal of hostility from professionals suspicious of corporate strategies (Mintz 1988, 1; Sarner 1984, 1). Rather than give credence to such wariness, social marketers are able to

trivialize it as a fear of the new, "the concept [social marketing] was new, and like any

innovative idea it was first greeted with some scepticism" (Mintz 1988, 1). Several simultaneous discursive strategies can be identified as confronting this initial scepticism. These strategies have little to do with the effectiveness of social marketing and are more focused on establishing its credentials. The first of these strategies is to identify social marketing as a cutting edge and innovative practice that lems frorii the best practices of the business world, With its components of marketing and consumer research, advertising and promotion - including positioning, creative strategy, message design and testing, media strategy and planning, and effectiveness-tracking - social marketing ciearly has a central role to play in the public health programs of today . (Mintz 1988, 1) Just infoming people about a particular issue isn't enough. What is required is a strategic mix of marketing tactics: special events with corporate sponsorship; special promotions; information, skills-developrnent and communication resources; direct marketing: and publidmedia relations. (Health Canada 1995, 1) Note here the quiet insertion of the idea of "corporate sponsorship", which blossoms shortly into the advocacy of private sector partnerships, as 1 discuss below. The unspoken assurnption on the part of social marketers is that practices from the business world have a value simply by virtue of their use in the business world - associated with efficiency, cost-effectiveness, and innovation. The innovation and efficiency assumed io reside in the private sector contrast shaply with the characteristics that are assumed to be inherent in the public sector - an innevitably turgid bureaucracy, stasis, waste - regardless of the good intentions found in the latter: "Let's face it. The image of govemment departments and social agencies is somewhat tamished. The public doesn't think of these organizations as the well-spring from which innovative ideas and great programs emanate" (Young 1989, 6). The slick appeal of marketing as a strategy is encapsulated in the easy shorthand of the 4 Ps: "product", "price7', "place" and "promotion" (Mintz, Rawlings and Steele 1 99 1,4-5).

A second strategy is to emphasize that, although social marketing is innovative, it has tried and tested roots and a long affiliation with health promotion. Social marketing is simply a new name for a refined approach to endeavon that have been around "as long as there have been social systerns" (Young 1988, 1). And health promoten were amongst the first on the scene, "the field in which social marketing has its deepest roots is health promotion" (Young 1988,2). In fact, "long before the tem 'social marketing' was coined and its process defined, health promoters were involved in activities that incorporated its techniques" possibly "dating back to the 19th century", but certainly "since World War II" (ibid). In other words, although social marketing is a new, fresh and innovative strategy, health promoters are sophisticated enough to have been doing it al1 dong and calling it something else. Rather than attempting to convince health promoters of the value of a new approach, the aim here is to convince them that they are almost already doing it.

A third strategy for consolidating the legitimacy of social marketing is the establishing of its intellectual and acûdernic credentials. Social marketing might well be a product of concreie and practical disciplines such as advertising and market research, but it also "has some deep roots in religion and politics, in education and even, to a degree, in military strategy. It also has intellectual roots in disciplines such as psychology. sociology, political science, communication theory and anthropology" (Young 1988, 2). Evidence is not provided to back up these claims for such an eclectic and seemingly all-encompassing intellectual l ineage. The sweeping range of the claims, however, seems designed to pre-empt critics. In particular. the inclusion of "critical" social disciplines such as sociology, anthropology, political science. and communication theory functions to distance the theory of social marketing from the profit-oriented origins of marketing itself. Furthemore, for those sceptics who are concemed that marketing merely amounts to the hawking of products and lifestyles, there is reassurance tliat what we are dealing with is actually a precise science: the "science" of "market segmentation". This practice actually consists of the social scientific rnethods of demography. "the statistical study of human populations" and psychographics, which "provides details about the lifestyle of a particular target market" (Health Canada 1995, 2). The knowledge of populations attained by a combination of demography and psychographics borders on the divine. When we combine the demographic and the psychognphic data, we are able to get an accurate picture of Our target groups. Knowing them intirnately helps us to better prepare communications messages in their own language. We corne to touch them verbally, visually and in writing. (Health Canada 1995,2. , emphasis added) A fourth strategy for marketing social marketing acknowledges the commitment of many health promoters to combatting the broad deteminanis of health such as poverty, homelessnes, and various forms of exploitation and discrimination. Social

marketing, it seems, is the proud inheritor of the mantle of movements stmggling against injustices to bring about progressive social change. Young informs us that in addition to its intellectual heritnge, social marketing has its origins "in the work and experience of social activists, advocacy groups and community organizers" (1988,2).

Health Canada's Social Marketing Primer provides us with the following rhetorical sleight-of-hand that collapses an entire history "campaigns for social change" into social marketing: They have been wuged from time immemorial. In Ancient Greece and Rome, campaigns were launched to free slaves. In England during the Industrial Revolution, campaigns were mounted to abolish debtor prisons, grant voting rights to women, and abolish child labour. Notable social refom campaigns in nineteenth-century America included the abolition, ternperence, prohibition and suffragette movernents and a consumer movement to have governments regulate the quality of food and drugs. (Health Canada 1995, 1)

My assertion is that these four discursive strategies together constitute an effect, in that they present social marketing as a legitimate discourse before any actual

discussion of the principles and practices of social marketing iis a strategy for health promotion. In other words, social marketing is established as an authoritative discourse on the basis of a constructed intellectual and activist history, and the assertions that whilst it cm be chancterized as a cutting-edge corporaie strategy, health promoters are sophisticated enough to have been doing it al1 dong, had they only

redised. My next step, then, is to look more closely at the discourse of social marketing and to relate the discourse to its socio+xonomic context in order to assess the consequent ideological effects.

Advocates of marketing claim that it is a neutral methodology. In other words, regardless of the origins of the principles and practices of marketing in the corporate world, the form of the rnethodology constitutes an empty vessel, devoid of values, assumptions, and perspectives. This "empty vessel" is assumed to have no pre-determining or unintended effect on the content that might be poured into it. Regardless of its connections to the endless meny-go-round chase of spending and getting, getting and spending of consumer society, marketing is in fact a neutral methodology, a methodology which organizations with a social cause can use to help them better achieve a social effect. (Young 1988,3)

Or, Marketing hlis been developed in the field of business and more specifically, in relation to consumer products marketing. Yet marketing is in fact a neutral methodology which non-profit organizations... can use to achieve socially beneficial objectives. (Mintz, Rawlings and Steele 1991, 2) However, a closer examination demonstrates that the methodology of marketing is, in fact, riddled with assumptions and values. In other words, it is naive to presume that form in this case is devoid of its own content. Marketing methodology is based upon marketing theory, and it is a peculiar theory that does not refer to basic principles. It is in these basic principles that we find the assumptions and values - the "content" of the "f~rrn"~- which cannot but shape the form of the '*content". Marketing, this "neutral" methodology, "is the means by which an organization tries to influence people to achieve its goals" (Samer 1984, 2), and in the case of social marketing it is a means of "changing the way individuals and groups lead their lives by transforrning adverse or harmful practices into productive ones" (Mintz 1990, 1). Of course there are assumptions and values inherent in the rnethodology of (social) marketing, just as there are in any theory and practice of individual and social change. These assumptions and values condition the effects of al1 practices. Just as Freire points out that neutral education is impossible, so is neutral marketing. It is time to take a closer look at some of these assurnptions. In particular 1 propose to highlight the following assumptions: first, that there exists a free market of ideas that equates with the free market in goods and services; second, that within this free market of ideas, the individual subject constitutes a consumer exercising a free choice in the selection of ideas to which they adhere; third, that health itself is a commodity to be traded in this market of ideas; and fourth, that the simultaneously neutral and progressive value of the free market - whether in ideas or goods and services - legi timises the advocacy of public and private sector partnerships in the marketing of health. The most basic assumption underlying social marketing methodology is the assertion "that just as there is a marketplace of products, so there is a marketplace of ideas, and that the concept of marketing should be expanded to embrace it" (Young 1988, 1). Although the suggestion that there exists a free market in ideas that corresponds to the market in goods and services is asserted almost in passing as a basic principle of common sense, it demands closer scrutiny. The first chapter of this thesis is reillly an extended argument against the assumptions packed away in the phrase "there is a marketplace of ideas". This phrase begs the questions of the nature of the production of ideas, the ways that some ideüs attain authoritative status while others do not, why people "buy in" to certain ideas and not others, and the historical investments in equating the free market in ideas with the free market in goods and services. In short we are concemed here with the liberal concept of the subject - the "leamer" at whom the messages of health promotion marketing campaigns are targetted - and issues of ideology . Social marketers' worldview, as it is illustrated in the assumption that "there is a marketplace of ideas", is situated firmly within a liberal paradigm. To social marketers, it is "comrnon sense" that ihere is a relationship of extenority between individuals and ideas. On the one hand is the individual as rational, self-directing and autonomous, and on the other, at a distance, the marketplace of ideas from which she is free to choose. The ssumption is that the choice can be influenced by cornpeting ideas, not that there is anything in the nature of how we become who we are as individuals that pre-determines. not only the choices that might be made, but the selection of ideas on offer from which the choice will be made. In other words, without repeating the arguments I have already made in chapter one, this liberal pandigm - where we may locate social marketers - assigns an overly autonomous character to the way in which

individuals rnake meaning of their world. It is inattentive to the fact that individuals

recognize meaning as much as they rnake it. How else could we function in Our social

world? As Delgado and Stefanic point out, "we subscribe to a stock of explanatory scripts, plots, narratives, and understandings that enable us to make sense of - to construct - Our social world" ( 1992, 1280). Just as marketing in the world of goods and services is said to be a reflection and characteristic of the free play of the market and its inherent cornpetition, in which the consumer chooses the "best" product for their needs, so social marketers urge health promoters to respond to the needs and wants of the population to whom they direct their practices: "the marketing process is client-driven: it should always begin

with an ünalysis of the clients' needs" (Mintz, Rawlings and Steele 199 1, 3 , emphasis

added). The individual ihen, although she is rational and self-directing, represents the embodiment of determinable needs, wants and desires. It is the job of social marketing health promoters to present their product as one that is attractive to the "consumery' by

"determining that the praduct has the attributes clients want" (4 , emphasis added).

Marketing, then requires a priori, both a commodity to market, and a consumer to

whom the commodity can be marketed. Far from being a "neutral" methodology, these categories, which are produced by a specific market-oriented perspective, detenninr

the presentation of "health" itself as a commodity chat can, in sorne way, be consumed by an individual who is now a "consumer". But, as I have already suggested, we should be sceptical of the extent to which the marketplace is "free", for any commodities, whether they be goods and services or ideas, and the extent to which "needs" and "wants" exist independently of their construction in marketing discourse. Not only are many of the products that are marketed to us actually produced by companies that are owned by the same multinational corporations, but marketing does not necessarily represent an orientation

to give the consumer what he or she "wants" or "needs". Its primary purpose is to

shape, or even to produce, a sense of wants and needs that corresponds to an already deterrnined product. This may well have very Me, if any, relation to what actual needs or wants might be. In other words, marketing, whether of the corporate or social variety, serves to generate a need for a specific product, whether dog food or health information, a need that is represented as existing prior to its revelation by marketing strategies. This process - the ongoing reproduction of needy consumers - is a necessary component of the sustainability of the capitalist economy. Through the use of social marketing, as Gnce suggests "Health promotion actually models the individual subject as a consumer. The consumer is constnicted to act according to a model" (Grace 199 1, 339) - the model of the free market indespensible to capitalist economics. The pay off for necAiberalism is not only ideological preparation for a greater role for markets in health care, but for a smaller role for the state in general.

This brings me to the fourth assumption in the discourse of social marketing, that of the role of the private sector. In 1994 James Mintz, Director of the Program Promotion Division at Health Canada's Health Promotion Directonte wrote: "with the growth of altniism in corporate North Arnerica corporations will become much more involved in 'social causes"' (1994,2). While the growth of corporate altruism is perhaps Iess obvious to sorne of us than it is to James Mintz, Health Canada in its Guidelines for Working with the

Private Sector has "recognized the importance of working more closely with private sector businesses in the development of national social marketing campaigns" (Health Canada 1996,2). The "importance of working with the private sector" is instantly elevated to the level of common sense because, as we all "know", "driven by economic pressures, govemments in the 1990s can no longer fund al1 the needed programs to deal with societal issues" (3). Not only is any debate regarding the role of the private sector in areas formerly presumed to be the business of the state presented as reduntant - there is no room here for a discussion about a more progressive tax system and increasing social spending - but it is we, the people, who are said to be pushing for further advances of the private sector into the social economy: "Consumers demand increased private business involvement in dealing with pressing healthlsocial issues"

(3). So much for any suggestion that private business might be the cause of pressing health and social issues. Once again, the assumption seems to be that we are talking about a neutral process, that allowing the private sector into the marketing of health as a commodity will have no effects other than providing resources for campaigns that would not otherwise take place. Canadians, however, might be well advised to exercise somewhat more in the way of sceptical caution than uncritical enthusiasm when debating the role of the private sector in the nation's health care system. Unfortunately, such a debate has never really taken place, and the opportunity may have already passed. Health Canada boasts that "HPPB [Health Promotion and Programs Branch] is at the forefront of partnership arrangements and bas extensive experience in partnerships with the private sector. In the Iast six years we entered into close to 200 partnerships, adding an estimated $60,000,000.00to the resources available to the department" (3). It is obviously the string of Os that is meant to catch the eye of the reader here, producing perhaps a whistle of appreciation at the revenues raised. Given the lack of other criteria, it seems that it is on the bais of this money amount that we are to judge pnvate partnerships "successful". Health Canada is also coy about telling us what parts of the private sector it has partnered with, but we do find out that "a Canadian magazine brought in a fast food chain as a partner" for at least one project (5). Although it provides a checklist of criteria for choosing private sector partners,

Guidelinesfor Working with the Pnvate Sector is at least equally concerned to argue the case for such partnerships, and it does so enthusiastically. The effectiveness of these criteria has been questioned and it has been suggested that the platform for publicity provided to the private sector in partnerships with Health Canada "may lead govemment to do. not 'more with less,' but something very diflerent with less, something that no govemment has any business doing" (Ryan 1998, 19). Ryan describes the ways in which Health Canada health education materials have incorporated product placements for various junk food manufacturers and manufacturers of electronic leisure equipment. The overall picture inferred by Ryan's research is that partnerships. from Health Canada's perspective, are increûsingly driven by econornic imperatives that result in partnerships with businesses that might be considered strange bedfellows from a health promotion perspective.

In the end, the discursive effect of Griidelinesfor Working with the Private

Sector is to open a space through which the private sector can be ideologically ushered in to a role in health issues in Canada. Among the long-term benefiis of partnerships will be "improved linkages between senior managers of business and government", "improved image of govemment amongst the business community", and "encouragement of private sector funding of NGO and community-based programs" (3). Although, as 1 have said, bringing in the private sector is supposed to be a poli ticall y neutral process, we are told that partners hips "enhance the private businesses' corporate image and reputation. By being involved, private busnesses will be perceived as meeting the demands of consumers concerning its social responsibility" (4, , emphasis added). No clairn is ever made that this perception is matched in reality. We are rerninded though, as if a silent question is nagging ai the authors, that "it is a valid and acceptable objective of private business partnen to gain benefit, directly or indirectly, from the partnership activity" (4). One wonders what this might mean in terms of the campaigns that are chosen for support, the ways in which potential changes in lifestyle. or behaviour might benefit the businesses involved. and perhaps more importantly, what issues will not make it onto the health promotion agenda for fear of offending potential corporate partners. AI1 the while, the repeated assurance that even though a business is altruistic enough to be financially supponing a carnpaign - for the rnere retum of "public recognition such as the display of a corporate logo or a product display at a sponsored event" (Health Canada 1995,3) - "endorsement of their products or services is not implied in any way" (Health Canada l996,4),contributes to a climate in which private sector involvement in health issues becomes merely a matter of course.

There are two further arguments 1 wish to make with regard to the commodification of health inherent in the social marketing model. The two are closely related and might be more accurately described as two aspects of the sarne point. They relate to, firstly, the fetishism of health as a commodity within health promotion, and secondly, the relationship of "health" in health promotion discourse to power and a

"politics of truth". In other words, 1 want to take a closer look at the central assumption of health promotion by asking some, perhaps heretical, questions of "health" itself. "A commodity appears", says Marx "at first sight, a very trivial thing, and easily understood. Its analysis shows that it is, in reality, a very queer thing, abounding in metaphysical subtleties and theological niceties" (Marx 1906, 8 1). This statement seems to me to be particularly pertinent apropos the commodification of health. Although "health" as a concept carries with it a son of self-evidentness in common speech, it is in practice a much more layered term. It does indeed incorporate metaphysical and spiritual elements. But, on the other hand, in what way, and to what extent is "health " a commodity? "Health" perse is not, and it cannot be, of course, a commodity. For one thing, as 1 will discuss below, the term itself is ethereal, airy and amorphous and eluding definitive categonzation. Health is not visibly an objectified product of human labour in the sense that a table crafted from pieces of wood can be, for example. It is not available, in other words, in any obvious way for exchange, consumption, and the derivation of surplus value. Nevertheless, within a health promotion paradigm, health is a "product" that is produced through "labour", though the labour is exercised upon the self. Amongst the resources, or raw materials, necessary for this labour process are the health education and information provided by health promoters. The idea of health as a pmduct produced by individual labour upon the Self is central to health promotion; it is the "business" of health promotion, and as such the idea of health as a product is a condition of its continued existence. The

"product" is commodified by the social character that it acquires, at one level, through its insertion into the social relations of social marketing. The production of health as a comrnodity through social marketing in health promotion connects seamlessly with a broader grid of is one element of health marketing. The idea of health as a commodified product of self-oriented labour is also central to contemporary debates regarding the provision of publicly funded health care services - a debate very much connected to the rise of health promotion as 1 have been arguing - and to an entire econorny that has been constructed around the idea of health as something that can be produced. This economy includes the fitness industry, the health food and health product industry, the "nutriceutical" industry, the weight-loss and body image industry, and the sslf-carefrecovery industry to name but a few.1° The blumng of the boundaries that we can see here between social marketing for "progressive" social ends and "green" marketing that casts the consumer as the historical agent of social conuol, points up another problematic assumption of social marketing. The advocates of social marketing, as we have seen, argue that the biggest distinction between social marketing and business marketing is that while the latter is about selling "things", the former is about selling ideas. However, marketing, as the practice of green marketing makes very clear (e.g. Smith 1998), in any form is about the selling of ideas Nt order to seIl

"things". It is naive at best to fail to grasp, as social marketers appear to do, that the mynad forms of marketing to which each of us is exposed continually, is bombarding us with ideas that are intended to influence Our conduct. The power of the ideas that "work", frorn a marketing perspective, is derived from their ability to connect effectively with the narratives of the world to which we subscribe and the assumptions tliat inform them. In other words, social marketing is no different from any other form of marketing in that its purpose is to sel1 ideas so that it brings about a change in conduct. In order to do so successfully, these ideas, far from being "new" or challenging, need to "fit" with established, or emerging, ideological fnmeworks. The "selling" of personal responsibility for health through a process that hails us as consurnen becomes a part of the broader ideological restructuring of neo-liberaiism and the rolling back of the interventionist state.

Within and through this web of social relations the idea of "health", while it is not severed from its association with individual labour, acquires an abstract and objective existence that is separate from the subjective nature of "health" as it is experienced by individuals. This objectification and attribution of properties that separate the product frorn the labour that produces it is, says Marx, "the Fetishism which attaches itself to the products of labour, so soon as they are produced as commodities and which is therefore inseparable from the production of comrnodities" (1906, 83). It seems reasonable to talk of the fetishishization of health in the context of the cornmodification of "health that health promotion in part creates and sustains through the consumerist discourse of marketing. 1 still want to take a closer look ai what "heaith" actuaily is, but first the idea of the effects of the fetishization of health need futher scrutiny. Health fetishism, as 1 have described it, is similar to the concept of

"healthism". "Healthisrn" is a term first used by Crawford ( 1980) who describes it as

The preoccupation with personal health as... the primary focus for the definition and achievement of well-being; a goal which is to be attained primarily through the modification of life styles, with or without therapeutic help. The etiology of disease may be seen as complex, but healthism treats individual behaviour, attitudes, and emotions as the relevant symptoms needing attention. Healthists will acknowledge, in other words, that heaith problems may originate outside the individual, but since these problems are also behavioural, solutions are seen to lie within the realm of individual choice. (Crawford 1980,368) Healthism is the discourse that lies behind what Conrad calls the "wellness revolution" (Conrad, 1994, 386), a revolution characterised by the punuit of wellness as a moral imperative, by the "will towards health" (Greco 1993, 34 1 ) that has acquired spiritual ovenones. This discourse asserts, more or less explicitly, that individuals have a "duty to stay well" (Greco 1993, 370) and that to "fail to be well" represents a sort of moral failure. The idea of health in ni neteenth century public health discourse was bound to issues of morality through broader concerns with class-identified anxieties about the vigorousness of "the race". Health, closely associated with hygiene in the wake of the new germ theories of disease, became identified as one of a range of "duties" the fulfillment of which was characteristic of the bourgeoisie's moral legitimacy as a dominant clus. Today we cm see this (re)tum towards the equation of health as virtue exemplified in responses to very specific practices such as smoking and other substance use, diet, exercise, and sexual behaviour. There is a moral tenor in the equation of contemporas, "lifestyle" diseases with the inability of penons to either desist from certain activities - such as smoking or "unsafe" sex - or to pursue others - such as regular exercise or healthy eating. This mon1 tenor suggests, more or less explicitly, that such inabilities reflect a lack of will or effort that itself borders on the pathological: 'The mastery of the self is thus a prerequisite for health; the lack of self- mastery, accordingly, is a 'disease' prior to the actual physical cornplaint, whose symptoms are detectable as behavioural, psychological and cognitive patterns" (Greco 1993,36 1). The theme of morality in healthism is manifested in the language of innocence and culpability. There are, for example, "innocent" sufferers of HIVIAIDS who unwittingly fall victim to the tainted blood provided by others. There are others whose suffering from the same disease is presumed to be brought on by their own - often gay - sexual activity or the use of "illicit" substances. This moral reflex in relation to health is also revealed in the controversies associated with the health promotion strategies collectively known as "hm reduction". These strategies, which are oriented toward the amelioration of the harmful consequences of certain substance use practices. are considered controversial because they are designed to promote heaith without seeking the termination of the substance use. Others, particularly those whose body mass is considered to be in excess of generally accepted noms, are considered culpable for their own il1 health on the basis of assumptions about the food they eat and their slothfulness. Moral discourse around health is reflective of more general assumptions, ideas, and beliefs and it forms a part of what Gramsci calls "common sense" in that it is a means whereby the dominant values of a culture can be expressed, policed and sustained: "Health is a moral discourse, an opportunity to reaffirm sharrd values of a culture; a way to express what it means to be a moral person" (Crawford 1984, 76, quoted by Conrad 1994, 388). The ideological nature of healthism - reflected in its moral judgements - produces technical inconsistencies in its worldview. The smoking of tobacco, for example, is targetted for the most zealous of moral attacks, and those who indulge are held responsible not only for their own il1 heaith, but also for "innocent" others who are the victims of "second-hand" or "passive" smoking. Meanwhile, motor vehicle use, which is arguably a far greater public health hazard than cigarettes (Freund and Martin 1993,29-41) remains largely unchallenged by the public health movement. Indeed in North America in particular, though its hegemony is global, the rnotor car remains for many the highest expression of individualism and its inalienable rights and freedoms (Freund and Martin 1993, 81-94). Healthism assumes, in other words, an objective state called "healh" that is attainable through an individual's labour on his or her Self. Despite its turn towards the social determinants of health, the health promotion movement remains largely fixated on the individual and her or his behaviour, particularly within marketing discourse, rather than the social determinants themselves. 1 have already pointed out that to a large extent the health promotion movement has sought to distance itself from what was perceived as a victim-blaming, moralising, individualist orientation based on behavioural change models. However, if the socioenvironmental model has rendered problematic holding individuals responsible for their own illness, this negative has been replaced by the equally individualistic, but now positive, exhortations to wellness that characterize "heal thism". To conclude, then, the cornmodification of health and its fetishisization within a market revering consumer-centred discourse becomes problematic at two levels. First, it serves ideologically in the demise of socialised health care, and second, it is CO-opted into a panoptic strategy for producing entrepreneurid self-managing subject-consumers tailored to the demands of the restructured, flexible economy (about which 1 have more to say in the following section of this chapter). The emphasis on individual freedom and choice in neo-liberal market-based consumerism is matched by a growing emphasis on individual duties that is increasingly retlected in the assertion of the duty to avoid risk and to live a life conducive to the maintenance of good health (Petersen and Lupton 1996, 18- 19). In turn, this focus on the individual consumer and personal responsibility for health provides a convenient rhetoric to accompany the restructuring, downsizing, and perhaps even the demise, of socialized heaith care in Canada. The emphasis on choice, deinstitutionalization, and self-care lends ideological support to the withdrawai of commitments to existing models of health care without providing an articulated vision of socialized health care to replace them. Consumer+entred health promotion discourse incorporates a critique of the medical mode1 in terms that appear radical. But the reality is that by relying upon consumerist discourse and the fetishisation of health as a commodified product to do so, the apparently radical orientation of health promotion in fact manages to capture more radical alternatives (Alford's repressed structural interests) and to manage them within a nediberal paradigm of post-interventionist state - and subject - restmcturing. The question that continues to demand a response in al1 of this is "what is health?' As 1 have already suggested. this is ai once both a banal and complex question. On the one hand, "health" in common speech signifies a physical, mental, and emotional status about which there is a generally shared characterization based on the simple tautological equation that one is "healthy" when one is not "unhealthy". In practice, however, both terms are uninformative abstractions that require context-speci fic elaboration in order to have any practical mean ing: this person is healthy because of X, or this person is unhealthy because of Y. On the other hand, if there is any validity to any of my claims in this chapter, "health" has acquired a huge cultural and poli tical signi ficance that places it among the central discourses of hegemonic reconfiguration in the post-interventionist state erü. "Health," as Richard Klein (1993, 100) reminds us, hm becorne one of the criteria by which we detemine what is good and beautiful. The ideological role that 1 am ascribing to the term "heaith" suggests that is a more cornplex concept than one that allows us. for example, to distinguish a person with tuberculosis from one free of the disease (leaving aside the issue of whether or not this itself is an "innocent" scientific matter rather than a loaded cultural one based on the discursive construction and nosology of diseases). The very evasiveness of the term "health", and its relationship to the visceral human experience of life, illness, pain, and death is what constitutes "health" as such a powerful ideological category. The ideological power of "health" is perhaps less a function of the evasiveness of the term than it is with its emptyness as a signifier. Health in the context of Candian health promotion has been characterized in the following way: Health as perceived in the context of Canadian health promotion has to do with the bodil y, mental, and social quality of life of people as determined in particular by psychological, societal, cultural, and policy dimensions. Health is seen by Canadian health promoters to be enhanced by sensible lifestyles and the equitable use of public and private resources to permit people to use their initiative individually and collectively to maintain and improve their own well-being, however they mov define it. (Rootman and Raeburn 1994,69, emphasis added) This rather expansive contemplatior! appears to be packed with description; "this is what 'health' is", it seems to say. But when we look more closely, it in fact tells us nothing about what "health" is. We are informed of the factors that "have :O do with" it, "determine" it, or "enhance" it, but, as Bill Clinton has recently reminded us all, we cannot always assume that we share a common understanding of what "it" actually is.

Rootman and Raeburn's definition begs the question it supposedly sets out to answer, "what is health?" Health here seems to consist of an empty plenitude in that an apparently full answer tells us nothing. Ernesto Laclau suggests that Our most powerful ideological categories - the most psychologically and culturally embedded, unquestioned, taken for granted and impelling - are those that derive their meaning in the context of an "equivalential chain" of other terms. This means that such ternis do not have a meaning that refers to their own "content", but rather each is only meaningful in relation to a series of associated concepts that together constitute a rnutually defining and refemng sense. Within this chah of equivalence each concept works as an alternative name for the totality of meaning - an empty plenitude - that their equivalential relations create. Laclau's example of such a concept is "dernocracy", a tenn that means very different things in different contexts and within different discourses - liberal, communist, conservative, for example. "If 'democracy' is presented as an essential component of the 'free world"' within libenl discourse. the fixing of the meaning of the term will not occur purely by constructing for it a differential position. but by making it one of the names of the fullness of society that the 'free world' attempts to achieve. and this involves establishing an equivalential relationship with al1 the other terms within that discourse. 'Democracy' is not synonymous with 'freedom of the press', 'defence of private property', or 'affirmation of family values.' But what gives its specific ideological dimension to a discourse of the 'free world' is that each of these discursive components is not closed in its own differential particularity but functions also as an alternative name for the equivalential totality which their relations constitute. (LacIau 1997.3M) This inter-referential relationship between tenns that generates the effect of a full meaning, whilst simultaneously lacking meaning, suggests, according to Laclau. that chains of equivalence are made up of "empty" and "floating" signifiers. That is signifiers that refer to other signifiers rather than to their own signifieds. In the case of "democracy" the chain consists of "freedom of the press", "family values", "private property" and more. I am suggesting that "health" is a similarly empty and floating signifier, and that its ideological power is constituted by its location within its own chain of equivalences. Rather than referring to its own signified, for example, in Rootrnan's and Raeburn's "definition", "health" is a signifier that refers to other signifien, "quality of life", "well-being", and "sensible lifestyles". We could extend this list, or produce others depending upon the point we wish to rn&ake.or the paradigm we speak from. Rootman's and Raeburn's essay with which they conclude the above definition claims that "the concept of health ... is a minefielci" (56) because of the various "views about health including lay, medical nursing, political, academic, holistic, and Canadian concepts" (56). As 1 have tried to demonstrate in this chapter, "health" as a "floating" and "empty" signifier can serve the purposes of various interests, particularly when it is set within an equivalential chain that consists of concepts such as "free market of ideas", "product", "consumer", and ''corporate sponsorship." Within the discourse of the "new" health promotion that has supposedly progressed from a lifestyle~behaviourfocus to a paradigm that incorporates the socioenvironmental, health promotion incorporates a discourse of social justice - as it has been shaped by the new social movements of the last thirty yens - into its own

(Stevenson and Burke 199 1 ; Labonte 1994). The danger of this, it seems to me, lies in the current coincidence of putatively socially progressive discourse with some of the central ideological themes of neo-liberalism: less state intervention, devolution of political and economic power, local accountability, and self-help. The danger, 1 am arguing, is that without a careful, Iiistoricised, and structural/systemic critique of neo- liberalism, progressive discourse, as exemplified by the health promotion sector, not only loses its power to effect progressive change, it is incorporated into the goveming technologies of neo-liberdism. In other words, health promotion sacrifices its potential as a site for the formation of counter hegemonies and instead serves to further maintain existing hegernonic relations. The potential for recovering a counter-hegemonic role for health promotion is a theme to which 1 will retum in the conclusion of this thesis. Potentially, the most powerful equivalential chain of al1 for health promoters is one in which "heal th" - already fetishized - becomes a sort of meta term whose meaning consists of' the equivalential totality of trrms such as "justice", "peace", "equality", "democracy". In other words, nther than attach health promotion to a broader cntical and transfomative paradigm, "health" is situateci within an equivalential chain that allows health promoters to, one rnight say, usurp a radical discourse by incorporating it within that of hedth promotion. By folding al1 movements for progressive change into "health promotion", health promoters - "authoritative experts", usually funded by the state - become the carriers of the "one true torch"; the amorphous concept of "health" is elevated to the status of metanarraiive within which al1 possibilities are subsumed. However, it is precisely because "health" is an empty and floating signifier that it is readily ccwpted into a neo-liberai agenda aimed at the disrnantling of publicly funded health care services. Health is determined by everything, it seems, but health care services; rather it is the free-market itself, cumnt

'bcommonsense" seems to dictate, that is the best way to secure an environmerit conducive to sustaining health: employment, affordable housing, disposable income, consumer choice. Health is thus tied to a productivist paradigm in which it is dependent not on a redistribution of wealth, but upon ongoing capitalist econornic development. Two of the most prominent signifiers that form links in an equivalential chain of social change with "health" are "empowennent" and "community". It is an exploration of the this relationship that makes up the final section of this chapter. Specifically, 1 will look at the ways in which the floating and empty nature of such signifiers allows them to be coopted, dong with their considerable ideological weight, into a neo-liberal hegemony.

The "New" Health Promotion: 46Empowerment" For Health

"Underlying al1 health promotion initiatives is the concept of empowen>ienf"(Working

Group on Integrated Health Systems 1998, 8). This assertion is corroborated by others

(e.g. Grace 199 1 ; Labonte 1994b; Airhihenbuwa 1994; Robertson and Minkler 1994) who agree that to "empower [is] the central act in the new health promotion" (Labonte 1994b, 255). Ultimateiy, even within the context of an understanding that health is determined by factors beyond the individual as well as lifestyle, the goal of community oriented health promotion is to produce "ernpowered" individuals - and thus ernpowered communities - able to take responsibility for their own health regardless of structural social circumstances. In this section, 1 want to first explore the concept of

"empowerment" in health promotion as it has been developed in both a Freireian inspired critical pedagogy and "border" pedagogy. We can contrast this ideal mode1 of ernpowerment with the "consumerist" tum taken by empowerment in health promotion.

Empowerment in health promotion often serves more to disguise the actual role of the state and its professionals than it does to redistribute power and resources. More generally, over and above positioning subjects as consumers, empowerment discourse serves to encourage the emergence of self-goveming subjects in ways very similar to the fetishisation of health discussed earlier. In particular the arguments made in this section are derived from a further analysis of The Role of Health Promotion Within hitegrated Health Systems (Working Group on Integrated Heal th Systems, 1998) Empowement discourse within the health promotion paradigm, nominally at least, dnws upon the ideas and concepts elaborated in Freirian education theory, Alinsky-style community organizing, and participatory research (Wallerstein and

Bernstein 1988; Wallerstein 1992; Allison 1982; Flynn, Ray and Rider 1994; Rains and Ray 1995; Eisen 1994). In addition, though less commonly, it has also attempted to incorporate the attentiveness to difference articulated by theorists of border pedagogy

(Airhihenbuwa 1994). The issue that 1 want to address is the rxtent to which, by subsurning these radical discourses within the state sanctioned and funded paradigm of health promotion - and by substituting nther than complernenting an historical structural analysis with the concept of "empowement" - repressed structural interests in health are at risk of CO-optioninto the goveming strategies of neo-liberalism. It is within the empowerment discourse of health promotion that we fiind rnost clearly articulated the concepts of the consumer and the insistence on choice in the attainment and maintenance of health. As one writer cornments of the consumer choice mode1 of empowerment, "This mode1 provides for the construction of the consumer as a needing, wanting individual who can assess his or her own needs and wants and cm take steps to hlfill these by purchasing or othenvise obtaining the goods and services required to satisfy these needs and wants" (Grace 1994, 334). What is specifically missing from these assertions of a cornmitment to empowement is any acknowledgement that a socialised, free and freely accessible health care system is, in and of itself, empowering. Empowerment is presented in such a way that it can appear alrnost antithetical to state supported, socialised health care services. The authors of The Role of Health Promotion in Integrated Health Systems argue that "increased attention and resources mut bc redirected frurri treatment and rehabilitation" (Working

Group on Integrated Health Systems 1998.4 ,emphasis added) and towards health promotion initiatives. This in a report to a Conservative govemment in Ontario that has ken more than eager to take money away from health care services and to propose instead an alternative in which people take care of themselves and their families. The implication seems to be that social services actually get in the way of a consumer's inherent freedom: "the way in which the language and concepts of empowerment are incorporated into an individual behaviour-change approach is through linking behaviourdhange to a concept of 'need' that a person experiences for a different

'lifesty le,' which the person 'chooses' to adopt" (Grace 199 1, 33 1 ). In the spirit of applying the imperatives of the market as a means of improving quality in health services, the authors of The Role of Hrcrlrli Promotion Within Integrated Health

Services argue that Consistent with the principle of empowering communities through access to information, the IHS Report Card must be made available to al1 rostered rnembers as well as the general public. thereby enabling the public to make more inforrned choices about the IHS they wish to belong to. (Working Group on Integrated Heal th Services l998,47) In this neat rhetorical shift. ernpowerment ceases to be about the power to create and is instead reduced to the "power" to choose from an already established range of options. Ideologically, this consurnerist representation of empowerment feeds into, and from, a broader context that priviliges a vigorous individualism, freedom of choice, and an emphasis upon personal responsibility for health. It is this broader context that further fuels the shift towards the corporatisation of health care and the off-loading of state responsibilities.

Empowerment as it is used in the report, The Role of Health Promotion

Within Integrated Health Systems, although defined as "the capacity of individuals and communities to exercise the power they require to improve their health through increasing their control over the determinants that are important to their health" (45), remains an ephemeral and elusive concept. This is primarily because the concept of

"power" is not interrogated by the authors. an evasion that neatly begs the question of how individuals and communities can assume power that rests at the supra-local, often provincial or national level. 1 have already suggested that for the Working Group on

Integrated Health Services empowerment cm be easily reduced to the consumer's power of choice from a pre-determined range of services. Empowerment does not ever seem to mean democratizing the process by which budgetary priorities are established in the Province of Ontario. for exarnple, so that local communities actually have a say in how much is spent, on what, and where the money comes from. The closest the report comes to allowing "the community" a say in the spending of money, turns out to be not very close at all, "By devolving certain responsibilities for resource allocation, strategic planning, and structure to IHSs wliile establishhg and enforcing critical provincial wide standards. the Ministry of Health can create the opportunity for community empowerment" (Working Group on Integrated Health Systems 1998,46 , emphasis added). In other words, what we have here are specific health policies on the part of the state - in Ontario in the late 1990s the deinstitutionalization of heaith care - with health promotion advocates, inadvertently or otherwise, providing the discourse with which such policies can be presented to the public in terms of local community control replacing faceless bureaucratic imposition. This point is one that 1 take up in more detail in a discussion of "community" below. The extent to which people really want to be able to exercise control over the health services that they use is perhaps uncertain, but it is dishonest to represent what can only amount to limited input as "empowerment", particularly when this representation serves to disguise the real agenda. It is unclear to the reader of The Role of Henlth Promotion in Integrated

Health Services how a process initiated by professionals can be empowering for others. As authors such as Allison (1 982) and Wallerstein ( 1988) suggest, a key element of empowerment within the context of community health promotion is that people take the power to name their own issues and to take action accordingly, based on their own perception of priorities and needs. The form of empowerment presented in The Role of health Promotion is one in which the agenda is controlled by pmfessionals. Certainly, the üuthors argue very strongly that the agenda should be shaped by *'community" input and consultation: Information related to opportunities for involvement on IHS' decision-making bodies, cornmittees, or projects should be be provided to rostered members on a regular basis, as should information regarding IHS' priorities, strategies. structure, resource allocation, and services. Modes of communication may include Town Halls, I-8OGinformation phone lines, mail outs, posters and pamphlets, and community newspapers... Suggested channels of communication include sample surveys. focus groups, community consultations, and robust committee structures with high mernbership involvement. (Working Group on Integrated Health Systems 1998,46) But input is being sought on an already determined array of services and pre-defined issues. As Grace points out, "professionals get the answers they want to hear by virtue of the questions they ask" ( 1 99 1 , 256). And although "it appears as though the professional is facilitating what already exists in the cornmunity" (Grace 1991, 33 l), the "needs" of individuals and communities are actually constnicted within the quite limited parameters of professional and poli tical objectives. By situating both the problems of health and their solutions at the level of the "empowered" individual, health promotion advocates locate empowerment within the discourse of self-care and wellness as a crypto-moral and spiritual pursuit typical of

"healthism". The authors of The Role of Health Promotion Within Integrated

Health Systems announce that "Health promotion theory and practice is grounded in the belief that health is far more than the absence of disease. Rather it is a positive concept that emphasizes one's mental, social and spiritual wellbeing" (Working Gmup on Integrated Health Systems 1998, 1 . emphasis added). It is here that we can see that "health", as a function of itc nature as an empty and floating signifier, viewed through the lens of heûlth promotion, intersects with the concept as it is understood by wellness advocates whose theory and practice is defined as "alternative" or "complementary": What distinguishes this gaze from the more traditional, biomedicall y based strategies of preventive medicine and public health is that bodies are now controlled under the new idiom of freedorn and empowement. Alternative therapies as well as the new public health movement ... invoke theones which are global, holistic, spiritual or ecological in scope, compared to the local, partial and physical classification and theories of preventive rnedicine and public health. (Braathen 1996. 158. , emphasis added)

Health promotion, in other words, seems to be drawing upon the idea of health as a persona1 project from the discourse of advocates of "alternative" medicine: "Education and intervention strategies could be developed to increase clients' knowledge and skills, mabling them to more activrly participate in creatirtg their own health" (Working

Group on Integrated Hecilth Systems 1998,28. Italics added). The particular effects of locating this way of speaking of health - in which "being a 'healthy', 'responsible', citizen entails new kinds of detailed work on the self and new interpersonal demands and responsibilities" (Petersen 1 997, 204) - within the ideological vortex of hegemonic reconfiguration in the post-welfare state era in Canada, need to be explored. 1 am suggesting that, regardless of the intention of their authors, this way of representing health is readily coopted into a aeo-liberal paradigm. Within this paradigm, and within the context of hegemonic restructuring in the wake of the demise of the welfare state as an ameliorative salve, "empowerment" discourse encourages the developrnent of the self-managing individuals required by neo-liberal strategies of govemment. Briefly, self-goveming individuais are subjects produced by the fom of govemment that has evolved to suit the requirements of neo-liberdism. In the context of welfare state liberalism, according to Nikolas Rose, "persons and activities were to be governed through society, that is to Say, through acting upon them in relation to a

social nom, and constituting their experiences and evaluations in a social form" (Rose

1993, 285). These social noms were established by a new breed of authoritative experts. Rose continues, "Political rule would not itself set out the noms of individual conduct, but would install and empower a variety of 'professionals' who would, investing them with authority to act as experts in the devices of social nile" (Rose, 285). In the post welfare-state neo-liberal world, govemment now "depends upon expertise in a different way, and articulates experts differently into the apparatus of rule. It does not seek to govern through 'society', but through the regulated choices of individual citizens" (Rose, 285). Neo-li beral govemrnent is increasingly characterised

a detaching of the centre from the various regulatory technologies that it sought, over the course of the twentieth century, to assemble into a single functioning network, and the adoption instead of a fom of govemment through shaping the powers and wills of autonomous entities. This has entailed the implantation of particular modes of calculation into agents, the supplanting of certain noms - such as those of service and dedication, by others such as those of cornpetition and customer demand. (Rose, 296) Empowennent in health promotion discourse, then, is not achieved in relation to a system that oppresses, marginalises and exploits in tems of stnictured systems of power, but simply in relation to an individual's or a community's ability to exercise control over his, her or its own corner of the world. Empowerment in this context ultimately amounts to iittle more than the capacity to exert an assertion of the self thai dovetails nicely with the goveming requirements of restructuring, downsizing neolibenlism. In short, 'The institution of 'health promotion' produces an ideology of empowerment that, it can be argued, effectively masks its collusion with the contemporary form of political economy, consumer capitalisrn" (Grace 1991,34 1).

The Turn To "Community" Closely affiliated with the concept of "empowerment" in health promotion theory and practice is the concept of 4bcommunity".In fact, it is claimed that "together with the concept of empowement, it is the notion of community participation that the new health promotion movement invokes as its defining feature" (Robertson and Minkler 1994, 303). and that "community is often presented as the engine of health promotion, the vehicle of empowerment" (Labonte 1994b, 260).

In their introduction, the editors of Cornmurii~/Organization and the

Canadian State point out that "there is no agreement as to what 'community' actually means" (Ng et al 1990, 14). Labonte points out that "community" as it is used by health promoters is generally an undefined concept that "leaves unanswered three key questions: What is community ? Which community groups should be supported? and, How do we understand power-relational issues?" (Labonte 1994a, 86). This lack of interrogation of the tenn means that in health promotion literature "community" is generally charactenzed in two conventional ways: first, as a concept based on shared geographical space - a neighbourhood as a community - or perceived common interests (Labonte 1994b, 262); and secondly as a concept based upon a clienthood of social or health services, the "community" made up of a hospital's patient population, for example. In this section 1 examine the concept of "community". Again 1 am seeking to chan the possibly unintented effects of well intentioned motives by situating health promotion's reification of the "community" within a broader neo-liberal context. "Community" is a disconcertingly mirage-like concept. In popular usage, and in health promotion discourse, it is used as though its clarity of meaning is self-evident. But on closer examination its meaning becomes much more blurred. "Community" is often characterized as a naturd and organic space occupied by individuals and families. In this sense, "community" is synonymous with civil society, or the social spaces in which people live their lives. But "community" is also a uniquely apolitical, ahistorical space where healing and empowerment take place; it becomes a nebulous, almost spiritual, and intangible concept. This romanticised notion of community as a caring, supporting environment evokes a connection through the mists of tirne with an earlier more "natunl", pre-industrial pastoral existence. The concept then seems tc blend a conservative and libenl vision in which a mystically organic and spontaneous human social formation is populated by rational individuals who come together in voluntary association. The spatial (or neighbourhood) definition is what Ng et al have characterized as the "standard" use of the term. This way of defining the idea of community usually takes the following form: The focus on a given temtory or space as encapsulating the common needs of those who live and work there. Residents of an area may identify issues affecting their lives and organize for and against change in opposition to or support for urban development, or in relation to concems over economic needs and the revitalization of a local workforce and indistrial base. (Muller et al 1990, 14) This concept of 'bcommunity" as a means of organizing has ken challenged on the basis of its homogenization through which it erases differences, tensions, challenges, and conflicts of interest that arise on the basis of class, culture, race, gender, age and other markers of difference and relative privilige. Although the authors of The Role of Health Promotion Within Integrnted Healfh *stems claim to appreciate the risks of homogenizing ( 1998, 33), the instances that they cite as exemplars of community development betray an inclination to view "community" rornantically as the site of shared interests, common ground, and cornmon good, "In CornwaI1, for example, a diverse range of community stakeholders, from residents, local industry, Boy Scouts, and the Kiwanis and Rotary Clubs worked together on a nurnber of initiatives" (Working Group on Integrated Health Systems 1998,34).

Marjaleena Repo (1977a; 1977b), citing her experience as a community worker in the Riverdale area of Toronto, claims that a focus on the neighbourhood concept of community is politically debilitating. In seeking to develop an organization that is broad based, the concept "assumes a classless society at the local level, in which a mysterious 'people of dlclasses' work towards a common goal" ( 1977a. 48). In practice, as Repo argues energetically. in mixed class neighbourhoods people are not al1 equal in ternis of resources and access to political power. Despite the persistence of romantic notions of communities in health promotion literature (that often characterizes community members as virtually siraining at the leash to work together to build a better and healthier world, if only the bureaucratie barriers can be removed) serious conflicts and divisions exist that cannot-and should not-be wished away by local CO-operative efforts. Not only do people more often than not display a disinclination. contrary to health promotion's tendency to assume that people are inherently so inclined, to work together for the cornmon good, it is very far from clear that there is in fact a "common good" to work for. In fact. Repo claims that such attempts to develop coaperative community organizations can produce anti-working class alliances between the middle- class and the lumpenized poor ( 1977b). In addition to the class issues noted by Repo, an uncritical reverence for a homogenized "community" can conceal significant intensifications of exploitation. In particular as "Canada's forward looking health promotion policy has become a justification for reducing institutionalized services and increasing individual and family responsibility under the guise of public participation" (Wuest 1993,407), the i ncreasing individual and famil y responsibility has alrnost invaiably fallen on the shoulders of women as prirnary caretakers (Armstrong & Armstrong 1996, 135-44; Laurence 1992). What is more, the homogenization of a neighbourhood as a "cornmunity" can undermine struggles that take place within neighbourhoods against racism, homophobia, and other forms of discrimination and violence. Not only cm the idea of "community" serve to mask these sorts of tensions and conflicts, the insistence on "common good" and consensus that often accompanies the rhetoric of community can position groups struggling against discrimination as divisive and unconstructive. As Labonte points out, "the healthful importance of conflict in social change processes is often overlooked in a health promotion~empowermentrhetoric of consensus which frequently defines empowerment as a non-zer+sum commodity" (1994b, 26 1).

A definition of community that does not rely on geographic boundaries, but that is similarly narrow in its scope is that of the idea of community constmcted around a common interest or concem. In a sense, this way of defining community is an elaboration on that of territorial community, the idea of community is premised upon a location which, though it is not necessarily geographic, transcends difference. A community might, for example, be defined in terms of religious belief or, in the case of Toronto and other cosmopolitan cities, in terms of ethnicity or country of origin. A third common means of ascribing the category "community" to a group of people is to do so on the bais of their common use of services. This is a "client" definition of community which, according to Repo, h;is its own problems, which also result from a Iack of class analysis. It assumes an êxclusive common interest on the part of the clients; separates them from their class contexts-which invariably is the working class-thus creating political abstractions out of real people. ( 1977a, 49) In other words, a client based concept of "community" commits the sarne homogenizing and decontextualizing sins as does the neighbourhood concept. This is not especially surprising as there is often very Me, if any, distinction made between the two in practice. For the authors of The Role of Heulth Pmmotion Within integrutai health Systems, for example, community as clienthood cm be synonomous with a geographical definition. The service area of health services, in fact, tums out to be one way of defining a geographic community. This rather tautological definition defines a community from the outside; it is a bureaucratie and service providers' construction, and hardly the organic, spontaneous concept that health promotion claims to valorise. Once such a client-area "community" has ken "established" - and it will change according to bureaucratically and politically determined shifting boundaries - other ways of designating community status, common interest for example. have to exist as a subset of the primary client-area category, Al1 rostered members may be considered a community. Yet within that rostered community, there are other groups of people who share a collective identity, and a sense of collective purpose. These groups, or communities, may or may not live in the same local neighbourhood. They rnay be a community based on a shared belief system, common interests, or some other defining characteristic. (Working Group on Integrated Health Systems 1998.33) Whether determined by the arbitrariness of the client-area template. or on the bais of a sub-geographical common interest, each community is held to be a discrete entity, distinctive in its own needs which only it can identify and meet. This atomistic way of comprehending communities is structurally determined and typical of a bureaucratic, or service-based outlook. Professionals employed by the state work for organizations with specific catchment areas, which as we have seen, they then identify as "the community". This community may contain other kinds of communities, but communities, by definition, cmnot transcend the geognphic areas determined by the the state; that is to Say, health promoters involved in comrnunity development will not be funded to make linkages across the boundaries they are funded to work within. Consequentl y, This common definitional approach offers a truncaied and disconnected view of people. Residents of one geographical area may be considered separate or distinct from those in another locale. Similady, those individuals sharing an interest, for instance, in an educational context, are triken to be separate from others. The relationship to any other group of people at the local or national level is left unexamined. (Muller et al 1990, 15) The effect of focusing attention at the level of "the community" is the assumption that social problems only arise locally and that therefore local actions can resolve them. The political consequences of this can be profound in that situating the solution to problems at the local level can deflect attention from broader social issues which might cal1 larger questions into existence. In The Role of Health Promotion Withh Integrated

Health Systems we find the assertion that community development "is a strategy for strengthening communities*economic capacity and self-sufficiency so that they are less vulnerable to the negative impact of rnacro+xonomic trends" (Working Group on Integrated Health Systems 1998,36). In fact, far from king "natural" - whatever we might take the term to mean - ideas of community as 1 have described them here an ideologically constnicted (Walker 1990). This construction of comrnunity serves at least two related, though not necessarily consciously intended, purposes. The first of these is the developrnent of the idea of community in ways that serves to conceal the nature of the actual relationship between professionals. generally working on behalf of the state, and the people with whom they work. As Grace (199 1) tells us, "There is a discourse of 'finding out community needs,' which involves doing a survey of 'individuals'; these data are interpreted according to a 'population' basis and the 'community' is then told what its needs are" (340). In other words, health promotion professionals approach a "community" with a particular agenda, based on assumptions about the value of, and the need for, health promotion. On the bais of this agenda and these assumptions they establish a set of questions which are presented to a "community" regarding its health promotion requirements, and the responses are taken to represent the unified expression of the cornmunity's already existing, but hitherto unarticuhted priorities. The "community" is thus considered to be "empowered", and "when communities are empowered in this way, they can truly work in partnership with the formal health system towards the shed goal of improved, and equitable health and social well-being" (Working Group on Integrated Health Systems 1998,35). This statement by the Working Group belies the fact that "prograrns falling under this rubric have, in most cases, had more to do with implementing specific policy objectives than with redistributing power and resources" (Petenen, 1994b 21 3). It also reveals an idealized image of communities as sharing the cornmon goal of equitable health and social well-king that we might want to challenge. In chapter one I sought to describe the effects of ideology and the ways in which an understanding of the role of ideology in knowledge construction complicates simplistic ideas of information transference. In other words, though we might hope that the majority of the members of communities would share the goal of equity and social well-being, this is not necessarily the case. And even if we can assume a general consensus around such unspecific and general goals. we certainly cannot assume that that any consensus exists regarding the means of achieving those goals. Over and above this masking of bureaucratie imperative. ideas of community, like that of empowerment, are actually irnplicated in strategies of govemment in the neolibenlism of the post-interventionist state period. That is to Say, that the conventional ways of understanding bbcommunity"that I have described play an important role in the reconfiguntion of hegemony in the era beyond the welfare state. Instead of a nation whose potential is unfulfilled because of a debilitating culture of dependency and whining "special interests", we have a vision of self-sufficient, independent, autonomous and healthy communities made up of self-sufficient, self- goveming subjects whose individual health becomes a project for self-management: The strategy of 'community participation', universally applauded by new public health commentaton as the means of 'empowering' citizens, establishes its own disciplines of the self (e.g. that one engage with formal political structures and with various experts, and the ability to demonstrate cornmitmenet to shared goals and to minage interpersonal conflict). (Petersen 1997,204) This focus on self-goveming individuals and self-sufficient communities serves to manage dissenting or oppositional voices by incorporating an apparently radicai discourse into a paradigm that ultimately serves an agenda of downsizing, deregulation, and possibly prîvatization. As I suggested earlier, the representation of repressed structural interests in health care are in danger of king cwpted because "health promotion conceptualizers have usurped the discourse of social movements, ernphasizing the empowenng capacity of 'the community' but failing to address the the role of the state... or macrosocial power structures in creating unhealthy conditions" (Labonte 1994b, 254). Opposition to change is no longer an option for communities that are successfully recruited into the implementation of change itself, which "requires changes in the thinking of community members, and their willingness to participate in planning and implementing actions so as to achieve better heal th" (Working Group on Integrated Health Systems 1998, 32, , emphasis added). Responsibility for the planning and implementation of health services is downloaded whilst at the same time the resources necessary to provide those services in increasing l y wi theld. Ultimatel y, the transfer of "control" to the local level serves to absolve the state of its responsibilty for the provision of funding for those services. "'Community empowement' has strong political apperl, especially for supporters of the New Righi economic policies, since it justifies the cutting back of state services in the name of community control" (Petersen 1994, 2 16). Without the means with which to provide services, of course, local control is worse thrit futile, and in the end "community development in health promotion may, nt best, amount to empty rhetoric and, at worst, provide a potent means of population regulation" (Petersen 1994.2 17).

As Grace ( 1 99 1,34 1) points out with regard to health promotion, "it is ironic that a discourse articulating a concem to promote health in the name of freedom and 'wholeness' functions to alienate people from their capacity to engage in protest, and effectively operates to subject them further to the political and economic order." What 1 have attempted to demonstrate in this chapter is that whereas first wave public health in Canada. between 1880- 1920. played a role in the economic and the ideological configuration of the nation, the "new" public health is perfoming a parallel function with regard to the neo-liberai reconfiguring of the nation. At issue in this ongoing reconfiguration are the redefinition of the role of the state in an increasingly posi- interventionist period, and the reconstruction of the "ideal" Canadian subject as a self- sufficient, self-managing entity no longer in need of the "disempowering," "interfering" state. In the "new" public health we can see the reframing of two dominant characteristics of first wave public health. Unlike its predecessor, late twentieth century health promotion no longer articulates its agenda explicitly in terms of "race"; this is not to say that its concems are no longer racialised, simply that 1 have not reviewed the "data" on which to base such a judgement. But health promotion continues to couch the instruction of individuals in personal conduct in the Ianguage of moral responsiblitity. The overtly racialised nature of the discourse may have disappeared, but behaviour remains framed, as a moral imperative. as that which is conducive to "wellness". The second characteristic of first wave public health that we can see repeated in the contemporary version is its propnsity to manage radical social critiques by reframing their objects of analysis as technical problems of health. In other words, "hedth promotion has attained legitimacy by exposing the need for radical change, but it offers no fundamental challenge to the established power relations underlying problems" (Petersen 1 994,2 1 7). At the same time that it may be seen as a response to a set of "problems in relation to the actual prxtice of governrnent or management" (Smith 1990, 1 S), health promotion ac hieves the institutionalisation and dilution of radical discourse by enfolding it within the dampening folds of of its own.

This is not to say that racialised subjectivities are no longer constructed in and through public health discourse, but simply that the form of address in the "new" public health has been "democratised" in the sense that it now purports to speak to "dl" Canadians in a way that Victorian public health could not have envisaged. Whether or not contemporary Canadian health promotion is, in practice, as concerned with "race" as its forebear would require a reading of its texts somewhat different from that taken in the present chapter. The ways in which the Canadian committment to mutticulturalism become operationalised in health promotion, for example, would require the selection of differents texts that the ones 1 have selected for analysis. ' 1 am not suggesting that the welfare state appeared instantly in 1945. Not only did it develop unevenly across Western Europe after the war, it also has roots that can be traced back to the end of the nineteenth and early twentieth centuries. The rise of working-class movements, particutarly through the trades union movement, but also through political parties, had already wmng, by 19 14, concessions that would be developed later by welfare state pianners. For example, the principles of old age security and unemployment insurance had been successfully implemented in Britain by 1914, even at the cost of some of the historical powers of the House of Lords (Lloyd 1979, 1 3-23). ' It was not until 1984 - forty years after both the federal health insurance policy proposals of the 1945 "Green Book" and the CCF's decision to "go it alone" in Saskatchewan - that the Canada Health Act final 1y consolidated two earlier pieces of legislation, the Hospital Insurance and Diagnostic service Act ( 1957) and the Medical Cure Act (1966) into a more cornprehensive and national approach to the provision of access to health care services (Taylor 1978; Armstrong and Armstrong 1996).

* These five principles as enshrined in the Canada Health Act ( 1984) are: comprehensiveness, universal coverage, accessi bi lity , portability, and public administration. ' This neo-liberal agenda, it needs to be noted, is being camed forward with just as much enthusiasm by the current Labour government in Britain, just as it has been by the Liberals in Canada. There is, in fact, a third rnodel of health promotion - the medical rnodel - which is much more oriented towards disease prevention in a clinical sense than are the "lifestyle/behavioural" and "socioenvironmental" models. The medical model of health promotion is more closely associated with a conventional public health approach and its concerns with sanitation, imrnunization, and epidemiology. The medical model is not a concem of this chapter because, although it is usually ciied as part of the trinity of rnodels that makes up the general approach to health promotion (Working Group on Integrated Health Systems 1998, l), its clinical focus sets it apart from the other two rnodels which are, more or less explicitly, critical of the conventional medical model.

Pagination for references cited in this section, other than for The Role of Health Promotion Within Integrnted Herrltlr Systerns, refers to the numbering of pages of the documents as printed from Health Canada's web site. The publications as they appear on the web site are not paginated. See bibliography for full citations of the original publications of Mintz ( 1988189; 1990). Samer ( l984), Young (1988189; 1989), and Mintz, Rawlings and Steele ( 199 1).

1 borrow this term from Hayden White (1990) who uses it it describe the ways in which the narrative form imbues the representation of history - which, even in a "scholarly" context, almost always occurs within the narrative form - with a meaning that is derived as much from the form itself as from the content. In other words, the narrative structure represents history to us in the ways that we expect history to be represented to us by virtue of our ideological conditioning to the narrative form. Thus, the form of the narrative structure bears its own ideological content. 1 am suggesting that the "form" of marketing discourse - which constitutes its methodology - likewise bears an ideological content.

'O I need to introduce a caveat into my argument here. It is not my intention to disrniss any of the practices included in this rather sweeping statement. I am attempting merely a characterisation of the economy ihat has evolved around the issue of heakh. I am not, in the present discussion, passing judgement on the effects, beneficial or othenvise, of any of the components of the health industry included in this list. FOUR CONSUMER HEALTH INFORMATION: THERAPY ON THE ELECTRONIC HIGWAY

Evey hisroricnl period has its godword. There wns an Age of Faith, an Age of Reason. and Age oj'Discovep. Our the has heen nominated to be the Age of Information. Theodore Roszak ( 1994, 19) Information: The New Magic Bullet This chapter consists of the third and final of my three case studies. It focusses on an understudied element of the new public health. "consumer health information" (CHI). It is logical to examine consumer health information as an outgrowth of the new public

health because it parallels the emergence of health promotion both in ternis of the historical period in which they have emerged and the features they have in common. In genenl. of course. the meta themes of the chapter are the same ones that govem the thesis as a whole: what is the role of public health in strategies of govemment and in the articulation of hegemonic discourses? In addition, because of the similarities and parallels between health promotion and CHI, further themes will be familiar from the previous chapter: the themes of self-goveming subjects, consumerist discourse in heülth, corporate restructuring of health care, and "healthisrn." At the core of this chapter, however. are themes that have not been addressed hitherto. In particular these include the social relations of knowledge production in health and the role of "information" in contemporary discourses of "empowerment." At the very heart of consumer health information as discourse is the double assumption that a) knowledge equals power, and b) "information" as the means by which knowledge is operationalised is the mechanism of empowennent. US and Canadian librarians (as in other fields) have professional bodies in common and CHI is a transborder discourse. This might, ai first glance, appear to complicate the discussion of CHI because of the fact that the two countries have different health care systems. However, the study of CHI is instructive in that it not only clarifies the points of similarity in the two systems, but it helps us to understand the ideological dimensions that may presage significant changes in the Candian health care system that still lie ahead. The structure that I propose to follow in this chapter is as follows: an introduction to CHI and a review of its history is followed by an examination of its social and discursive context and genealogy; 1 then consider the ideological effects of CHI in the neoliberal context of the post-interventionist state; finally 1 challenge the central claim of CHI that knowledge equals power with the assertion tha power produces knowledge, in the context of a discussion of the reassertion of the authority of scientific medicine to determine the conditions of knowledge production in health.

Introducing Consumer Health Information A dominant theme in this thesis is the issue of timing. Why do certain social movements and specific discourses rise to prominencewhen they do'? What are the contingent political circumstances that seem to legitimise certain progressive, even radical. projects when, on the surface at least, they can appear to fly in the face of prevailing pol i tical trends? My two previous case studies have examined public health in the period 1 880- 1920, and the "new" public health since the early 1970s in this regard. 1 have concluded that in the context of shifting hegemonic contingencies, seerningly radical discourse becomes legitimised when it cm be incorporated into the prevailing ideological framework of the time, a framework that accommodates and manages opposition on the terms of dominant groups: in chapter one the terms of nation-building and capitalist consolidation; in chapter three and the present chapter, the neo-liberal terms of globalising late capitalism. Oppositional discourses that do not coincide with these terms - socialism, of course, but now also Keynsian social democracy - rernain marginal and are denied the status of legitimacy granted to other discourses within the context of a putative pluralism. By framing the issue as one of timing and context I am avoiding the suggestion that the discourses of public health and health promotion are "bad" per se - though there are elements of both that 1 find politically problematic in and of themselves. There is much in both that I can characterise as "progressive" and "in good faith." To paraphrase Foucault, "it is not that everything is bad, but that everything is dangerous." This is true also of the discourse under examination in the present chapter: consumer health information. The idea that people should be educated about their health, both when they are ill. and also to avoid that state, has been with us for centuries. As a "good idea it seems obvious to the point of banality. But why has it acquired such prominence in the last twenty years or so? And what is its connection, if any, with curent restructuring initiatives in health care. and in the economy more generally? In this section 1 look briefly at the history of consumer health information, and consider some definitions of the term. Although the teminology of health consumerism might be new, the language of personal responsibility for henlth based on a knowledge of the factors that contribute to health and illness is not. Writing specifically of the medical tradition in the West, Gann (1991a) points out that "there has been a flourishing publishing trade in lay health care guides since the Middle Ages" (287). In Tudor and Elizabethan England, and on into the seventeenth and eighteenth centuries, there were rnany such guides in popular circulation (Conrad et al 1995, 322, 324,443-6). It was not untii the rise of scientific medicine through the Victorian period that education for self-care becarne subject to the ministrations of the now state-sanctioned expert authority of the medical doctor. It is no coincidence that this period also saw the marginalization and exclusion from the realm of "legitirnate" medical practice of "fringe" medicine, or approaches that were subsequently derided as "quackery." Medical approaches such as homeopathy, hydropathy, or eclecticism, based on an holistic approach to the individual that scientific medicine had abandoned, were much more iikely to emphasise the importance of education to encourage li fcsty les that would promote health and avoid illness. Similarly , medical systems from outside of the Western tradition, such as Chinese medicine and Ayurveda with their assumptions that health is the product of an equilibriurn of cosmic forces, have had education, in the fom of prescriptions for healthy living, at the core of their philosophies for thousands of years. Scientific medicine in the West has only rediscovered the value of inforrning and educating in relation to making sure that people do what their docton tell them to do. This idea has become woven into the idea of health education in the twentieth century and is an issue 1 retum to below. In particular, it was with regard to tuberculosis and matemal and child welfhre that the value of education became apparent, in the context of public health concerns that I looked at in detail in chapter two. With tuberculosis it was "the chronic nature of the illness, and the requirement that infected persons take medications over long periods" (Bartlett 1986, 138) that pmmpted the awareness for the need of education. The education of potential and new mothers took place, as 1 argue in chapter two, within a gendered context of concems for racial purity and anxieties of racial degeneration. In both cases, education and surveillance of the day-to-day lives of individuals are closely entwined. Since the 1960s, for reasons 1 explain in greater detail below, a major development in health education has been the emergence of the consumer health information movetnent. In the US, Canada, and the UK in particular, consumer health information services (CHIS)have sprung up and spread rapidly. These services have been created and staffed pnmarily by librarians in hospital and public library settings

(Gann 199 1a; 199 1b; Marshall 199 1 ; Rees 1 99 1 ).' A familiar locd example is the Consumer Health Information Service the main reference library on Bloor Street in Toronto. Accordingly, the existing research and professional statements on consumer health information corne out of a library and information science (LIS) paradigrn. It is within LIS literature that we cm find elaborations of what consumer health information is. In practice. however, LIS literature is short on reflection upon the nature of CHI, and long on procedural and technical concerns that take it for granted. 1 will not atternpt to produce here an authoritative definition of consumer health information. My argument is that, like the component ternis "health" and "information", CHI is elusive of definitive categorization, and al1 the more ideologically powerful for that. It contains within it much more than the relatively simple idea that people should leam about their health and what affects it. The aim of the present section is to introduce curent common usage of the term in a desriptive rather than cntical light. Consumer health information has been described as "any information that enables individuals to understand their health and make health-related decisions for thernselves or their families" (Patrick & Koss 1995). Though this is a somewhat thin and tautological definition, it seems to be the staning point for CHI prrictitioners and writers. as 1 discuss in more detail in a subsequent section. According to Deering and

Harris ( 1996). there are three categories of CHI: persona1 health, medical treatment. and public health. In the context of the last of these three categories, "the objective is to modify individual or institutional behaviours in order to mitigate disease or promote healthy practices" (210). This form of CHI is more commonly known as "social marketing" in hedth promotion discourse and wüs discussed in some detail in the previous chapter. The tensions between the other two categories are instructive as to the different perspectives on CHI held by different players. This tension is central to the issue of the social relations of knowledge production in heaith that I discuss below in a later section; it is the tension that surrounds the distinction between health itzfomtion and patient education.

Health care providers, and in particular doctors, have historicdly been the agents of transmission of health information and education, whether for "wellness" or in the context of medical treatment. That they should continue to maintain a monopoly in this area, rather than sharing the role with non-clinical but professional information workers, is an assertion that generates controversy within CHI circles. Librarians have evolved a compromise that serves to further their professional role in the provision of health information whilst simultaneously distancing them from issues of liability. The compromise is to attempt a distinction between ir~ornzutionprovision on the one hand, and education - and most especially, "udvice" - on the other. This nervousness with regard to liability is evident in the importance placed within CHIS circles of the disclaimer of legal liability. Alan Rees, who has become a prominent figure in the CHI movement through the publication in several editions of his exceedingly useful Consiirner Health Infonnotiori Soirrwhook. rnakes the following distinction between CHI and patient education: Corisionrr Iledfh injbnnntion is information on health and medical topics that is relevant and appropriate to the general pubiic. By way of contrst, patient ediiccitiori is the process of influencing patient behaviour to produce changes in knowledge, attitudes and skills calculated to maintain and improve health. (Rees 199 1,33 emphasis in original) However, despite the nervousness on the part of information workers, the boundary between the two concepts blurs unavoidably, a fact that is recognised in a policy statement issued by the Medical Library Association and its Consumer and Patient

Health Information Section ( 1996): CHI and patient education overlap in practice, since patient behaviour may change as a result of receiving health information materials. Patient education and CHI often differ in terrns of the setting in which the process occurs, rather than in terms of the subject matter. (238) This overlap of the two concepts, 1will argue, is crucial to the issue of knowledge production in health. It is central to an understanding of the response of scientific medicine to the challenge to its hegemony that consumer heaith information poses. What makes CHI librarians threatening in this context is their provision of information to health consumers in a way that excludes health practitioners, especially doctors, from the process. What hinders the threat that librarians pose to scientific medicine's hegemony, and in fact makes CHI vulnerable to a reassertion of biomedical authority over knowledge production in health, is the way that librarians conceive of their stock-in-trade: information. 1 want to explore the way that CHI information workers view the concept of "information" by unpacki ng the concept "consumer heal th information" i tsel f, and then piecing it back together through an examination of its social context and its genealogy. By the broader social context 1 am refemng specifically to prevalent and influential discourses about information in general that have led to the present age being labelled the "information age." Within this context, the genealogy 1 propose to explore consists, on the one hand, of the theoretical understanding of the concept of "information" within the epistemology of library and information science discourse (dong with the attendant terminology of information "need." "gap," and "users"), and on the other, the emergence of consumerism in health.

The "Cult Of Information" And A New Hegemonic Order Whcn Theodore Roszak pubfished the first edition of The Cdt cfhfonziation in 1986, the internet was still large1y unheard of and its use was limited to a small number of researchers in American universities and research institutes. And yct even by the mid 1980s Roszak felt that discourses of "information" were so pervasive that he was compelled to characterize them as a cult. Even when the second edition of the book was published in 1994, the world wide web was in its infancy and only the most enthusiastic speculators would have forcast the explosive growth in its popularity and use. As we enter the new millenium, of course, the internet itself has become pemasive, particularly in North Amenca and Europe, but also around the worlcL2 Roszak could not have known just how perfectly his phrase "cult of information" would come to characterize a world seemingly obsessed with the internet in its two most popular forms: electronic mail and "the web." The internet has become a shorthand reference, a synecdoche, for the multiple discursive and technical components of the "information age." In this chapter I will not not be focusing on the intemet per se, but upon the discursive

constructs for which it stands, and within which 1 situate consumer health information. Although the mass use of the intemet is still something of a novelty, Roszak reminds us that the cult of information preceded it. In fact, "information" has been extolled as the dominant resource of knowledge-based "post-industrial" societies for three decades by theorists such as Daniel Bell and Alvin Toffler (eg Bell 1976; Toffler

198 1 ). Increasingly, in conternporary media, govemment, and corporate

pronouncements, information is presented as both the primary raw material and commodity of the new global economy. The society of the future, already immanent in the present, is characterised, "as a service economy with the majority of people working no longer in the extraction of raw materials or the fabrication of goods. but in an information exchange" (Poster 1990, 26). This characterization of the economy of the future is evident in reports produced by the Canadian govemment. of which the following are illustrütive: If Canada is to succeed in a global economy based on the creation, movement, storage, retrieval and application of inforrnation, Our communications networks must be knitted into a seamless and powerful information infrastructure serving al1 Canadians. (Industry Canada 1994, 5) These powerful new technologies are becoming the infrastructure for a new 2 1 st-century society, which is based on the exchange of intangibles - ideas, information, knowledge and intelligence. There are many terms for this new world - "information society," "knowledge-based economy," "digital econorny," "post-industrial society." (Industry Canada 1997a, 2) This transition from industrial to information society is herdded as being of revolutionary irnport, perhaps even representing the emergence of a post-capitalist era, in which the old exploitative relations of production disappear. In the previous chapter 1 argued that health promotion is contributing to the reconfiguring of the Canadian nation in a post-interventionist, neoliberd context. Currently pervasive discourses of information and popular assumptions regarding its potential for bringing about dramatic, positive change, are pivotal to the reconfiguration of the nation, both economically and ideoiogically. within the context of the globalising econorny. New information and communications technologies are without doubt deeply implicated in capital's increased mobility. a mobility necessary for the search for ever cheaper labour. Discourses about "information" on the other hand. successfully represent these technologies as bringing the world closer to a knowledge-based society, an "age of inforniation" free of poverty, dmdgery, and inequalities. There is no doubt that the character of the global economy has been changed over the 1st tliirty years by the emergence of new information and communications technologies. Globalization has accompanied the successful discrediting of the interventionist stnte in the West and in the countries of the former Eastern Bloc. Theorists of the Left have had difficulty responding to the collapse of social democracy and the tnumph of liberalism that Francis Fukuyama has characterized as "the end of history." In the scramble to understand the reconfigurations of the "new economy" in the midst of postmodemist challenges to oppositional and revolutionüt-y

me ta narrative^*', theorists of the Left have produced an array of characterizations of the curent era thrit illustrates a confusion with regard to the extent that it remains capitalist. Andre Gorz (1985, 39) argues. for exürnple. that "What is being preserved is not the capitalist system but capitalism's system of domination, whose chef instruments were the wage and the market." Gandy (1993.35) comments, "1 would only invite ridicule by speaking as though capitalism was nearing its end. Yet the transformations in capitalism that have been predicted by Marx. Weber, and Schumpeter have surely produced a kind of capitalism that Adam Smith would quickly disown", whilst Mark

Poster ( 199 1 ) has coined the term "the mode of information" to replace "mode of production." On the other hand, and more convinceingly, David Harvey ( 1989; 1991) has characterized the evolution of the capitalist economy since the earIy 1970s as a transition from Fordism to flexible accurnulation, whilst Robins and Webster ( 1988) have introduced the term "cybernetic capitalism." Rather than assuming that economically we have entered the realm of "post-capitalism", the argument of this chapter is that the Iast thirty years have seen heightened capitalist expansion. accumulation. and exploitation. I agree with Blanke (1 990-9 1, 10) who claims that "the production, organization. and dissemination of information has taken on an unprecedented socio-economic importance, but it bas done so within the paradigm of corporate capitalism and under the imperatives of pnvate profit and corponte hegeinony." In other words, as Frederic Jameson suggests, the issue of how to understand the nature of the changes in the global econorny, may be rephrased as a question about Marxism: do the categories developed there for the snalysis of classical capitalism still retain their vülidity and their explanatory power when we tum to the multinational and media societies of today with their 'third-stage' technologies? The persistencc of issues of power and control, particularly in the increasing monopolization of information by private business, would seem to make an affirmative answer unavoidable, and to reconfirm the pnvileged status of Marxism as a mode of anal ysis of capitalism proper. (Jameson 1984, xiii) New information and communications technologies and, of course, the idea of "information" itself, are deeply involved in the rnove into this new phase of capitalism, which, in contrast to the social democracies described by Habermas cited in chapter three. is characterized by an increased flexibility and mobility of capital, large scale unemployment. the rolling back of welfare services, the denial of opportunities for upward mobility for many members of society, and the deskilling and increased exploitation of those who continue to find paid employment. In the previous chapter 1 have categorised this new phase of capitalism as neo-liberal. The social consequences of neo-liberalism are already well documented, and they do not support the suggestion that we have passed beyond the dysfunctional attributes of the free market. A recent Canadian report (Yalnizyan 1998). for example, demonstrates that the period since 1973

- the period of the rise of neo-liberalism - has seen a widening of the gap between the weaithiest and the poorest members of Canadian society. This is the same period that has been characterized by the increasing ubiquity of the information and communication technologies that were supposed to bnng about a utopia of equality and leisure. The report points out tliat the gap between the wealthiest and the poorest in Canada has increased more quickly since 1993 which. we might point out. was also the year in which the world wide web first appeared. At the very least this is a deeply ironic coincidence. In the previous chapter I argued that the dismantling of the welfare state as an ameliorative to the social dysfunctions of the unfettered free market creates something of a hegemonic crisis. 1 went on to suggest that herlth promotion and discourses of health cornmodification and consumerism have been incorporated into hegernonic reconfigurations in the wake of the demise of the interventionist state. In the present chapter I return to the question of how hegemonic consensus might be sustained in a period in which the state in Canada, as elsewhere, is retreating from the interventionist policies that characterized the period from the end of the second world war to the 1970s. It is my argument that discourses of information fom pan of the array of strategies that arise in response to problems of govemment in a neo-liberal context. Similar to the way that 1 argued that "heülth" is an empty and floating signifier in the previous chapter, so "information" and the "informed consumer" perforrn parallel ideological functions through an equaiion with democricy, wealth, freedom, and decentralization.

Information AndAs Democracy, Freedom, And Wealth Robins and Webster (1988) argue that the "information society" represents a new stage in the mobilizing function of capitalism, which they have chosen to characterize as "cybernetic capitalism." They claim that the discourse of the "information society" is central to this mobilizing function, and that it can do so because "the new information technologies promise to meet and satisfy the clamour for more freedorn, democracy, leisure, decentralization, and individual creativity" (51). This discourse is common in both the media representations of technology and the work of futurologists or "post- industrial utopians" (Finlay 1987; Frankel 1987). Throughout the 1970s and 1980s these writers promised more leisure time for all, booming economies. more equal and more democntic societies. These predictions have been repeated so many times that they have become part of a shared, and rarely questioned. "common sense." Of course. this is in spite of the fact that most of these predictions are far from being realized, regardless of how true they are proving to be they are still accepted as "facts." Narratives of liberation through technology and progress are woven into the discourses of both Left and Right. John Durham Peters reminds us that the "rhetoric of the electrical sublime" ( 1988, 17). the promise of a utopian new age of social relations ushered in by wonderous new technologies. has been with us since the discovery of electricity. This particular narrative seems to have attained an unshakable status within the cultural fabric of North America in particular. In an astute characterization of the "cult of information". though she does not use the tenn, Brenda Dervin ( 1994) argues that, in the North American context, the dual concepts information and democracy have become embedded in a powerful cultural narrative based on the following premises:

That access to "good information" is critical for the working of "good democracy "; that when information is allowed to flow freely in a free marketplace, "truth", or "the best information," naturally surfaces rnuch like cream in fresh whole milk; that the value of "good information" is such that any rational person will seek it out and that, therefore, availability equals accessibility; that "good information" ought to be available to al1 citizens in a democracy, that there should be no information inequities and; and that it is unfortunare that some citizens have fewer resources, and that we must therefore provide means of access to "good information" for these ci tizens. (Dervin 1994,369) Similarly, whilst arguing that new technologies have been central to the process of global restructuring and a "'new flexibility' [which] has been introduced almost entirely on cqitalist ternis" ( 199 1,68), Harvey contends that the political strategies for organizing consent and participation in this process have involved "maintaining highly centralized control tlirnrigh decentralizing tactics" (73, Harvey's emhasis). In other words, although information and communication technologies are intimately implicated in power-centralizing tendencies, the discursive effects of information narratives is to constmct the appearance of power becoming increasingly diffuse. The argument that the networking of new information and communication technologies is inherently decentralizing is central to claims that such technologies will lead to enhanced democracy. However, there is no obvious reason why technology that overcomes the barrier of distance should be in herentl y decentralizing. On the contrary, Gillespie and

Robins ( 1989, 1 I ) argue that "advanced communications technologies have. because of their space binding characteristics, an inherent central izing bias", which facil itates enhanced forms of inequality and uneven development. In particular, the ability to shift huge quantities of information at high speed across global data networks has become fundamental to the cohesion and flexibility of the global operations of corporate structures. Corporations are now able to centralise administrative functions in areas of the world where labour and other costs are cheapest. Marike Finlay (1987, 35) argues that "information" has also become fused with the discourse of "econorny" at both macro and micro levels. At the macro level are arguments that information is essential for success in the global market and for a vibrant provincial or national economy (Industry Canada 1994; 1997a; 1997b). But there are also micro level arguments that assert that at the individual level too "information is weiilth." The effect of such an assertion becoming accepted at the level of unquestioned common sense is a consequent discourse of the "information rich" and the "information poor." This discourse, utilized by both Left and Right, reconstructs injustices, inequalities, and other social issues as problems that cm only be solved by more, and more readily accessible information (see, for example, Murdoch & Golding 1989; Cubberly & Skrzeszewski 1992; Canadian Library Association 1992). The centrality of information to economic performance and to individiial well-being leads to constant dernands for the "free flow" of information (Finlay 1987, 37), demands that increasingly take the place of more critical and political ones. What one rarely sees in these reifications of "information" are any debates about what information actually is. "Information" defies definition not because it is a particularly complicated concept, but precisely because as a signifier it is both empiy and floating.

Definitions if information invariably place it within equivalential chains that include "informative data," "operationalized knowledge," "ideas," and other "intangibles." Information is situated within other equivalential chains by clairns that access to it will enhance participation, interaction, dernocracy, innovation, creativity, economic performance, community, and that through access to information, humanity will be liberated from tedious, dangerous. and dirty work. And, of course, from il1 health. AH of this is backed up by the powerful and pervasive belief that information is bound up with "progress", which is assumed to be both inevitable and desinble. It is perhaps not an exaggeration to say that "information" - "a word used al1 too uncircumspectly in conternporary discourse" (Peters 1988, 10) - is constructed as a universal panacea to all of late capitalism's social ills. It has become, one might Say, the dominant "quack remedy" of the late twentieth century. With phrasing reminiscent of clairns that we have reached the "end of history", Caroline Myss, a popular advocate of the care of the self, claims that "we have reached the end of the 'divide and conquer system' of power" and that "our interconnected 'information age' is the symbol of a global consciousness" in which "information technology is the symbol of our energy interactions" (Myss 1996, 185). It is reasonable to speculate that such utopianism will be increasingly reflected within the rhetoric of the "information superhighway" (see for example, Industry Canada 1994; 1997a; 1997b; The Information Highway 1993; The National Information hfrastructure 1993). This "cult of information" is a crucial component of the social and cultural backdrop against which it is necessary to locate the emergence of the discourse of consumer health information. It is by situating CHI within the context of these broader and pervasive discourses of information that it becomes possible to understand its discursive power. The other source of its power, of course, is the rise of consumerism in health, which will be discussed in the second part of the following section. There are, however, aciors who occupy the terrain constructed by information discourses. and these actors must be addressed. Information, including consumer health information, has both its users and its providers, and the relationship between the three has conventionally been the dornain of librarians and information workers. Not surprisingly, it is within library and information science (LIS) research that we find concems with the practical issues of information provision. As consumer health information is a field largely dominated by those trained or experienced in the LIS field, it is my contention that the epistemological approaches of LIS and its philosophical concerns fom pan of the genealogy of CHI.

The Genealogy Of Consumer Health Information 1: From Positivisrn To Cognitive Constructivism In Information Science

Michriel Harris ( 1986, 230) argues that positivist epistemology has been somewhat discredited in the social sciences in ment years, just when, in fact, it has attained widespread acceptance in the field of library and information science (LIS). From the positivist perspective, information is believed to correspond to truc statements about an objective reality. Information, then, has its own objective status as that which captures, represents, and communicates the essence of this reality. Information is produced through the careful observational procedures of science - both natural and social - and "good" information is instructive as to the nature of the "real" world. It is the role of the information worker' to ensure the storage of, or otherwise provide access to, information appropriate to the established needs of a defined clientele, and to act as a neutral conduit for its transmission. Information is considered to be "good" information to the extent that it cmbe judged to be accurate - by scientific standards - objective, authoritative, and current. Conversely, information is "bad" if its claims are judged non-scientific, if it is judged to display bias, if the voice that produces it is not considered authoritative, and if it is thought to be "old." 1 take up these issues in more detail below in a discussion of the social relations of knowledge production in health. A positivist approach to information may be characterised as system-focused; that is an approach that is concemed with the acquisition, storage and retrieval of knowledge from an institutional perspective, in tems of quantifiable effectiveness. An alternative modcl that has arisen in LIS is one that focuses less on a system or institutional orientation and instead is centred upon what is temed the "ünomolous state of knowledge" (Belkin 1984) of those in need - regardless of whether or not the need is perceived - of information. This "user-centred" reonentation of research into the processes of information provision has ken called the cognitive model or perspective (Belkin 1984; 1990). Although positivism seems to remain the dominant epistemological approach to research in LIS, it has been suggested that "the user- centred approach is about to offer the traditional intermediary-centred approach a serious paradigrnatic alternative" (Savolainen 1993, 14). The theorist rnost closely associated with the user-centred approach is Brenda Dervin (Neill 1987; Suvolainen 1993; Cole 1994). It is therefore Dervin's particular form of the cognitive, or user- centred, model - her "sense-making model" (e.g. 1977, 1980, 1986) - that I will address in this section. Dervin has argued that the approach to information that she advocates provides not rnerely an alternative methodologicai approach to positivist research, but that it represents an "alternative paradigm" (Dervin & Nilan 1986, 16-24). The basis of this "paradigm shift" is the claim that the proposed characterization of information need and use is "communication-based rather than merely information-based" (Dervin 1977, 29). and that it rejects the central assumptions of the positivist approach "that information is something that: exists extemally. outside individual frames of reference; can potentially provide a complete description of reality: is rneasurable on single, quantitative, unirhnensionnl scales" (Dervin, Jacobson & Nilan 1982,420. emphasis in original). In other words, whilst conventional approaches to the provision of information are system oriented, either from the perspective of a single institution, or in an attempt to generüte universal and generalisable rules to govem the practice of information provision. the sense-making model challenges the idea that information can exist objectively. independently of the information user. As its narne implies, the central concept of the sense-making approach is that information only exists in the mind of the individu1 who throughout the course of her life is in a continual process of making sense of her or his erivironment and her or his own location in i t. According to Dervin, situational factors will always be of central importance in determining information needs, and not the attributes of the individual (demographic or otherwise) which do not change across space and time.

When it cornes to dealing with this individual as an individual, the attributes are but labels imposed on him [sic] by the outside world. And whether they are relevant or not. this person's attributes are not the reason he intersects with an information practitioner at a given time. His reasons would be situational - that is, he finds hirnself in a situation in which he feels an information practitioner would be useful. (Zweizig & Dervin 1977,150) The sense-making model emerges from a phenomenological or existentialist perspective, which argues that

Extemal reality can be posited as never complete, forever imperfect, always filled with gaps. In this context information seeking and use are seen as activities individuals participate in in order to make personal sense in the presence of incomplete instruction from reality. Since life is inherently unmanageable, individuals are forever encountering instances where they need to make sense, and where obtaining complete, exact pictures of reality is impossible. (Dervin, Jacobson & Nilan 1982,425) The sense-making model suggests a number of consequences for methodologies in information provision. Rather han concentrating on knowledge structures as subject systems from the perspective of the library, or collectivities of people grouped together on the basis of shared attributes - and hence shared information needs - the focus should be on the situated individual. Research should seek to identify moments in the life of the individual which the individual feels represented a gap in her cognitive map of her environment and her own location in it. Research should attempt to identify the successful ways in which such gaps were bridged, and use these to develop a set of predictors that infon information workers about likely information-seeking behaviour and patterns. The sense-making approach contains, 1 bclieve, the seeds of a radical refrarning of the field of information work based on its assertion that "social order comcs to be seen as a result of concrete, communicative interaction" (Savolainen 1993, 22). This reframing is consistent with a form of radical politics based on new ways of understanding knowledge production and multiple subject positions. 1 will have more to say on this in the final section of this chapter, and in the concluding chapter that follows it. For now, however, I want to look more closely at the short comings of the sense- making rnodel, as it is in its problernatic form that the rnodel is making inroads into LIS reseürch which will in turm impact upon consumer health information services." Dervin's emphasis is nominally on the sense-making individual, who is the putative subject of the user-centred approach to information. In f5ct however. the potential information user is at best a passive subject within the framework of a sytern in which the information provider's expertise remains key to the successful acquisition of appropriate information. It remains the role of the information provider, as the active subject in the process, to identify the information gaps in the world view of the the individual with, potentially unrealized, information needs, and to utilise expert knowledge of the world of information sources to fil1 those gaps (Frohmann 1992a, 142). Additiondl y, despite the theoretical comrnitment to the contingent, or the situational, in which the sense-making individual constmcts his own information according to a need that is specific in terms of both time and place. the search for abstractable and generalisable predictors of information need and use continues. Centrai to both the positivist and the sense-making approaches to information provision is a commitment to a pluralist perspective. The pluralist perspective represents North American society as a level playing field upon which rational. sense-making individuals are free to choose from a marketplace of ideas. It is zissumed that North American society represents a consensually attained democracy that is not in need of fundamental transformation. Discrimination and inequality are categorised as technical problems that it is within the capacity of the system to rectify through the enlightened work of rationiil actors: the democratic rnechanisms - intellectual freedom. parliûmentary representation. rule of law. and freedom of speech, for exarnple - that cün bnng about such intemal self-correction are alreridy in place. In Dervin's theory, the basic values of American culture are interestingly reflected: the central position of the individual actor. the importance of making things happen and moving forward, in spite of barriers faced. and relying on individual capacities in problem solving. (Savolainen 1993,26) The libenl ideology of library and information science mirrors this broader ideology of liberrilism and underlies the commitment of librarianship to the ideals of neutral, objective, and value-free professionalism. The emphasis on the free individual. self- fulfillment, self-improvement, and intellectual growth in the orientation of libraries in

North America is a legacy of this liberal ideofogical foundation. In short, if it is üssumed that existing social structures and processes are fundarnentaily as good as they can be, social problems are essentially reducible to lack of information. People may be said to be unhealthy, or to become il], because they lack the information that would enable them to manage their health more effectively.

This idealisation of contemporary North Arnerican society, dong with the reification of the goals of objectivity and neutrality dictates the sorts of questions that are likely to be posed by LIS research. This is most obviously tme of conventionally positivist research. but it is also a criticism that can be made of the sense-making model. What remains absent from such research are discussions of power, and how this shapes the social production of knowledge. More fundarnentally. perhaps, there is a failure to perceive the processes being researched, that is information production, information need. and information use, as social practices. Consequently, particularly from the posi tivist perspective, "the researc h agenda thus becomes nmow 1y confined to 'administrative problems' amenable to 'technical solutions"' (Harris 1986, 2 16). The individualist liberalism described above is perhaps most extreme in the sense-making approach to LIS research. Frohmann ( 1992; 1992~1 992b: 1993) identifies the sense-making approach as one which succeeds, through its radical 1y individualist strategies, in erasing the social: Since information transfer is conceived as an alteration of interna1 representations, rather than, for example, as a social practice, the cognitive viewpoint bars LIS theory from investigation of the social. political and economic forces which configure each pole of the inforrnation systern. (Frohmann f 992a. 143)

Despite its daims to the contrary, the sense-making model assumes that information needs can be met by information that exists objectively and that can be identified by information workers and LIS researchers. The determination of information need in this sense arnounts to an exercise in marketing; information workers have privileged and expert access to a product (information), and a constituency of consumers with gaps in their cognitive maps that will constitute a dernand for the product if information workers can identify the gap accurately.

Although it is risky to generalise, LIS as a field is probably now somewhere between positivism and cognitive constnictionism in its research and practice orientations. In other words, while it does not seem ready to relinquish the tenets of positivist social science, LIS does seem willing to incorponte elements of the user- centred approach in the sense that some individuals will have specific information needs and requirements. An extension of this user-centredness is the attempt to incorporate a sense of cultural relativity into the process of information provision by taking account of the specific infomation needs of cultural groups. LIS research using the sense-making mode1 has often been used specifically in this way to mess the information needs of, for example, abused women (Dewdney & Hams 199 l), lesbians (Creelman & Hams

1990;Whitt 1993). the working poor (Chatman 1989; 199 1 ). and the health information needs of African-American women (Gollop 1998). However, both user-centred constructivism and cultural relativity are incorporated into LIS epistemology in ways that seek to correct some of the dysfunctions of positivism rather than to rethink its basic assumptions. These basic assumptions, already outiined above. include the belief that there is a universal and objective reality. that "good" information is instructive as to the nature of this reality, that "good" information will be equally instructive to all, and that the rolc of the infomation worker is to provide neutral access to "good" information. User-centredness and cultural relativity in information provision are merely designed to overcome barriers to "good" and instructive information that may be experienced by certain individuals or cultural groups. There is no evidence in LIS theory or practice to suggest that there are any challenges to the idea of a single, universal, and objective reality and the assertion that "good" information is "accurate" infomation that is transparently isomorphous wi th that reality (Dervin 1994, 378-9). This comhination of the positivist and the cognitive constructivist. modified perhaps to take account of individual needs and different cultural groups in information theory echoes very closely the orientation of mainstream adult education theory, characterized in the opening section of chapter one above. The characteristics of adult learners turn out to parallel the characteristics of the sense-making individual; in fact "learning" and "information-seeking" become more or less synonyrnous. Adult learners and information-seekers each exercise autonomous self-direction in their learninglinfomation-seeking, and have acquired a bank of persona1 life experiences that can serve as a resource for learning/information-seeking. Learning/information-seeking is a life-long process, in which different (but identifiable and predictable) transitional stages act as catalysts to learning/infomation-seeking. Learning styles and information needs are heterogeneous and differ, according to contingencies, both between individuals and at different times in the life of a single individual. Despite such differences, in general adults leam what they do, and so prefer learning to be problem- centred, to be relevant to their life situations and to have obvious applications. In other words, adults prefer their education to be about the acquisition of information that is appropriate to their current situational information needs. Adult education theory then, is becoming leamer-centred, just a. user-centredness is making inroads into LIS theory. What is interesting here is that the shift away from positivism in both Adult Education and LIS theory displays strikingly similar characteristics. Both retain enough of their positivism that despite "progressive" embellishments, the central assumption of a single, universal reality about which the adult lems or is informed, remains. Both have shifted. at least partially, from a positivist system or institutional-orientation towards a focus on a cognitive rnodel of the needs of the individual. In both, the needs of the individual can be simultaneously specific and universal in the sense that situational needs will be particular according to contingencies of time and place. whilst, in general, all individuals displüy similar characteristics (they are self-directed, they leam what they do). Increasingly, both display a concern that the response to learning and information needs to be modified by an awareness of cultural relativity. As 1 have already suggested, this concem with cultural relativity is a concem with the issue of nccess to "good" information about the "real" world. The assumption is that different cultural groups experience barriers accessing this information, not that the very idea of the "real" world is itself culturally produced. 1 will return to some of these issues below when 1 discuss consumer health information itself in more detail. For now, however, 1 want to turn to the other genealogical tributary that flows into the discourse of consumer health information, the health consumer. This health consumer, we will see, turns out to share many of the characteristics of the adult lemer, and the sense-making individual.

The Genealogy Of Consumer Health Information II: The Rise Of The Consumer In Health Care The health consumer movement has emerged. particularly in North Arnerica, over the last three decades. In part it grew oui of a more general consumer movement started in the United States in the late 1960s by activists such as Ralph Nader, a movement which was itself bom of the antiauthoritarianism of the l960s, levels of education that were higher than ever before, and the unprecedented success of the US economy in the post- war period. The consumer movement was a reaction to the iiicreasing trend towards monopolization in the economy which generüted a scnse of an imbalance in the forces (supply and demand) upon which a successful free market economy depends. The consumer movement wu an attempt to assert the power of consumers in the face of the growing power of monopolies. The health field was by no means immune to ihe emergence of consurnerism: Consumerkm as a social movement arises when the power of the seller is consolidated in order to limit cornpetition, monopolize production. and contain buyer choices. In the dialectic of power relations, the increasing monopolization of medical knowledge and medical practice could only cal1 forth a countervailing force in the form of patient consumensm. (Haug & Lavin 1983, 16)

By the early 1970s the tenn "medical consumer" had already been coined to describe this newly active role played by patients in the relationship with their health care providers (Reeder 1972) and the concept had migrated north of the border into Canada

(Consumer Reports 1 974). It has also been argued that health consumerism emerged from the "new" social movements that appeared in the 1960s and early 1970s. In particular, "consurnerism in health was pioneered by the women's health movement" by groups such as Heaithsharing in Canada and the Boston Women's Health Book ColIective in the United States (Marshall & Taylor 1993, 8). These "new" social movements reflected a growing awareness and political activism on the part of a number of groups

histoncally and stnicturally excluded from social, economic and political power. As

medicine is an integral part of structural systems of power, it was inevitable that

movements such as feminism would pose challenges to it that displayed similarities to the broader consumer health movement. What, then, are the characteristic of health consumerism? Heal th consumerism challenges the conventional authority of medical practitioners by demanding more say for the informed consumer in her or his own health care. This is not a new expectation. Before the rise to dominance of scientific medicine in the late nineteenth and twentieth centuries, a much looser marketplace of medical ideas existed, and the field of medicine itself was much less rigorously credentiatised. In this context doctors were much more dependent upon the patronage of their patients. who in retum expected to be the dominant partner in the relationship (Jewson 1976, 234).' The consumer health niovement. then, reflects a resistance to the institutionalized expert authonty granted to individual practitioners of a state sanctioned dominant medical paradigm. Consumensm suggests an assertiveness on the pan of the patient-consumer that stands in sharp contrast to the conventionally passive role of the patient in the encounter wi th doctors that has characterized much of the twentieth century. It demands that a patient be treated as a person - "as an integrated psycho- sornatic totality" (Jewson 1976,233) - rather than being reduced to a conglomeration of symptoms or the embodiment of pathologies. The consumer movement argues for an informed consumer actively participating in his or her own care and in the relationship with his or her provider, "In simple tems, consumerism in medicine means challenging the physician's ability to make unilateral decisions - demanding a share in reaching closure on diagnosis and working out treatment plans" (Haug & Lavin 1983, 17). Health consumerism also advocates for greater consumer power in the larger

marketplace of health care providers. A patient, in other words, should be able to move bewteen providers if he or she feels that they are not receiving adequate treatment. Implicit in this "right" to choose is the ability to choose between practitioners of different hraling approaches. The rise of consumerism in health care has also Ied to something of a renaissance, since the 1960s, of cornplernentary and alternative medicine and practices (CAMPS). Although Western scientific medicine is the only state funded medicine in Canada, the avriilable evidence does seem to suggest that more and more Canadians are turning to CAMP practitioners, notwithstanding the prevailing ümbiguity surrounding professional status, training, and credentials (Angus ReidICTV 1998).

Before I conclude this section there is one further point to highlight. 1 have already discussed a form of health consumerism - in the discourse of social marketing - in the previous chüpter. In chapter three 1 simultaneously both deny that "healîh" itself cm be a commodi ty, and 1 assert that it is constructed as a commodity through the reification of health - producçd by labour upon the Self - in social marketing discourse. This reification. 1 argue, leads to health fetishization, or the separation of health as

product from the labour upon the Self that produces it. However. though it is comrnodifed, health never actually becomes a cotnniodi~.Health status - however it is defined - can be said to have rt use value, but it can never have an exchange value in and of itself. The present discussion however, is concemed with a different, though related. form of health consumerism that is centred upon a relationship much closer to the idea of commodity exchange. Although the "consumer" in health consumerism seeks to maximise his or her health status, she is only actually a consumer in the moments that s/he seeks or obtains goods or services that she believes will restore or enhance her or his health status. In particular, it has been in response to the transactions between doctor and patient in particular that health consumerism has emerged. I will return to this issue in greater depth in the following section, as the problematics of health consumerism are key to a critique of consumer health information.

Having established a lineage and a context for consumer hedth information, I want now to explore in more detail the ideoiogical effects of its discoune. I should emphasise again at this point that I am not claiming that it is a bad thing for people to find out about their health and the issues that affect it. On the contrary, it is only by becoming educated about the forces that impact upon their sense of physical, mental and emotional well-being, that people can make the decisions. ai the micro and the macro levels. that they believe to be most appropriate. 1 was cntical in the previous chapter of the ways in which the new public health is recreating the Victorian public health paradigm through both presenting the maintenance of good health as a moral mission, and the management of radical discourse by reframing al1 social problems as problems of henlth promotion. In this chapter 1 am concrmed with why CHI is so prominent in the last quarter of the twentieth century. Once again the main overlapping themes are the emergence ol new strategies of govemment for neo-liberalism and the need for hegemonic reconfiguration during the restructuring the post-interventionist state period. Other themes that emerge in what is left of this chapter are the relation of power to knowledge, the social relations of knowledge production, and the authonty of state- sanctioned expertise. Consumer Health Information: The Ideological Effect

Earlier in this chnpter 1 suggested that CHI librarians do not engage in critical debates about the nature of consumer health information, but tend instead to concentrate on procedural and technical issues. In other words, any critical discussion that does take place in the field is intemal to it; common assumptions, values, and concepts are not challenged. The issues that stimulate debate in the CHI literature can be grouped into two general categories. The first category addresses broad, overlapping issues of service provision such as client confidentiality, professionial liability, and accessibility to information. The second category is made up of discussions about the appropriate selection of information, and it is chancterised by concepts such as "accuracy," "reliability," "currency," and "authoritativeness." These concepts are, in turn, founded upon more basic assumptions that information should be "objective" and empirically valid. The present discussion is concemed with the latter category nther than the former, but 1 am less interested in contributing to the debate that takes place wi thin a CHI paradigm than 1 am in addressing some of i ts core assumptions and concepts from a more "external" perspective. In particular, in this section 1 want to address the concepts of "information" and "consumer" within CHI as concepts with identifiable ideological effects. These effects are related specifically to broader discourses of information that have already been outlined, and to the goveming and restructuring requirements of neo-liberdism.

There is an appeal at the heart of the discourse of consumer heaith information that is extremely visceral. This appeal is directly related to the evolution of scientific medicine that has resulted in the "alienation of the sick person", to use Jewson's tem, from the healing process. CHI promises to enable the individual to overcome this alienation by restoring her to a position of power in relation to her own health. What makes the consumer powerfùl? It is not simply the purchasing ability with which consumers are endowed. Although consumption can be witheld or redirected, as an activity it is little more th'm a symptom of a larger dynamic. Real power is said to derive frorn information. The assumed equation that underpins the discourse of consumer heal th information is information equals knowledge equals power: "consumers in the

medical arena are able :O challenge professional power when they acquire sufficient knowledge to encourage them to make choices between health care options" (Haug & Lavin 1983, 15). The infonned. therefore knowledgeable, consumer can achieve more than dominion over his own health. he can reshape the social relations of medicine (e.g.

Calvüno & Needham 1 996;Advisory Council on Health Infostructure 1 999). This perspective is derived irnmediatel y from the broüder discourses of information as a universal panaceü described earlier. The "expert" panel6 that made up the government's Advisory Council on Health Infostructure. for example, concludes in its final report. "Our vision is about how the health of individuals and communities can be improved by the power of information" (Advisory Council on Health Infostructure 1999. 1-3). Similar sentiments had been expressed earlier by Canada's Associate Deputy Minister of Health, who suggested thrt "perhaps the greatest long-term benefits

for the use of information technology will be in the way that it provides information so

that people cm make informed decisions on how to maintnin and improve their health"

(Nyrni.uk 1997, 6). In both government and professional literaiure, in other words, we can see an almost mystical faith in the capacity of an entity called "information" to improve not only the health of individual Canadians, but also to cure the ills undermining the health care system itself - "Making health information available to the public is an essential public good with enormous and positive implications for transforming Canada's health care system" (Advisory Council on Health Infostructure 1999,2-3). In statements such as these we cm see a parallel with Brenda Dervin's assertion that in the "information-democracy" narrative. "good information" leads to "good democracy", a parallel that announces that "good information" is critical for "good health." When heal th is reduced to an issue of accessibility to information, the responsible social ünswer to health problems is to insist on the provision of more information and to design efficient mechanisms for its dissemination. What we see here, in other words, is the liberal idea that al1 problems are ultimately amenable to technical and administrative solutions. However, if such solutions are to be effective, there cmbe no barriers to their universal application. Accordingly, we see concerns expressed that "good information" ought to be available to al1 citizens in a democrücy. In order for information to bc the solution that it is heralded as, there should be no information inequitics, and efforts need to be made to ensure that, should some citizens experience difficulties in accessing information. steps are taken to overcome them: It is paramount that there be universal, affordable, equitable access throughout Canadian society to the Canada Health Infoway ... Health Canada should also take a leadership role in ensuring that health information ... be accessible to al1 citizens, irrespective of their geographic location. inconme, language, disability, gender. age, cultural background or level of traditional or digital literûcy. (Advisory Council on Heralth Infostmcture l999,8) The necessity of universal access to health information from the perspective of neoliberat strategies of government will be argued in more detail below. Perhaps the apotheosis of the assertion of the role of information in health is the appearance of the term "information therapy" in the early 1990s (Lindner 1992). This term has been taken up subsequently and defined as "the therapeutic provision of information to people for the amelioration of physical and mental health and well- being" (Mitchell 1994,7 1). It is never explicitly ciear what the "therapeutic provision of information" actually entails, beyond the assertion that "the new Information Age with its information 'super highways', should provide consumers with endless access to massive amounts of health information" (Mitchell 1994,72). This fact alone, so familiar is the reader assumed to be with the "obvious" benefits of information, is deemed sufficient to convince the reader that "information" is "therapeutic." It seems clear, then, that consumer health information discoune is heavily invested in broader discourses regarding the power of information. As a largely unarticulated concept in such discourse, "information" is granted an almost metaphysical quality. However. 1 have already suggested that the way the concept of information is understood within a CHI paradigm emerges out of research and practice in the field of library and information science. Presumably therefore. CHI practitioners have a more specific idea of what they mean by "information" than the vagueness expressed in generally utopian assertions? In fact, there is remarkably little. if any discusion in the CHI literature regarding the nature of "infortnation." and certainly nothing to suggest that "information production" might be an epistemologically contentious terrain. The following characterization. by the Advisory Council on Health Infostructure. is representative of the components of which CHI is generally supposed to consist:

0 general health information, including health promotion information and information on healthy lifesty les and maintenance; health care infomation. including information on treatment options. drugs, and pharmaceutical products. and managing illnesses or heal th conditions...; informationon public health issues such as the quality of air, water and food; 0 accountability data or report cards on. for example' the performance of health care services and providers; 0 [information on] health policies..; data on the impacts of policies for areas othrr than health; and information on the effects of health determinants. ( 1999,2-3) This is a usefully descriptive checklist, but as a definition of consumer health information it rather begs the question of what informution actually is in relation to the individual's experience of health and his or her points of contact with health care services and practi tioners.

What we find when we look for more elaboration of the way that information is undentood within the CHI paradigm is that, as with LIS more generally, the field is epistemologically located between positivism and cognitive-consüuctivism. Although rarely announced explicitly, in CHI litenture "information." "information need" and

"information user" seem to be understood in terms very similar to those identified in the sense-making model. Consumer heaith infomation is almost invariably described in vague operational terms as "any information" that is useful to the individual's specific and contingent information needs. 1 have already quoted Patrick & Koss

( 1995, ), for example, who define CHI as "any information that enables individuals to understand their health and and make health-related decisions for themselves or their families." Mitchell, an advocate of the concept of "information therapy", defines CHI as "vimially any information dealing in any way with medicine, health, wellness or quality of life chat cm be informing, increase skills or improve the attitude of a penon" (Mitchell 1994.73). And the Advisory Council on Heal th Infostructure itself asserts that "information must be tailored to individual users of specific groups of users and to people's differing needs for information over time" (ACHI 1999.2-4), and that the Canada Health Infoway should "Empower the generül public by ... providing reliable health information useful to Canadians ris patients, informa1 caregivers and citizens" ( 1-

5). Underwriting this operational characterization of information and the "sense- making" perspective reflected within it is the assurnption that "good" - that is "reliable" and "accurate" - health information is a more or less transparent representation of a reai world that exists "out there." In order to be a "useful" and reliable representation of that reality, health information must be b'objective" and CHI workers "neutral" in their selection of it. This point is well illustrated by the perpetual vigilance within consumer health information pnciice regarding the distinction between education on the one hand, and information on the other. Whereas education is an implicitly subjective process, information is perceived to be reawringly objective and therefore relatively "safe"; that is to Say, libnrians believe that as long as al1 they do is provide access to information, they are legally protected from liability. This is not to say, however, that CHI workers would deny the existence of epistemological pluralism in health. On the contrary, the traditional comrnittment to intellectual freedom in libnrianship generally is reflected in the specific CHI committrnent to reflect the range of viewpoints contained within the "marketplace of ideas." As Brenda Dervin hris pointed out, this cornmitment to a marketplace of ideas in LIS is underwritten by the assumption rhat "when information is allowed to flow freely in a free marketplace, "truth", or "the best information" naturally surfaces" (1994, 369). In other words, whilsi the LIS paradigrn is capable of acknowledging that there may well be a pluralism in the world of ideas, this does not mean that al1 ideas are of equal value, or that al1 information is "good" information. The role of the CHI worker is to sort the wheat from the chaff, and to ensure that, while access to information in general should not be inhibiied, there are objective criteria for identifying "good" information. These criteria are invariably the criteria of science, which is deemed to be the only valid adjudicator of accuracy, reliabilty. and disinterested objectivity. Anything else, it seems, is to be suspected of dubious motives: Health Canada, in partnership with provincial and territorial ministries of health, should take the lead in ensuring the development of standards or guidelines to distinguish between objective, evidence-based health information and infonation intended to promote a product. (ACHI, I999,S-7) This conviction within CHI that science, with its evidence-based practices, is the means by which it is possible to distinguish "good" information is a central issue to which 1 will return. I earlier suggested that the sense-making "information-seeker" and the "adult leamer" are in fact different aspects of the sarne liberal cognitive subject. 1 claimed that the charactenstics of both are essentially the same and that the differences between them are differences of ernphasis dependiing upon whether one is talking about information provision, or education (a distinction librarians are keen to make). The same can be said of the "health consumer", who is also characterised as a rational, autonomous, self- motivated and self-sufficient. It is this chmacterisation of individual subjects that is at the core of neolibenl strategies of govemment. This therne was introduced in connection with "healthism" in the previous chapter. The idea of the informed consumer of health is a key mechanism of healthism; if wellness is transformed into a moral imperative. then we are al1 duty-bound to seek out the information that will enable us to achieve and maintain that status. Anything less is an abrogation of our persona1 responsibilities, particularly when the state is going to such lengths to make appropriate information available to al1 of its citizens. Consuinerist discourse, fueled by "health fetishism" - the reification of the abstract idea of health as an object - provides an efficient segue, notwithstanding any jack of intention, into a neoliberal agenda for the reform of health care in Canada. In particulûr, the Fraser Institute has published a series of books over the last twenty years (McArthur 1996: Hamowy 1984: Blomquist 1979) that provide a practical illustration of the discourse of Alford's "market reformers." These publications advocate for free markets as a panacea for the perceived ills in the health care system, and they argue that the way to reform the health care system is through empowering the heal th consumer. The empowered consumer assumes, as part of the deal, responsibility for iheir own health. Hamowy's meticulous history of the rise to dominance of the medical profession in Canada, for exampie, is subtitled "A Study in Restricted Entry", and it purports to reveal how medical authority in Canada became the exclusive preserve of practitioners of scientific medicine through the exclusion of other types of practitioner (that is removal of the consumer's right to choose). This process, according to

Hamowy, has as much to do with the desire to protect established physicians and to increase their incomes power and prestige as it does with the superior efficacy of their approach to healing. This is not a problematic assertion. However. the primary purpose of the study is to illustrate that this dominance serves to impede the supposed efficiencies of the free market. Market reformers argue against professional dominance from a free market perspective, the very same perspective that lies behind the current neoliberal agenda to privatize - economically and socially - health care. The efficacy of different approaches to achieving health - and the long term social benefits of health promotion. for example - is not a concern of market refomers who focus instead on consumer choice. supply and demand, and ultimately the privatization of health care insurance. The dominance of the "curative" mode1 in health care is simply an impediment to the free play of market forces from this neoliberal perspective.

Blomquist's ( 1979) publication for the Fraser Institute goes further in müking explicit tfie link between marketdriven ne-liberdism and a fetishized idea of health as a product produced by individual work on the Self. It provides an illustration of the intersection of neo-liberal discourse with that of health consurnerism. He argues that socialised health care in Canada has created a "moral hrizard" which deprives individuals of an incentive to stay healthy. Free markets, in which individuals are not shielded from bearing the costs of their own health care. would encourage a new breed of ethical citizen able and willing to bear an exclusive responsibility for their own health status. Part of what it means to be an ethical citizen is assuming the responsibility of becoming an informed consumer of health. This again assumes. as Dervin points out, that the value of "good information" is such that any rational person will seek it out. Convcrseiy. anyone who is perceived to fail to seek out health information is irrational. ignorant or their "real" needs, or morally lacking. There is no doubt that the newly ethical, informed consumer of health - or what Ferguson calls the "health active, health responsi ble consumer" (Ferguson 1992) - represents a new category of ci tizen-subjeci that was not possible within the shackles of dependency created by the interventionist state: The Information Age has established the legitimacy and importance of self- care... The old Industrial Age healthsare system is failing away before our eyes, and Information Age health care is graduatly taking its place. Consumers are taking much more responsibility for their health. (Ferguson 1992, 11) These sentiments are echoed by Mitchell who daims that "the aim of Information Therapy is to increase the knowledge of the general public and to create a sense of responsibility in patients for preserving and maintaining their own wellness" ( 1994, 72). The discourses of both the "consumer of health" and of the responsibly informed consumer are ideologically available for groups engineering the current corporate restructuring of health care in Canada. They are implicated through their suitability for incorporation into a neoliberal discourse of health care reform that is built around the idea of persona1 responsibility for health. Discourses of health consumerism. often expressed in the form of critiques of medical dominance and its narrowly biological focus, can serve to manage, in ways that are productive for the restructuring agendas of corporate liberalism, what Alford ( 1975: 19 1 ) refers to as "repressed structural interests" in health care.

Focussing reform of the health care system on the informed consumer has been characterised as "empowering the demand side" (Kronick 19%). This empowering of the dernand side essentially serves to lend legitirnacy to the withdrawal of the state from the regulation and the provision of health care. The new role for the state is simply as the guarantor of the sovereign rights of the consumer. In other words, the holy grail here is the complete privatisation of health care provision. What stands in the way of the realisation of this form of health care free-market is the lack of üppropriate information, or as Kenkel characterises it, the "informational asymmetry" between consumer and health care provider (1990,587); or as others put it more bluntly, "the main barrier to consumer sovereignty in hedth care is the asymmetry of information between 'buyers' and 'sellers"' (Shackley & Ryan 1 994,524). Ideally, "based on the perceived marginal product. the consumer decides the optimal quantity of care by comparing the marginal benefits of improved health to the marginal costs" (588). but in practice the consumer often lacks the information that dlows her to make this level of decision. This lack of information reinforces the consumer's dependency upon the health care provider. and maintains a barrier to the attainment of optimum efficiency of the health care system. As long as the health care provider has access to more information thrin the consumer, there is a danger that - particularly in a context in which doctors bill the state - consurners will be induced to consume health care services that they do not, in fact, require. By empowering the demand side, that is by regulating heül th care almost exclusive1y through informed consumers, the argument goes, much greater efficiency cm be achieved within the system because, it is assumed, "a patient with as rnuch information as the physician would never purchase treatments defined as induced demand" (Kenkel 1990, 588). Of course, this assumption is based on the premise that the consumer is paying for his own health care out of his own pocket. If the state funds health care services, there is no incentive for the consumer to exercise this level of judgement as slhe suffers no financial consequences. State intervention, we are to believe. fosters ri morally suspect dependency, whilst the rigours of the free market instill in the individual a sound and ethical capacity for rational judgement: A good consumer can be defined as someone who can adequately assimilate inforrnation on the costs and quality of health care, and on the buis of such information. has an ability and a desire to rnake health care choices and is then prepared to search for the best "package" of health care in terms of cost and quality. (ShackIey & Ryan 1994,5 18) What stands out in these market reforrnist arguments is that health care needs to be restructured to give primacy to the regulating function of the consumer in the context of a free market in which individuais bear the financial burden of their own choices. This might not be the sort of health care reform that many "progressives" who advocate for consumer empowerment in health care wish to see. The fact is that arguments for health care reform that privilege the sovereignty of the consumer risk relegating progressive interests - dernocratically controlled, publicly funded heaith care - in health care reform to an agenda of corporate restructuring. In short, the privileging of the consumer in heaith succeeds, ideologically, in sustaining both consent to the withdrawal of the state from previous levels of support for health care services. and also for broader strategies of neolikral govemment through the autonomous, rational, self- regulating subject in the "free" environment of market-dominated social space. It is true that these particular examples of consumer-centred market reformer arguments are taken from U.S.debates on health care reform. However, this does not mean that they have no relevance to the Canadian context. Canadians. in fac t. would do well to beware of the powerful interests that are lined up to exploit any opportunity of opening up cracks for private sector involvement in Canada's health care system, especially in the wake of the Frec Trade Agreement. U.S. insurance companies are poised to take advantage of my openings and are already lobbying through Cünadian proxies for reform that will serve their interests (Nelson 1995). However. if the consumerist discourses that underpin consumer health information are setting the ideological stage for the privatization of health care. the provision of such information is already being occupied by private business interests. This might well turn out to be the vanguard of much more extensive private involvement in Canadian health care that will develop a momentum that various levels of the Canadian state will find it difficult to resist. even assuming there is a will to do so. In May 1998, the Globe ctnd Mail riin an advertising supplement on behalf of a Company called MedAction Health Croup Lnc. MedAction daims to be "an independent Candian cornpany providing consumer health-care in formation and educütion through a wide range of products and services" (CI ,emphasis added). However, MedAction's services are already "successfully extended to some 35 million people in the United States... and are well developed there." This is clearly then a U.S. Company riding into the Canadian health care system on the back of consumer health information, presumably with aspirations that go much further. We should also notice that MedAction is not so concerned to maintain the distinction between education and information that public sector CHI workers have thus far been carefui to do. MedAction promotes its services using familiar rhetonc: "the problem with the

Canadian health care system is we can't necessarily afford it with today's demographics and technology and cost" (1998, C 1) and, "a system based on treating the sick must increasingly becorne one helping people to stay weli, to manage their own health successfully and reduce the incidence of illness" (ibid). Given that it appears quite legal for MedAction to provide health information, education, and even advice "on a subscription basis" (ibid), consumer health information seems to provide not only the ideological means for private interests to gain footholds in Canada's health care system, but the actual means by which they are able to do so. As 1 have suggested, the discourse of consumer health information is based upon the assumption that knowledge equals power. Much of its ideological effect in health care restructuring, and its role in ensuring the sovereignty of the rational, autonomous, self-managing subject is derived from this assurnption. Although there is a certain obviousness to this assertion, we are again dealing with an assumption that begs the important questions: knowledge about what? on whose terms? whose knowledge? how is it produced? according to what criteria? in whose interests? In other words, to what extent does powerprodice knowledge? In the field of health, in particuiar, we are dealing with a field that has a well established institutionalised expertise. Medical doctors, backed by a research structure that ties their place of practice to the academy, have long enjoyed the absolute authority to speak the "truth" about illness and health. They have controlled the conditions of knowledge production in the field. If consumer health information is to provide the means by which the power disequilibrium between doctors and consumers is overcome, then presumably it will have to break the monopoly that doctors have over the production of information in health. There is some evidence to suggest that this monopoly has been challenged in the last three decades. In particular, the rise of complementary and alternative medicine and practices, well publicised iatrogenic death and injury, the failure of scientific medicine to deal adequately with increasingly common chronic health disorders. the rise of AIDS and the retum of TB, the increased authority of allied health professionats, and increasing frustration with the inability of doctors of scientific medicine to deal with the individual "as an integrated psycho-somatic totality" has diminished the aura of omniscience doctors once possessed. Ironically however, the discourse of consumer health information does not ultimately contnbute to this challenge to scientific medicine's hegemony because, in the final analysis, it does not question the production of knowledge zq the preserve of its institutionalised expertise. Dervin describes how "good" information is produced in a context in which authontative knowledge is produced by experts: [Wlith expert power, the authorid voice must invoke procedures and structures which confer the right to speak based on expertise. With this tum, the definition of good in formation. .. must necessaril y reify not on1 y particular observers but particular modes of observing. (Dervin 1994,374) In the crise of health information, the "particular observers" are the researchers of medical science. The insistence within CHI that information should always be selected according to criteria of "accuracy," "authority," and "objectivity" has always, in practice, meant that the yardstick by which information was judged to be "good" was the judgement of science. The distinction between education and infonncztion. and the legal distancing of CHI workers from the information that they provide, encourages the viewpoint that "good" information about health is produced elsewhere by scientific experts employing "particular modes of observing." Since the early 1990s a new mechanisrn for the scientific determination of the "truth" about health and illness has emerged. It is my contention that this new mechanism. "evidence-based medicine", represents the reassertion by scientific medicine of its authority within the social relations of knowledge production about health. The epistemological paradigm into which CHI is locked, that views information as a transparent representation of the "real" world, established by objective scientific procedures, accepts uncritically the ternis of evidence-based knowledge production. In fact, the final reports of both the Advisory Council on Health Infostructure (1999) and the National Forum on Health

(1997). refiecting the general viewpoint of the CHI field, cal1 for consumers CObe provided w i th access to heal th information that is evidence-based. If evidence-based medicine really is the reaîsertion of the authority of doctors. then by accepting evidence- basedness as the defining characteristic of "good" information, consumer health information succeeds only in perpetuating the inequalities between consumer and provider. Rather than empowering consumers. CHI becomes more about ensuring cornpliance with scientific medicine's hegemony. In the remainder of this chapter. 1 will take a closer look at the consequences for the social relations of knowledge production in health of evidence-baed mcdicine.

CHI And The Social Relations Of Knowledge Production

As Jewson (1 976) argues, the exclusion and alienation of the "consumer" from health care and from his or her own experience of health and illness - what Jewson calls the "disappearance of the sick man" - cornes about primmily because "true" knowledge about health becomes lodged in the discourses of state-sanctioned institutions of expert authority. In other words, it is not so much a lack of uccess to knowledge thüt excludes the patient from the relationship, so much as a shift in the social relations of knowledge production whereby knowledge production itseif becomes the exclusive domain of expert authority . In a period when the terrain of knowledge production in health was more tluid and pluralistic, the patient was more powerhil. not because he or she necessarily had access to the myriad foms of knowledge about health - whether folk or professional - but because no single body of practitioners was endowed with the socially derived authority to speak the "truth" about healtfi and illness. in the previous chapter 1 introduced Aiford's framework for understanding structural interests in health care. This framework is particularly germane to a discussion of know ledge production in health. Alford ( 1975, 190-2 1 7) identifies three different structural interests in health care: "professional monopolists" namely physicians and the infrastmcture that supports them; "corporate rationalizers", a group consisting of "bureaucratic reformers" and "market reformers"; and "equal health advocates", those "who seek free, accessible, high-quality health care which equalizes the treatment available to the well-to-do and the poor" (19 1). These three groups represen t "dominün t," "c hallenging," and "repressed" structural i nterests respectively. Despite the fact that "repressed" structural interests in Canada have achieved victories inconceivable in he US, the differences between publicly and privately funded insurance systems do not fundamentally alter the terms of Alford's framework in the Canadian context. The Canadiiin health care sytem. for exarnple, has been stnictured üround the dominance of physicians whose private practice is publicly funded. And this system is increasingly challenged by the policies of corporate rationalizers, whilst in the post-interventionist state penod equal health advocates are once again marginalised, or incorporated into the discourse of health consumensm that favours the reforms of corporate rat ionalization. This three-cornered framework is crucial to an understanding of contemporary social relations of knowledge production in health and the position of CHI within them. If, as I have already suggested, health consumerism reconfigures repressed structural interests in health such that they are aligned with corporate rationalization, the challenge to the epistemological hegemony of physicians is even more intense. It has been suggested, in fact, that the corporate restructuring of health care is bringing about the "proletarianization" of physicians. In this context, evidence-based medicine can be seen specifically as a response to the challenges of both corporate rationalizers and health consumerism. By reframing repressed structural interests in terms of consumerism and evidence-based information, the discourse of consumer health information succeeds in binding those interests, in a subordinate position, to a debate centred upon the authority of physicians and corporate restnicturing rather than free, accessible, high-quality health cm. Before exploring the rise of evidence-based medicine as a reassertion of the hegemony of scientific medicine in health care, 1 will review briefly the threat to Canada's publicly funded health care system posed by private sector involvement in health information.

Health Information And The Private Sector In a previous section 1 have already noted the encroachment into Canada's health care system of a US Company that provides consumer health information that enables individuals to better manage their own health. In this section 1 have in mind health information of a somewhat different form that enables the management of the health care system itself. The accumulation of data regarding the health of individuüls and populations is crucial to the management of the health care system itself. The allocation of resources, and short- and long-term planning depend on the ability to determine what type and level of care is required, where it is required, and the most effective foms of delivery. Ln the context of a publicly funded health care system, one might assume that the vital importance of health information requires the public control of health information for effective policy development. The Advisory Council on Health Infostructure goes as far as to suggest that this son of information is a vital component of consumer health information as it provides the tools for public debate on health policy. However. as research by the Canadian Union of Public Employees (CUPE)has revealed, Behind the scenes, corporations are drumming up business and exploiting vaiuable information contained in patient records. Pharmaceutical manufacturers, biotechnology firms, service providers and other private companies profit by using health information to design targetted marketing strategies and to influence policy decisions which favour privatization and contracting-out. (CUPE 1998, 1) In fact, the field of health information management is becoming an increasingly privatised market environment in which the now privatised national health information system charges for al1 but the most generic health data. The data on which health care policy decisions will be made in Canada is king increasingly produced, collated, and distnbuted by private companies that are hired to manage public health databases or to provide the equipment and software with which they are rnanaged. The supposedly empowered consumer is excluded from the process. and most Canadians are probably unaware of the threat posed to the future of a publicly funded health care system by the privatization of knowledge production about macro level health issues. The increüsing role of the pnvate sector in the production and management of health system information demands more attention than 1 can devote to it here. It is a crucial element of the more generd trend towards market dominated environments in the post-interventionist state period. For the purposes of the present discussion it is this general trend toward corporate restructuring in health care that is most acute. It is in the context of demands for "empowering the demand side", whether they corne from corporate rationalizers or health consumerists, that I will review evidence-based medicine as a reassertion of the power of "the supply side."

The New Paradigm In Knowledge Production En Health: Evidence-Based Medicine Over the last five years evidence-based medicine (EBM)has been promoted in mainstream medical literature in Canada, the United States, and the UK as a new paradigrn in medicül education and practice. "Traditional", "unsystematic" and "intuitive" methods, based on individual clinical experience, are eschewed in favour of an approach which stresses the need for greater scientific rigour. This scientific rigour cm be achieved by methodically basing clinical decision making on examinations of evidence derived from the latest clinical research. Access to evidence as accumuIated data is considerably enhanced by the storage and retrieval capacity of sophisticated and evolving information technologies (Evidence Based Medicine Working Group 1992).

The term "evidence-based medicine" has a ring of obviousness to it which makes it difficult to argue against. Few doctors, one suspects, would be willing to assert that they do not attempt to base their clinical decision making on available evidence. However, the apparent obviousness of EBM does raise the question of why such a movement should emerge as it haî, and with the evangelism with which its proponents advocate its adoption.

In this section 1 argue that EBM cm be read as a discourse which is responding to specific contemporary challenges to established medical authority, a medical authonty that haî a specific cultural and political, rather than a neutral professional or scientific, history. Although the discourse of EBM appears to question the individual authority of medical doctors. it actually reinforces such authority by regulating the conditions under which a physician may speak iiuthoritatively about health and illness. Evidencr-basrd medicine recisserts the autltority of scientific medicine iri the social relations of knowledgr production in hdrh. As 1 have already suggested, contemporary challenges to mrdical authority are rooted primarily in the consumer movement in health care of which the demand for consumer health information is a manifestation. Health consumerism, as 1 have indicated, is closely associated with two other trends in Canadian health care that are calling into question the dominance and the authonty of medical doctors in health. On the one hand, the restnictunng of health care within the broader context of downsizing and deficit reduction reflects the efforts of "corporate rationalisers" and "market reformers" to reshape health care in Canada dong the lines of either a corporatized publicly-funded system, or even a privatized U.S.style system. Both the "corponte rationalisers" and the "market reformers" accompiish the management of "repressed structural interests" by incorporating and encouraging heaith consumerisrn. Whilst health consumerism challenges medical dominance,corpontization challenges medical autliority by threatening to bring about the "proletananization" of doctors. Another potentially revolutionary consequence of the consumer movement in health is the desire for a freer market in approaches to health and healing; in other words, greater access to information about and to the services of, complementary and alternative medicine and practices. The increa~edand increasing use of CAMPS by Canadians poses a significant threat to the dominance and authority of practitioners of scientific medicine, as it suggests that scientific rnedicine no longer has a monopoly over knowledge production in health.

EBM can be understood as an attempt, in light of these challenges, to both re- enforce and re-regulate the medical authonty of medical doctors in relation to patients, other health professions. and practitioners of complementary thenpies. Evidence-based medicine, as an academic medical discourse, is an attempt to reframe the conditions of knowledge production in health in ways that restore the primacy of scientific medicine. By managing the production of knowledge, scientific medicine is able to exert control, not over the flow of information to consumers, but over the conditions under which information may bc said to be authoritative. Similarly, by insisting that "valid" CAMP "tcchniques" must be proven to be valid under the terms of evidence-based criteria, and then incorporated into scientific medicine, scirntific medicine is also able to manage the relationship between CAMPS and the state in ways that serve its own interests. tt does so by on the one hand, insisting that whatever cannot be accredited by EBM criteria is rejected as quackery. and on the other, by reserving itself the right to colonise whatever EBM determines to be "sound" practice. The themes that 1 address in this section are those of 1) knowledge production and medical authority, 2) knowledge production and the demands of health consumerism and corporate restructuring, and 3) EBM and the successful alignrnent of scientific medicine with conternporary discourses of "information" and information technologies. The term "evidence-based medicine" was coined in the early 1990s at the Department of Clinical Epidemiology, McMaster University, subsequently the home of the Evidence-Based Medicine Working Group. Along with the Oxford based Centre for Evidence-Based Medicine, it has become a leading centre in the promotion of EBM'. The advocates of EBM have had to establish EBM itself as an authoritative discourse. The EBM movement, which has initiated a significant discussion about the ways in which medicine is taught and practiced, is very much represrnted as doctors talking to doctors about ways of improving medical practice (though calls for evidence- based practice are now being heard within othcr health care professions). In addition EBM is simultaneously extolled both as an emerging "new paradigm for medical practice" (Evidence-Büsed Medicine Working Group, 1992, 242 l), and as an approach to medicine "whose philosophical origins extend back to mid- 19th century Paris and earlier" (Sackett et al., 1 996, 7 1 ). This is a neat rhetorical pincer move which serves to funher establish EBM as an nuthoritative discourse prior to, and quite separate from, its internnl content. The representation of EBM as a revoiutionary paradigm in science is made with explicit reference to Kuhn (Evidence-Based Working Group 1992, 2420), while the hint at nineteenth century origins and the association with French philosophy establish historical credentials and an authoritative intellectual pedigree. Advocates of EBM characterize "traditional" medical education and practice as

Throughout the centuries, docton have taught and practiced rnedicine by authority, which comes in many guises: departmental chairs, division chiefs, senior residents, textbooks, Delphi panels, and visiting professors. This medical paradigm rests on the assumption that the authority in question has comprehensive scientific knowledge. (Grimes, 1995,451)

This traditional mode1 has at least two unfortunate consequences: it encourages the perpetuation of questionable medical practices, and it often obstructs the uptÿke and application of newly developed beneficial treatments. EBM, in contrast, "is the process of systematically finding, appraising, and using contemporaneous research findings as the basis for clinical decisions" (Rosenberg & Donald, 1995, 1 122). This process involves the following steps: the formulation of a clinical question, a search of the litemture for relevant clinical aiticles. an evaluation of the appropriateness of the evidence thus gathered. and the application of useful findings. Of course, some foms of evidence are considered more appropriate than others and the most highly prized is evidence derived from randornized, controlled clinical trials. Awareness that practicing professionals have limited time to appnise an ever enlarging volume of published clinical triai evidence (even though the "experienced practitioner can lem to appraise critically most articles in undrr ten minutes" (Rosenberg & Donald, 1995, 1 124)) has led to the promotion of the use of "meta-analyses" (or overviews) of clinical trials

(Sackett & Rosenberg, 1995,623). or even more efficiently, the distillation of appropriate evidence in to "cri tical pathways" or "practice guidel ines" whic h map out standardized. sequenced patient management plans (Ringel & Hughes, 1996,868). Meta-analyses and practice guidelines still need to be evaluated, but the filtering process that produces them makes the volume of evidence more manageable for the EBM practitioner.

It is not my intention to argue the ments. or otherwise, of EBM over the "traditional" model.' Nor do 1 wünt to suggest that EBM has üchieved unchallengrd dominion in medical discourse, though its star does appear to be ascendant. There are enough dissenting voices in mainstrearn medical literature (Blair 1997; Grimley Evans 1995; Schuchman 1996; Carr-Hill 1995; Hope 1995)' to confirm that EBM does not yet occupy a position of absolute dominance. My aim in what follows is to examine the discourse of EBM in order to illustrate the ways in which it is renegotiating the terms of medical authority. By seeking to reinforce a regime of regulation over the production of medical knowledge and the practice of individual doctors, EBM can be seen as a means of buttressing medical authority in general and of managing challenges to it. Medical Authority And Autonomous Practice

Marc Berg ( 1995) has demonstrated the tensions in North American rnedical discourse since 1945 between the stated sanctity of the autonomy individual medical practice and the expressed need for decision-support techniques that ensure that such practice is regulated. Decision-support techniques in medicine are invariably derived from science, and the origins of the tension descnbed by Berg, I would suggest, can be traced to the historical rise of scientific medicine. Medical practitioners as individuals were authorized to make medical interventions bejbre their practice firmly established its association with science. Subsequently, in order for science to further consolidate the authority of doctors. their autonornous practice had to submit to its rules. There is a tension at the heart of the medical profession then between the authority of the individual practitioner, and the authority of its dominant scientific discourse. Berg categorizes the post- 1945 intra-professional debate, which attempts to negotiate the tension between the autonornous medical subject and the regulatory requirements of science, as developing in four stages. This is not to suggest that one stage replaces the previous stage cornpletely, nor that elements of the four stages do not continue to co- exist.

In the first stage medical practice is defined as an art which involves the autonomous practitioner applying scientific medical knowledge - determining what is appropriate for each case on the basis of their education, experience, intuition, and consultation with colleagues and authoritative reference sources. Problems with medical decision-making in this stage are considered to be largely beyond the control of the individual doctor, who is simply doing his or her best with the means at his or her disposal. In the second stage, medical practice is still understood as an art in that the individual practitioner is at Iiberty to choose appropriate courses of action based on their own criteria. However, problems in decision-making are now seen to arise from poor communication of scientific research findings to doctors. The third stage, accordingly, reframes the practice of medicine itself as a scie~rtificactivity which requires "more standardized terminology and procedures" (Berg 1995,450). The fourth stage locates the individual physician within this standardized scientific context. From this perspective the role of the practitioner includes the application of standardized terrninology and practices in specific circumstances. It is at this point of the particular application of the general standard that a fom of surveillance becomes necessary to ensure that ph ysiciüns' practices adhere to established noms and procedures. The fallibility of individual doctors "is increasingly seen as the primary source of medical practice's problems" (Berg 1995,465) and leads to the development of a range of decision-support tcchniques. These tensions between institutional regulation and the autonomy of the individual practitioner emphasize the contingent nature of medical authority and medical identity. The professional and social identity of the medical practitioner is in large put dependent upon the exercise of individual medical authority. However, this very medical authority is derived from the broader regulating function of science as a socially dominant discourse. In other words, the practice of individual physicians is considered

üuthoritative insofar as it is demonstrably, or a leut perceptibly, informed by the findings of scientific research - that is, to the extent that it applies, in specific circumstances. the standardized procedures that constitute proper medical practice. Consequently. an emphasis on individual autonomy in medical practice cm potentially undermine the scientific justifications on which medical authority is built by suggesting that standardized procedures cm be of secondary importance to the clinical experience and intuition of individual physicians. Conversely, an insistence on the regulating function of science over practitioners places limits upon and therefore compromises the exercise of individual authority - an essential component of professional and social medical identity. I am arguing that, in the face of yet broader social challenges to medical authority, EBM can be situated as an attempt to negotiate these tensions. Although the debate just outlined is never explicitly acknowledged in EBM literature, EBM can be understood as an attempt to resolve it. Although advocates of EBM place enonnous emphasis on evidence denved from clinical trials and meta- analyses, and argue that such evidence should form the basis for practice, they do not acknowledge that this is at al1 a threat to the autonomy of the individual practitioner. Rather, "the practice of evidence-based medicine means integrating individual clinical expertise with the best available extemal clinical evidence" (Sackett et al 1996,7 1 ) because "good doctors use both individual clinical expertise and the best available extemal evidence. and neither alone is enough. Without clinical expertise, practice risks becoming tyrannized by evidence... Without current best evidence, practice risks becoming rapidly out of date" (Sackett et al 1996,72). For Naylor, "the prudent application of evaluative sciences will affirm rather than obviate the need for the art of medicine. Clinical reasoning, with its reliance on experience, analogy, and extrapolation, must be applied to traverse the grey zones of practice" (Naylor 1995, 84 1 ). There are three things to note here. First. although EBM "puts a much lower value on authority" (Evidence-Based Medicine Working Group 1992,242 1 ) the authority in question here is of a very specific sort: the authority of experts of questionable scientific rigour. What is specifically not being devalued is the authonty of medicine itself in relation to the rest of Society: the power of scientific medicine, and of the medical practitioner in this context are not problematized. Second, rather than being diminished by it, the autonomous authority of the individual practitioner appears to be reinforced through a re-emphasis of the regulating and standardizing role of science. The methodologies of western science are not only left unquestioned, they are reified in the randomized controlled trial which represents their epitome. At no point in EBM literature are questions asked regarding who, in an era of immense cutbacks in spending on health care, might be financing and canying out research, and with what ends in mind. Questions are not asked about the role of the plimaceutical industry in funding medical research, and the vested interests it might have in supporting certain avenues of medical research over others. In fact, no consideration whatsoever is given to who sets the research agenda, and thus who determines what areas are well addressed and which receive scant. if any. attention. Science itself is not understood as situated or contingent knowledge: rather it can be distorted from its ideal of objectivity by bias. which the scientist mut guard against. Third, despite the rhetoric to the contrary in

EBM literature. the individual practitioner's decision-making autonomy seems to be reduced to deciding whether or not evidence is biased on the bais of pre-deterrnined principles. This might seem to be a good deal of autonomy, but we should remember that not only do meta-analyses and practice guidelines screen the evidence that rnakes its way to individual doctors. but a new breed of EBM joumals involve "sound ...articles reviewed by a panel of front line physicians who select a further subset that are both vciiid and of cirrreilt cliniccal intportcznce. This two-stage selection process reduces the ciirricczl literriauc bv 98 percent. presenting busy clinicians with an easily digestible

summary (average reading tirne is about 30 minutes) every 8 weeks" (Centre for Evidence Based Medicine 1996, emphasis added). Clearly, in the EBM universe there is not a great deal of space for ambiguity, contingency. social context, or qualifying discussion. Although the EBM literiture appeals to the sünctity of doctors' decision- making autonomy, in practice this ciittonorny is likely to becorne the price paid for reinforced acithorip. The authority of the (fallible) individual physician is bolstered through the reassertion of science as a regulating regime. Although EBM appears to assert the opposite. the dernands of evidence-based practice irnply that the idea of medicine as an art be sacrificed. Theoretically, of course, individual physicians adopting evidence-based practice are not bound to simply apply the findings of research, but rather to make inforrned clinical decisions based on the best available evidence. Moreover, in reality the actual and contingent circumstances of a doctor's encounters with her or his patients will determine the extent to which practice mirrors the ideal models of standardized guidelines. But equally . few physicians, one imagines, would be likel y to eschew broadly accepted standardized procedures and prüctices in favour of their own clinical intuition. Individual physicians do not work in socially isolated circumstances. but rather within contexts of patient refemls and the need to maintain access to hospital privileges, in which professional reputation and cornpetence are judged by colleagues and professional associations. Increasingly this is an environment in which physicians are expected to base their decisions on evidence (Davidoff, Case & Fned 1995,727;

Bordley, Fagan & Thiege 1997.43 1 ). The impetus to base practice on the distilled recommendations of the EBM formula is likely to become more acute as the concept of evidence-based practice becomes more pervasive and as more evidence is condensed into profcssionally authorized. and "user-friendly". practice guidelines and position statements. It is also possible that EBM will become relevant to issues of liability to the extent that adherence to the recommendations of the EBM literature will be considered the avenue of lerist personal risk for physicians.

Evidence-Based Medicine, Knowledge, And Structural Interests In Health Care Restructuring - the agenda of the corporate rationalisers - has become endernic in health care in Canada. Perhaps most significant consequence of this process for doctors is the extensive programme of hospital closures, premised on a new conviction that hospitals are not the most efficient way of providing health care (Globe & Mail 1997). a conviction which not only weakens one pillar of the Canadian clinic, but also threatens the livelihood of doctors themselves (Coutts 1997; Daly 1997). Canadian health care is dominated by the corporate rationalisers' demands for downsizing and cost-cutting, as well as being increasingly chancterized by the imposition of a regime of continuous quality improvement in which heaith care workers are driven to strive for excellence amidst dwindling resources. Armstrong and Armstrong ( 1996, 1 68), suggest that doctors may liccount for up to eighty per cent of health care spending in Canada, adding that this is at least partially responsible, on the part of corporate rationalisen. for attempts to trans fer duties to cheaper practi tioners, such as midwives and nurse practitioners, üttempts to cap doctors fees, and efforts to limit the number of doctors.

The accusation of costliness is one to which doctors are vulnerable, and it poses a threat to their professional autonomy. Managed care, in which health care is dominated by business interests with the overriding objective of reducing costs. threatens to relegate doctors to a "proletarianised" capacity. It is not surprising, therefore, to find emphases upon cost-effectiveness and quality assurance and how they cmbe achieved through evidence-based practice, as a key selling-point in EBM literature. Chessare, arguing that EBM is "the rnissing variable in the quality improvement equation" (Chessare 1996, 289), suggests that this is enough for EBM to become a staple of medical education, which will then create "the doctor who can improve health with the fewest possibte resources" (Chesscire 1996, 29 1). The argument for EBM as a cost-efficiency promoter seems to rest upon the fact that the application of EBM in practice can reduce unnecessary testing and screening, length of stay in health facilities, and medical interventions (Ringel & Hughes 1996,868). Ringel & Hughes suggest that, "since society is approaching a limit in the resources availabte for medical care, we al1 have a responsibility to mate mechanisms that control health care spending" (868). They find that EBM "has helped us to more critically appraise the medical literature to establish the appropriateness of our actions: identify ways to reduce variations in care and unnecessary services" (Ringel & Hughes, 867). Canada's National Forum on Health reminds us, We know that spending more money on health care does not necessarily lead to better health. The quest to balance budgets and reduce indebtedness at al1 levels of govemment has accelerated the speed of change in the health sector. Accordingly, with fiscal pressures on our health care budget. we must use best evidence to help us allocate finite resources to improve heaith care services and health status. This is fundamental to improving eficiency and effectiveness. (National Fonrm on Health 1997,9) There is an ovemding requirement then in the production of knowledge in health that it conform to the imperatives of cost-cutting in the context of downsizing neo-libenlism. Although EBM claims to be no more than the rigorous application of "objective" science, it tums out, in fact, to represent doctors as efficient business managers of health care. EBM positions doctors as being not oiily the authorities competent to intervene in health, but also as those qualified to decide what is affordable, and consequently what, though theoreticall y availüble and possibl y efficacious, is not worth the expense. These are dangerous decision-making powers to leave to an elite which is currently scrambling to represent its hold on power as disinterested.I0 The hegemony of scientific medicine, as 1 have already suggested. has also ken challenged by health consumerism in the last quarter of a century. In an age in which there seem to be few certain signs of advance in the treatment of cancers, arthritis, and AIDS. in which tiiberculosis in epidemic proportions is retuming to North America, in which antibiotics are losing their potency, and in which iatrogenic suffering and inappropriate medicating ore coming under intensifying scrutiny, there is increasing incredulity. it seems, towards scientific medicine as a dominant discourse. This growing disenchantment with the medical-phmaceutical complex is reflected. as I have argued in this chapter, in growing consumer movement demanding more responsive and holistic approaches to health care, and the increasing popularity of complementary therapies

(Eisenberg et al 1993; Angus Reid/CTV 1998). The consumer movement and advocates of alternative medicine both point up the contingent and situated nature of medical epistemology, questioning its claims to universality, and highlighting its alignment with power. Perhaps the greatest threat to medical authority is posed by those whose practices and epistemologies seem to provide aitematives to scientific rnodels of medical practice. Complementary or so-called "alternative" therapies suggest the possibility that scientific medicine is simply one of a range of options rather than a universal and neutral epistemology. Those who avail themselves of the services of such practitioners are apparently satisfied to base their health care choices on criteria other than definitive scientific "proof" of "universal" efficacy. To a lesser extent, nicdical authority is increasingly challenged by practitioners of other health disciplines whose expertise has traditionally been subject to the authonty of medical doctors. These practitioners, through professional licensing and organization into colleges and associations. not to mention the day-to-day experience of their practice by patients and clients. have also acquired a status which incrementally erodes the exclusive authority of doctors. The discourse of EBM appears to be open to other disciplines and other models of health care. while it in fact seeks to regulate them. It is difficult to find references to complementary therapies in the EBM literature, but the second objective of the Centre for Evidence-Based Medicine extends the principles, strategies, and tactics of evidence-based decision-making to other health professions (e.g., physiothenpy. dentistry, nursing, etc.). to public health practitioners. to health planners and purchasers. to health policy makers, to health administrators. (Centre for Evidence-Based Medicine 1996)

While this müy appear innocent enough. it represents an irnpenal move which rests on the assumption. real enough in practice, that doctors to a large extent control the conditions of communication (what it is, and what it is not, possible to say) about heatth care issues. Noticèably absent from the definition of evidence-based health care are practitioners of complementiuy therapies. However, we can read in the EBM literature a response to this threat in which practitioners of scientific medicine maneuver to manage the terms on which "non-scientific" therapists practice (and to iimit the extent to which scientific physicians themselves are able to explore alternative approaches). In the classic liberal sense. "alternative" practitioners are free to practice. and their practice will be considered the equal of "onhodox" western medicine in so far as the methods and knowledge of "alternative" therapists can be validated by the standards of evidence-based medicine. It is assumed that the evaluative standards of EBM are transparent, neutrd. objective. and universal.' l Who, after dl, can argue with expertise based on "evidence"? EBM can, in short, be read as a response to the consumer movement that attempts to manage it through an accommodation which does not threaten, but reinforces, the prevailing conditions of communication in medicine. The success of the advocates of EBM in promoting evidence-based health care in Canada is demonstrated by the report of the federal government's National Forum on Health (NFH).One of the papers that comprise the report calls for a wholesale committment to evidence-based decision-making in the Canadian health care system, "if Canada's premier social program is to be preserved" (Narional Fonon on Healtli 1997,25).

Evidence-Based Medicine And The "Cult Of Information" The rise to medical dominance of scientific medicine in the nineteenth and twentieth centuries wx5 intimatel y bound to the discourse of science. As a dominant discourse of the time, science was adopted by medical doctors for the authority it conveyed. Similarly, EBM succeeds in binding doctors to the current prestige of dominant discourses of information and information technologies. These discourses, it has already been argued, form an essential backdrop to the emergencr of consumer health information as a movement in the final quarter of the twentieth century. The authoritative voice of medical science needs, in order to maintah that very expert authority, to situate itself within those same dominant discourses. It would be difficult to envisage how a discourse which seeks to refnme medicai authority in late twentieth century capitalist economies could do so successfully without incorporating discourses about the range of potentialities offered by "inforrnation" and its attendant technologies. Thus, the EBM group at McMaster University has led to the formation of the Health information Research Unit "dedicated to developing new information resources to support evidence-based healthcare" (Haynes et al 1996,4 1). In fac t, information and information technologies are implicitly at the very heart of EBM. EBM is an edifice built upon a foundation of technologies that allow for the electronic organization. storage and retrieval of data. In an era preceding the development of these technologies - and before the ideological extolling of the importance of "information" which has become one of the defining features of Our own era - searching for the evidence necessary to practice evidence-based medicine would have ken impractical, even if it was possible. Now, however, "recent developments in the summarization, organization, dissemination, and application of high quality information, based on sound evidence, show promise in overcoming some of these problems and making healthcare more efficient and effective" (Hüynes et al l996,4 1). The National Forum on Health concurs, claiming that. "as health information systems advance, more accessible, complex and comprehensive data provide impressive opportunities to improve decision making" (1997.9). Furthemore. "many studies of health refonn in Canada have stated that this would not be possible without the effective use of information technology" (NFH 1997,9). A new form of medical authority, at the cusp of the new millennium, enthusiastically displays its technological credentials.

The literriture which advocates for evidence-based medicine can be read for the ways in which it repositions medical authority for the realities of the "new economy", and also for the ways in which it seeks to manage both the demands of health consumensm and the epistemological threat posed by complementary and alternative medicine and practices. It seeks to do al1 of this by reassening the dominance and the authority of scientific rnedicine in the social relations of medicine. In particular, the discourse of EBM represents a strategic move to reframe what it is possible to say about health. That is to Say, its effect is to restore the authoritative voice of scientific medicine in the production of knowledge about health. The discourse of EBM exposes the simplistic assumptions of the knowledge equals power equation by demonstrating how power actually determines the grounds on which it is possible to make knowledge claims.

Conclusion John Gaventa suggests the following questions as the ones we should be asking of the know ledge society : In the conflicts in the knowledge society, who wins, who loses, and why? What are the implications of the changing economic and social order on the relatively powerless'? Whose knowledge is growing and for whose benefit? Who are the have-nots in the knowledge society, and how do they organise against the new elements of oppression the knowledge society brings? (Gaventa 1993,23) These are crucial questions to ask in relation to the generation and dissemination of health information that is supposedly ernpowering health consumers. In view of populür assumptions about the value of "information" for health, the concept of "information" needs c loser anal ysis. Behind the apparent1y transparent and uncomplicated value of health information lies a much more contested sphere in which the putatively newly active health consumer remains a largely passive participant.

l CHI services are also often staffed by patient educators or health promoters with clinical backgrounds. In these cases the service might be more of a patient education centre than a consumer health information service. The issue of whether or not CHI services should be staffed by professionally trained information specialists rather than clinically trained educator is an unresolved tension, as 1 explain shortly. ' 1do not mean to suggest that there are no access issues in terms of information technologies. 1 suspect that there are still more people in the world who have not used a telephone than there are people who use the intemet. Nevertheless, there are few countries where the internet is yet to make an appearance and the number of people with access to it is ballooning every day. 1 think that focusing on the issue of wider access in some ways begs the central and more important issues of access to what?, on whose terms?, for what purposes?, and to whose benefit? ' My use of the term "information worker" is simply a persona1 choice. There seem to be an increasing number of names for the role that was once called "librarian." ' Dervin haî in fact already noted the shortcomings of her earlier formulations in more recent publications (Dervin 1994) and she has produced suggestions for elaboration of that work thcit will broaden its scope significantly dong the lines 1 am alluding to here. Unfortunately, the few LIS researchcrs who have taken up her work are still a long way from her current concerns with the interface between the social and personal construction and use of knowledge and the problematization of the concept of "information." ' 1 am not suggesting that there was universal access to a glut of trained medical practitioners from which any person seeking the attentions of a doctor was free to choose. This was a period in which most people - particularly the poor - would have relied upon established self-care remedies or the services of a folk healer from within their own community. Medical doctors would have been seeking the patronage of weal thy patients. n Interestingly, this panel of experts contained not a single health librarian. ' The Centre for Evidence-Based Medicine in Oxford was established by David L. Sackett who became an acknowledged EBM specialist whilst based at McMaster University in Hamil ton, Ontario. X 1 am prepared to concede. in fact. that EBM can lead to "better" practice within the prevailing social organization of medicine. However, 1 am not so much concemed with the issue of whether or not EBM is a "good" or "bad" development as with the effects that are consequent to it. An analysis of negative social effects does not preclude the possi bility of positive ones. For example, an argument that is critical of the consequences of the automobile for urban development and environmental pollution does not require that the increased cornfort, efficiency, and convenience of the automobile over other forms of transport be denied. The point is that EBM Ieaves unchallenged, and can serve to reinforce, the existing social relations of medicine in which health cüre is dominated by a professional dite. 9 In addition to these responses there have also been extensive and sometimes heated discussions in the letters pages of The Lancer (see for example February 22 1997 issue) and the British Medical Journal (see July 1996 issues).

'O ~herelationship between EBM and managed care, which 1 do not explore here, is an area that requires examination.

I I 1 do not attempt to rehearse here the extensive discussions regarding the social, cultural, epistemological, and political dimensions of science found in the literature of disciplines such as cultural studies. epistemology, philosophy of science, history of science, and sociology of science. Donna Haraway ( 199 1 ) supplies the term "situated knowledge" to reflect the social context and social construction of scientific knowledge. For other examples of discussions of the social nature of scientific knowledge production see Harding ( 1986; 199 l), Harding & Hintikka ( l983), Lyotard ( l984), Foucault ( 1980; 1994), Rouse ( l987), Lowy ( 1988). CONCLUSION

In the introduction to this work, the question was posed as to where, if anywhere, we should situate health promotion in relation to the methods and practices of governing individuals and populations. To retum to Dorothy Smith's question, how is health promotion "constituted as [a] discrete phenomen[on] in the contexts of mling" (Smith 1990. 15). What has remained at the core of this study then has been a concem to explore the relationship between the practices and discourse of public health - and in particular those stntegies broadly falling within what is now called "health promotion" - and the sustainability and reproduction of hegemonic govemment in Canada. In other words, how might we characterise the relationship of public health to the state, to ideological production, and indced to the capitalist mode of production? My answer to this collection of questions is, in short, to assert that public heal th does indeed have an identifiable role in the reproduction of hegemony, that it is implicated in the ideological sustainability of the capitalist mode of production, and that it cm be located among an array of strategies that enable the state to "govem at a distance."

Public Health And Hegemony If this aiiswer can be sustained it will hopefully provide the bais for critical debate in the field of health promotion that is attentive to the capacity for challenging discourse to becorne absorbed, managed, and employed in processes that reproduce the very structures and relations of which the discourse itseif originally arises as a critique. If this rinswer is to be substantiated, however, there is a need for a theoretical framework that can provide insight into the ways in which power and political dominance are established and reproduced, and the role - regardless oj'what tlwir espoused intentions might be - played in such processes by institutionalised expertise. As we have seen, one possible theoretical framework for addressing these issues is cultural materialism. This theoretical approach allows us, from the very outset. to challenge the assumptions of much educational and health promotion theory that assumes the psychologised individual as the focus of theoretical enquiry. It does so by insisting that we incorporate into Our framework the dialectical nature of the

relationship between the individual subject and the social world, and between the cultural and the material. Furthemiore. these dialectics must be explored in terms of an always ongoing history, of which the present is simply a transitory synchronic slice. Cultural materialism builds upon the earlier work of Gramsci and in particular his insistence upon the role of culture as a constitutive social process. With this insistence Gramsci seeks to redress the violence done by Marxist theory that wrenched the cultural and the material apart and made the former a mere epiphenomenon of the latter. Whereas Marx's rejection of idealist history opened the way for a theory that

insistcd on the material - that is to say the productive - nature of culture, Marx instead

reduced the cultural realm (the realm of ideas, beliefs, customs, and arts) to a secondary status. First cornes the material, then the cultural which is entirely detemined by it; the base and its superstructure. The base and superstructure analogy reflects Marx's failure to carry through the logic of his own work on the nature of human consciousness and

ideology. As we have seen, Marx insists that hurnan consciousness is socialIy produced, and that this consciousness is ideological in that it does not amount to an accurate reflection of the "real" world. In fact, consciousness is ideological for Marx in

that it disguises the true nature of material relations. Leaving aside the issue of "false consciousness" it seems clear that Marx is edging toward the suggestion that ideology is itself material in that (social) consciousness determines behaviour. If the materid world conditions consciousness. and it does so socially and ideologically. then human beings act in matenal ways on the basis of their ideological conditioning. This material activity in turn affects the nature of the world, which in turn produce changes in consciousness. This dialectic is incessant. It is the insight that the cultural and material realms have to be analysed as an interdependent totality that is especially useful for examinations of the cultural production of a field such as public health. Hegemony theory, as we have seen, is built on an understanding of this relationship. Through hegemony theory we see that political dominance is dependeni on the constitutive effects of ideology in the spheres of civil society. The effects of ideology amount to a generalised consent to prevailing social structures. relations, and processes. As we have seen though, consent is never total, and always contingent. Hegemony is thus a shifting and transient, set of social relations, not a fixed entity. Hegemony is in constant need of renewal and reproduction, and to achieve this dominant social groups are forced, within certain limits. to accommodate the demands and desires of subordinate social groups, to form alliances, and to successfully represent themselves as legitimate moral and political leaders. Amidst the broader ideological production within the heterogeneous spheres of civil society, a vital component of hegemonic sustainability are the discourses of authoritative experts. It is these discounes, as we have seen, that provide one mechanisrn by which potential critiques of the existing social and political order can be

CO-optedinto the service of hegemony rather than challenging it. Commencing an analysis from such a theoretical perspective allows us to gain insights into the role of public health, as an institutionalised and authoritative discourse, in the ideological sustainability of hegemony. It is possible to see that public health practice and discourse are actually forms of cultural production that have constitutive social effects that are not politically neutral. What is more, hegemony theory can demonstrate the ways in which politically chailenging ideas cm be managed in such a way that they ultimately end up in the service of the social relations that they initially challenged. Cultural materialism also demands that we incorporate an historical perspective into any analysis. It is on this bais, then, that 1 commence my examination of public health as a form of politicdly implicated cultural production with a chapter that examines the period 1 880-1 920. First wave public health. as we have seen. arose in response to the growing urban populations of Canada's industrial cities in the 1stthird of the nineteenth century. Public hed th during this period, in addition to representing a response to evident crises in the health of urban cornmunities. was one part of a wider social reform movement, aimed at achieving improvements in moral as well as physical hygiene. In particular, first wave public health in Canada at this time was at the forefront of the new sanitary rnovement that had crossed the Atlantic having ernerged in Britain earlier in the century.

The sanitüry movement, in Canada just as it had been in Britain. was a response to the massive social transformations wrought by industrialisation, in particulür the npid growth of urban populations. The huge increases in urban populations led io massive overcrowding in cramped slum dwellings which were il1 provided with the basic necessities for sanitary living: fresh water supplies, refuse collection. adequate sewerage. Concerns for community health in the expanding urban populations were made more ücute by new understandings of contagion brought about by the new germ theories of disease. Unlike Britain, where public health emerged before the general acceptance of germ theories, these scientific developments fuelled the emergence of the public health movement in Canada. At one level, the public health movement, as with the social reform movement more generally. was a genuinely philanthropic effort to alleviate the social distress caused by overcrowding, poverty, and their attendent disease epidemics. However, to understand the public health movement as a philanthropic movement of Victorian progress, whilst not necessarily wrong, begs a number of significant questions and provides a simplistic and one dimensional chancterisation of the effects of public health. There were other impetuses to the growth of the influence of the public health movement, as we have seen. Not the least of the concerns motivating the sanitary movement were the social and economic costs of the diseases caused by overcrowding and poverty. In light of new germ theories. this included the costs borne by those classes whose living conditions might lessen the liklihood of disease, but whose proximity to the labouring classes could expose them to contagion. But the costs involved in terrns of labour power lost to the newly industrialising economy, and the costs incurred in responding to epidemic diseases were also a spur to the development of institutional responses to the health of the community. A related concern, amidst the potentially disruptive consequences of urban living conditions - in a period, it should be rernernbered of growing trades union activism (Palmer 1992, 1 17-208) - was the need to alleviate such conditions in order to avoid anticipated social unrest. As we have seen, the public health movement emerged. at least in part. in response to a range of anxieties associated with the political economy of capitalist industrialisation (the need for pleniiful and productive labour) and issues of goveming a rapidly transfonning society. The requirements for state intervention entüiled in the demands of the public health movement ran quite counter to the prevailing political philosophies of the nineteenth century. The liberalism of the period emphasised laissez-faire, self- dependence, and necessity as the means of inciting provident behaviour in individuals. Any intervention on the part of the state or other institutions, it was believed, would encourage idleness (Rosen 1993, 173-75). Nevertheless, liberaiism wuundoubtedly faced with new problems of goveming in light of the social transformations taking place. As we have seen, part of its response was the emergence of new fonns of authoritative expertise specialising in the conduct of individuals. This was expertise whose authority was underwritten by the new Science - neutral expertise that could daim to produce "tme" knowledge of humans that was objective and efficacious (Rose 1993 284). Public health, among other disciplines, provided such expertise and produced the sorts of "tme" knowledge about conduct that provided ideological support to middle-class claims to moral and political leadership and simultaneously provided the means for close scrutiny and surveillance of the labouring classes. In the Canadian context these anxieties created by the need for a labour force healthy enough to be productive, and a population amenable to the requirements of govemment were heightened by the context of nation-building and relaied racialised anxieties. As we have seen, public health discourse of the time provided one forum in which these anxieties could be articulated and responded to. It had a part to play in the establishment of Canada as a nation belonging to a quite specific "race" - white, protestant, British descent - that wupoliced dong lines of gender and characterised implicitly in terms of class. In the period from the end of the first world war to the 1970s public health in Canada played a secondary role to an emerging approach to health that prioritised health care. Health care became centred around the institution of the hospital and the curative capacities of docton practicing an increasingly technologised form of medicine. This approach to health formed the bais of the publicly funded health care system that emerged in Canada in the period after the second world war. It was not until the 1970s that public health - now in the guise of "health promotion" - retumed to a place of significance on the health agenda. By the 1970s the backlash against the welfare state was beginning, and the first signs that the post-war Keynsian consensus was withering were emerging. At this time Canada produced its first signifiant contribution to the field of health promotion in the

Lalonde Report ( 1974) which emphasised the need for greater individual responsibility for health. The subsequent re-emergence of public hedth, and in particular the rise to prominence of health promotion as a dominant public health strategy, maps, as we have seen, ont0 a transition through which the neo-liberal state has in large part replaced the welfare state. This mapping of health promotion ont0 neo-liberalism happens both chronologically and ideologically. This is not to suggest any intent on the part of those involved in the development of heal th promotion as a public health strategy. In the period of massive economic and social transformations that have characterised the last quarter of the twentieth century, health promotion risks lending ideological support both to a withdrawal of the state from earlier cornmitments to the provision of publicly funded health care. and to new forms of entrepreneurial selfhood that are required by neo-liberal forms of govemment more generally. In shon - the intentions of the üctors notwithstanding - health promotion is ideologically involved in the reconstruction of hegemony in the context of the neo-liberal state. The ways in which health promotion is thus implicated can be characterised into two broad and intersecting themes that echo similar but earlier roles played by first wave public health. The first is concerned with modelling subjects according to the requirements of capitalist political economy, and the second with the practical requirements of goveming populations. An example of the former is health promotion's use of social marketing, while its recourse to the discourses of "'enipowerment" and "community" contnbute to the latter. Whereas first wave public health was caught up by the necessity of the availabili ty of labour for industrial production, so today 's health promotion has been similarly engulfed by late iwentieth century consumer cnpitalism. As we have seen, the health promotion strategy of social marketing models the individual as a consumer in terms of a free market. Health itself within the discourse of social marketing is reconstructed ideologically as a cornmodifiable entity. Although it cannot be bought and sold in the way that a genuine commodity can, health is nevertheless represented as that which cm be produced through attentive labour on the self if one "buys" the messages of social marketing in health promotion. A further product of the discourse of social marketing in health promotion is the conviction that if health cm be produced by labour on the self so, conversely, there are a range of States of il1 health that are held to be consequential upon a failure to exercise such labour. These states of il1 health are largely associated with certain behaviours that constitute "avoidable" activities particularly associateci with substance use, sex, and "poor" eating habits. Circulating throughout the representation of some forms of il1 health as avoidable, if one simply adopts appropriate modes of conduct, is the notion of the "will towards health" as a moral imperative that characterises what Crawford (1980) has labelled "healthism." The field of health promotion is not homogenous, and it includes actors and strategies whose approach is altogether more radical and challenging to prevailing social relations ihan that provided by social marketing and the advocates of behaviour change. In particular 1 am talking of the tum in health promotion to the concepts of "empowement" and "community", both of which have been derived from the "new social movements" of the last three decades and from radical cornmunity development theory such as that developed by Freire. However, as we see in chapter three, what is generally missing frorn both concepts as they are ürticulated within health promotion discourse is a structural analysis that locates (health promotion) experts in relation to the state and that identifies systemic bamers to the ends that are supposedly xhievable through the categories of empowerment and community. There is little analysis in the discourse of health promotion of the ideological fit of the advocacy of bbcommunity empowerment" with the reshaping of the neo-liberal state and the withdrawal of

(welfare) state provided services aimed at the amelioration of inequities. As Petersen (1994,2 17) points out, the advocacy of community empowennent by health promoters, in the absence of a critical structural analysis of neo-liberalism, may ultimaiely serve the agenda of New Right economic policies more than it serves communities themselves, which might end up more closely regulated rather than more empowered. An increasingly popular element of health promotion is the strategy of consumer health information (CHI). CHI bridges the fields of information science and health promotion and, not without controversy, patient education. The rise of the popularity of CHI has a history that matches chronologically that of health promotion, and that can he traced to the emergence of the "consumer" in health and the appearance of various discourses extolling the (empowering) value of "information." Knowledge is assumed, according to the firniliar equation. to equal power. At the core of the concept of consumer health infomation is the somewhat simplistic characterisation of information transfer between human beings as a simple rnatter of asocial message transmission that cm be likened to educational theones that Freire ( 1970) has categorised as "banking education." These foundational assumptions of CHI - that knowledge equals power, and that information is the empowering means linking the two - reflects. as Peters

( 1988, 10) argues, the lack of critical attention directed at discourses of information. In fact, as we have seen. CHI is part of a broader cultural phenornenon in which "information" - far from being approached with any degree of circumspection - is portrayed as simultaneously both the primary raw material and the most valuable commodity of the new global economy. "Information" is also, as Brenda Dervin

(1994) has claimed. enmeshed in a cultural narrative in which it is equated with democracy and a free marketplace of ideas. The information society is also represented as one that brhgs with it a liberation from the inequities. exploitation and drudgery of industrial labour. Mead it will be a society of greater citizen and consumer choice, greater flexibility and choice in the type and place of work, and a society with a good deal more leisure time enjoyed by al1 and a cleaner environment. It is the cultural power of these discourses of information - in the face, it rnust be said, of the stubborn resilience of inequities, exploitation, dirty and dangerous labour, poverty, and closely regulated workforces - that Roszak (1994) has labelled the "cult of infomation." It is by situating CHI against the backdrop of this "cult of information" that we can qpreciate its ideological power. It is information, as we have seen, in the hands of the newly empowered consumer, that is the means by which the social relations of health are to be transfonned. Once again we cm see here the blended neo-liberal language of self- government and the necessity of economic restructuring. In the wake of the "cult of information" - particularly with the rapid developments of the internet - there is an assumption that readily avoilable information can be accessed by any person rational and motivated enough to appreciate its value. Increasingly, the definition of ethical citizen incorporates the idea of the informed consumer of health in which the language of duty is at least as important as the language of empowerment. It is this morally characterised consumer -Ferguson's ( 1992) "health active, health responsible consumer" - who is to be the main actor in bringing about health care system reform that ha5 been Iabelled "empowering the demand side" (Kronick 1992). The point here is not whether or not people in general rerilly rire more inclined to play a more active role in the maintenance of thcir health than they were previously, but the ideological use to which the caiegory of the active and informed consumer can be put in the context of the hegemonic politics of the neo-liberal state. Focusing the reform of health care on the informed consumer - "empowering the demand side" - çan produce arguments for the complete withdrüwül of the state from the regulation and the provision of health care. What is said to stand in the way of efficient and appropriate health care is the infornational asymmetry between health care provider and consumer. This asymmetry reinforces the dependency of the consumer on the health care practitioner and leads to wasteful practices. A knowledgeable consumer, and one who bears the financial burdens of his or her own decisions, is said to be the best means for achieving efficiency in the system (Kenkel 1990; Shackley and Ryan 1994). The restructuring of health care - nominally at least - around the figure of the active and informed consumer and a freer marketplace introduces tensions in the established relationship between the state and the conventionally dominant authoritative experts in health. medical doctors. These tensions are centred upon knowledge production in health, and specifically who produces "authoritative" knowledge. The idea of the informed consumer and a marketplace in which the consumer may choose, in theory at least. from a range of practitioners and health practices poses a challenge to the authority and hegemony of scientific medicine. Scientific medicine has responded, as we have seen, with the discourse of evidence-based medicine (EBM). This discourse reframes the conditions of knowledge production in health by reaffirming the primacy of science. By managing the production of knowledge, scientific medicine is able to exert controi not only over the flow of information to cionsumers, but over the very conditions under which knowledge may be said io be authoritative. It does so by on the one hand insisting that whütever cannot be accredited by the criteria of EBM (for example the principles of Chinese medicine) is rejected as quackery. and on the other hand, by reserving for itself the right to colonise whatever EBM determines to be

"sound" practice (ücupuncture, for example). Evidence-hased >nedici>terecisserts the cilithority of'scientifc >nedicine in the socicil relations of knowledge production in hctdttt.

A question which has been begged throughout this thesis needs now to be raised, even if this is not the space in which it will be addressed. 1 have been concemed throughout this work to demonstrate - without imputing intention - the points of confluence between discourses of public health and the dominant ideological themes that sustain and reproduce certain forms of capitalist hegemony. The question we might wish to ssk then, is whether it is possible to imagine ways in which public health - and health promotion in particular - can become a site for the generation of genuinely counter-hegemonic discourses and practices. In other words, if this thesis has been an exercise in negation, how might one begin to frame a less negative project that contributes to a "strategy of constniction of a new order" (Laclau and Mouffe

1985, 189)?

Towards A Post-Liberal Public Health? The purpose of the final comments of this conclusion is not to provide answers to such a question, but to contemplate where one might begin formulating strategies for health promotion that are resistant to becoming implicated within dominant ideological frameworks. The first comment to makc in this regard, given the theoretical framework outlined in chapter one, concerns the value of Marxist theory to such endeavors. The contemporary restructuring and globalisation of capitalism - the vigorous scouring of the planet for access to cheaper resources and sources of labour - demonstrate

forcefully the accuracy of Marx's general analyses. As an interpretive and analyitical framework Marxism - and cultural materialism in particuliir - remains as relevant as it

ever was. Perhaps reaffinning the value of a Marxist analysis is even more important in the wake of capitalism's "failed" experiment with using the state to ameliorate its own dysfunctions. It is doubtful, given the success with which it has been represented as producing wasteful dependency, thai we are likely to witness the building of an alternative politics around a return to Keynsian welfare statism. What is far less certain, however, is the vaiidity of Marxism as a guide to bringing about radical and progressive social change. We are, it seems, well beyond the point of imagining that social change will be brought about by political rupture in the form of a foundational revolutionary process led by the proletariat as the exclusive agent of change. We have reached a point in time, it seems, in which we no longer have access to models of social change that can provide the sorts of reassurîngly holistic and totdising answers that were once provided by theoretical approaches such as Marxism, or even welfare statism. If it is true, as Lyotard (1984) suggests, that a defining characteristic of the postmodern condition is incredulity to metanarratives, it is clear that we now need to explore new narratives to guide Our activities and to help us define what we mean when we speak of working for a "better" society. What might this mean for the ways in which health promotion work - including consumer health information - is done? 1s it possible to move beyond the impasse created by the suggestion of this thesis that every attempt to act is likely to be appropriated. or at least implicated, within dominant discourses? The short answer is, I think, that we do not really know. The longer answer is that perhaps we have to believe that it is possible. and it is this possibility that 1 wünt to suggest by way of some concluding comments.

The first point to make is a reiteration of one made in the introduction of this thesis and in chapter one. This is Gramsci's affirmation that sites of hegemonic creürion and reproduction can also be sites for the generation of counter and alternative hegemony. What is crucial here is Gramsci's conviction that each individual is capable of intellectual work. That is to say in the context of the structures that determine the ideological shape of human consciousness in general. there can be no accounting for what Golding ( 1992, 124) calls "that disturbing element called the will." The active and critical agency of individual actors means that even in those moments when hegemonic discourse seems most pervasive there will be those who question it. The field of health promotion is one very prornising site for critical accoiints to emerge in ways that do not ultimately merely serve the purposes of entrenched interests. This is because health promoters work at the interface between the language of neo-liberalism - community care, health responsible consumers, the emphasis on preveiition rather than treatment - and the reality of the practices of neo-liberalism - unbridled free markets, rampant individualism. Whilst there may be much in the former that appears attractive, it is increasingly clear that the latter are antithetical to the achievement and maintenance of good health. Ironically, it might be that one way to take on neo-liberalism is to push at its own rhetoric rather than to renounce it. Laclau and Mouffe (1985) argue that "the meaning of liberal discourse ... is not definitively fixed: and just as this unfixity permits their articulation with elements of conservative discourse. it also permits different foms of articulation and redefinition which accentuate the democratic moment" ( 176). In other words, it might be possible that the very terminology of liberalism provides the field of hegemonic struggle that health promoters. among others. can use to articulate alternative mewings. For example. the terms "empowerment" and "cornmunity". of which 1 was critical in chapter three. take on a different resonartce if. instead of being taken up in an apolitical vacuum, are used to demonstrate the structural economic and political barriers that prevent their redisation. barriers that are out of synch with what we now know to be the broader deterrninants of health. We could also take up the term "community" so that we use it not to homogenise difference. but to insist on a radical heterogeneity. The terni takes on a very different meaning if - in the context of a globalising consumer culture - we use it to situate the tensions, conflicts. and energies of difference and diversity. 1 am not talking here of fixed differences bascd on static categorical identities, but of a concept of fluid. shifting and multiple differences that rejects the idea of a priori priviliged subjects. Such a concept has consequences for the ways in which we think about knowledge. how it is produced. what is considered authoritative, and the role of "experts."

As 1 demonstrate in chapter four, the failure on the part of those working in hralth promotion to tackle issues of expert knowledge production and "authoritative" versus "lay" knowledge, has meant that not only has health promotion discourse constructed its populations as consumers according to a market model. but it has also served to reinforce the dominance of the professional elite whose dominance is itself challenged by the rise of consumerism in health. What is perhaps more serious, particularly in a culture as diverse as Canada's, are the ways in which this process serves to reinforce the marginalisaiion of different ways of understanding the human body, health and illness that have evolved in epistemological frameworks that are radically different from the Newtonian and Cartesian dualist foundations of western science. Health promotion itself, by insisting that health is not reducible to the biological. chülleiiges the very basic assurnptions of scientific medicine. It is incumbent upon the field, then, to further embrace a radical heterogeneity by opening itself to the possibility that there is much to be leamed from forgoing the notion of true and universal knowledge. and encouraging instead genuine dialogue between varying epistemological perspectives. Opening and encouraging this kind of dialogue about knowledge production will Iiave consequences for the ways in which we view "infonnation." Information can no longer be thought of as the commodity - produced Dy experts - that instructs us as to the nature of the "real" world. The nature of Our ontological world is far more complex and our knowledge of it far more incomplete than current ideologies of information acknowledge. The cenainties implied in the discoune of consumer health information - experts produce authoritative knowledge, information encapsulates and transmits it - are drrived from an overly simplified model. It is a model that fails to account for the ways in which socially constituted but different subjects move between order and chaos as they stmglle to make sense of themselves and their place in the universe. A post-liberal approach to redefining the theoretical and methodological tools used to approach information systems obviously means broadening the present conception of sense-making seen rather narrowly as an intemal process through which individuals inform themselves (autocornmunication) to a more reasonable approach which also takes into account the dialogical and transindividual (cultural, societal, organizational) factors of sense-making. (Savolainen 1993, 26) These brief final comments are intended only to suggest avenues of exploration that might produce research and practice that can be described as post-liberal public health. These suggestions assume that public health has a role to play in figuring out what a "better" world for more pecple might look like, and in helping to bring it about. This is a political process. and public health. like any other intervention in the world. is irrevocably political. 1. Primary Sources: Chapter Two Annual Report of the Local Board of Health for the Year 1893. Toronto: J. Y. Reid, 1894.

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