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Public Health and the Rise and Fall of the Interventionist State

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Public Health and the Rise and Fall of the Interventionist State 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 O Copyright by Keith Demy 1999 National Library Bibliothèque nationale B*1 of Canada du Canada Acquisitions and Acquisitions et Bibliographie Services services bibliographiques 395 Wellington Street 395, rue Wellington Onawa ON KIA ON4 OttawaON K1AON4 Canada Canada The author has granted a non- L'auteur a accordé une licence non exclusive licence allowing the exclusive permettant à la National Library of Canada to Bibliothèque nationale du Canada de reproduce, loan, distribute or sel1 reproduire, prêter, distribuer ou copies of this thesis in microfonn, vendre des copies de cette thèse sous paper or electronic formats. la forme de microfiche/film, de reproduction sur papier ou sur format électronique. The author retains ownership of the L'auteur conserve la propriété du copyright in ths thesis. Neither the droit d'auteur qui protège cette thèse. thesis nor substantial extracts fYom it Ni la thèse ni des extraits substantiels may be printed or otherwise de celle-ci ne doivent être imprimés reproduced without the author's ou autrement reproduits sans son permission. autorisation. TABLE OF CONTENTS 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 .
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