Governing Lifestyle the Rationality and Practice of Type 2 Diabetes Care in Denmark

Governing lifestyle The rationality and practice of type 2 diabetes care in Denmark

PhD dissertation by Sine Grønborg Knudsen Department of Social Sciences and Business Roskilde University 2019 ISSN no. 0909-9174

Supervisor: Peter Triantafillou (Roskilde University) Co-supervisor: M. Azhar Hussain (Roskilde University)

The PhD project is supported through funding from Roskilde University (RUC), Zealand Region, Roskilde Municipality, Lejre Municipality and Holbæk Hospital

When you were young And your heart was an open book You used to say live and let live (you know you did, you know you did, you know you did) But in this ever changing world in which we live in Makes you give in and cry

Say live and let die Live and let die Live and let die Live and let die Linda and Paul McCartney

Acknowledgements

Even though the completion of a PhD project is often a lonely process, I have had the company and support from many and therefore owe several gratitudes and thanks. First of all, I would like to thank all the health professionals and patients who took the time to share their knowledge, experiences and thoughts about diabetes with me. Without your generosity in inviting me into your homes and workplaces, this dissertation would have been sincerely lacking in insight. In the same vein, I am grateful to the co- financing partners that made the PhD project possible. I would like to thank Roskilde Kommune, Lejre Kommune, Holbæk Hospital and Region Sjælland. I would like to express my sincere gratitude to my supervisor Peter Triantafillou whose persistent guidance in the world of Foucauldian analytics have been indispensable. Thank you for the countless hours of supervision and critical but constructive feedback that helped the sharpening of arguments and research papers. Your supervision will be missed as well as the numerous recommendations of books, music and television shows. Thanks to my co-supervisor M. Azhar Hussain for your guidance along the way. Thank you to my colleagues at RUC and especially the research group at Roskilde School of Governance. It has been a delight to participate in a friendly and competent environment. Thank you to all my PhD colleagues, not least Lena, Mie, Kristina, Manon and Sofie. PhD life would never have been fun or bearable without your sparing, advice and occasional drinking. Finally, I owe thanks to my colleagues at Steno Diabetes Center Copenhagen for their important support towards the end of writing this dissertation. A special thanks go to David Reubi as well as all the colleagues I met during my stay at King’s College. David was kind enough to open the doors to King’s College and generously shared his knowledge and expertise. I would also like to thank Lars Thorup Larsen for his comments and thorough reading of the dissertation. Last but not least, I would like to thank my friends and family for your patience, support and encouragement in the process of writing this dissertation.

Sine Grønborg Knudsen, March 2019, Roskilde University

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The dissertation at a glance

The aim of this dissertation is to increase the understanding of how lifestyle is problematised and governed in type 2 diabetes (from now: diabetes) care in Denmark in three fields of interventions: the politico-administrative field, the professional field, and the patient field. Table 1 provides an overview of the three fields comprising the dissertation and through which the central research question will be answered: How — and under what conditions — is lifestyle problematised and governed in the politico-administrative field, in the professional field and in the patient field of diabetes care?

Table 1. Overview of papers in the dissertation

Paper one Paper two Paper three Title Lifestylisation of the The facilitating professional: Self-government of social: the government of government and self- diabetes patients: opting diabetes care in Denmark. government of Danish health for freedom-based power professionals in diabetes care. versus direct power. Research How are rationalities of How — and with what How are diabetes question preventive lifestyle implications — do patients practicing their interventions in the social problematisations of diabetes as freedom (and shaping surroundings of patients a lifestyle disease inform the their lifestyle) in the employed in diabetes care government and self-government context of interventions in Denmark? of health professionals? that seek to optimise their self-caring capabilities? Study Examines how the choice Explores the self-government of Studies the various ways details of lifestyle has emerged the facilitative health patients exercise as a governing technique professional who are expected freedom in the context of not only in the public to govern themselves with new lifestyle interventions health domain, but in the forms of autonomy in which the seeking to enable them social domain in the last lay-knowledge of patients is a to choose a healthy two decades. central element. lifestyle.

iv Table of contents

Acknowledgements ...... iii

The dissertation at a glance ...... iv

PART ONE: Introduction and framework...... 1

Chapter 1: Introduction ...... 3

1.1. Background and context: the problematisation of lifestyle ...... 3

1.2. Objectives and research questions ...... 8

1.3. Research setting ...... 12

1.4. Research design ...... 14

1.5. Structure of the dissertation...... 15

Chapter 2: Literature review ...... 17

2.1 Principles applied in the literature review ...... 17

2.2 Part one: the politics of lifestyle ...... 21 2.2.1 Closing remarks ...... 27

2.3 Part two: how did lifestyle emerge in diabetes care? ...... 27 2.3.1 1950s and 1960s ...... 28 2.3.2 1970s and 1980s ...... 32 2.3.3 1990s ...... 43 2.3.4 The Danish development: self-care and prevention ...... 52 2.3.5 Closing remarks ...... 58

2.4 Closing remarks on literature review ...... 61

Chapter 3: Conceptual and analytical framework ...... 64

3.1. Analytical approach: problematisation ...... 65

3.2. Dispositive ...... 71

3.2.1. The lifestyle dispositive ...... 74

3.3. Governmentality ...... 76 3.3.1. The neoliberal art of governing ...... 78

3.4. Analytics of government ...... 80 3.4.1. Analytics of practice of government ...... 81 3.4.2. Analytics of practices of the self ...... 82

3.5. Biopower ...... 85 3.5.1. Biopower, discipline and sovereignty ...... 87 3.5.2. Biopower and neoliberalism ...... 91

3.6. Governing lifestyle through neoliberal politics — an extension of biopower? ...... 94

3.7. Closing remarks ...... 103

Chapter 4: Methodology ...... 106

4.1. Strategy and approach: a critical diagnostic of the present ...... 106

4.2. Case study...... 108

4.3. Methods and data ...... 112 4.3.1. Research process ...... 113

4.4. Ethical considerations...... 128

Chapter 5: Discussion and conclusion ...... 130

5.1. Main findings ...... 131

5.2. Contributions ...... 135

5.3. Ethical and methodological considerations ...... 143

References ...... 146

English summary ...... 167

Danish summary (Dansk resumé) ...... 170

vi Appendix 1: General practice interview guide (in Danish) ...... 173

Appendix 2: Hospital ambulatory interview guide (in Danish) ...... 175

Appendix 3: Municipality interview guide (in Danish) ...... 177

Appendix 4: Patient interview guide (in Danish) ...... 179

PART TWO: The three papers and empirical analyses...... 181

Paper one ...... 182

Paper two ...... 210

Paper three ...... 245

vii

PART ONE: Introduction and framework

Governing lifestyle

Chapter 1: Introduction

1.1. Background and context: the problematisation of lifestyle Above all, this dissertation is concerned with how lifestyle is problematised and governed in the continuum between health and illness in advanced liberal democracies. This dissertation uses what is often termed as the diabetes epidemic as a backdrop for an investigation into the prevention of unhealthy lifestyles in type 2 diabetes (from now: diabetes) care in Denmark. It examines the ways in which lifestyle interventions challenge classical notions of health and illness in the field of politics, in professional practice and in the life of patients. Thus, the focus is on grasping key elements of contemporary preventative health politics — and the prevention of diabetes in particular — and how neoliberal rationalities and techniques assert themselves in health government. It examines the ways in which the focus on lifestyle informs the government and self- government of health professionals and diabetes patients in Denmark across three fields of intervention: the politico-administrative field, the professional field and the patient field. Several studies have observed how the lifestyle of individuals is understood not only as a private matter but also as a political matter in advanced liberal democracies. The concept of lifestyle has been politicised and used as a government mechanism in a variety of public domains, for instance in questions of individual freedom, population security and well-being (Dahlager, 2001; Peeters, 2013b; Mayes, 2016). It has been noted how the concept of lifestyle can be traced back to classical sociological theory (e.g. Weber’s theory of class and status), where the concept was used to analyse the links between people’s way of life and economic class position and belonging to particular status groups (Larsen, 2010, pp. 205–6) and to political science, where it is considered to be a reflection of political attitudes (Mayes, 2016, p. 3). Scholars seem to agree that the concept of lifestyle

1. Introduction

entered the public health domain in the 1970s1, when lifestyle was increasingly used to describe health-related behaviour and the deliberate choice of behaviour made by individuals (Armstrong, 2009; Larsen, 2010; Mayes, 2016). More specifically, the concept of lifestyle transformed from signalling the way of life of human beings to also signalling harmful factors and behaviours. External risk factors of human beings such as diet, smoking, alcohol and exercise came to constitute the health-related behaviour understood by the concept of lifestyle (Armstrong, 2009; Larsen, 2010). As lifestyle has entered the public health domain, the perception of illness has shifted from a narrow biomedical issue to a behavioural, moral and social issue (Peeters, 2013b). As such, it can be said that the concept of lifestyle is used to denote people’s general way of life and as the cause and cure of the many challenges facing welfare states today. With the focus on the lifestyle of individuals, public health strategies in many liberal democracies are concerned not only with a traditional curative strategy but with disease preventing and health promoting strategies (Rose, 2001). This is sometimes referred to as the epidemiological transition (conceptualised by Omran 1971) denoting the change in the disease spectrum from the decline of acute and infectious diseases to an increase of degenerative and chronic diseases (Armstrong, 2014b; Weisz, 2014). As forcefully put by Ayo Wahlberg and Nikolas Rose (2015, p. 14): “One can say that morbid death is no longer the paramount epidemiological problem, rather it is morbid living”. Moreover, the body emerges as a moral object linked to prevailing neoliberal forms and problems of government governing through notions of choice, autonomy and responsibility. Through the body, the general self-government of individuals becomes visible (Rose, 1999). Hence, to address the health of the population and avert certain risk factors, individuals’ choice of lifestyle figures as a focal part of prevention policies, as prevention is believed to contribute to avoiding the progression of illness in the already ill population but also to attaining a certain level of health in the population at large. Thus, advanced liberal societies intervene with varying force into the everyday life of citizens attempting to responsibilise and empower citizens to choose a healthy lifestyle (Larsen,

1 There is a discussion among scholars of when the concept of behaviour entered the public health domain, see Armstrong (2010) and Vallgårda (2010), but they seem to agree that the term lifestyle is increasingly used in the recent decades.

Governing lifestyle

2016). The emphasis on prevention presents everything as a more or less manageable risk and lifestyle as endlessly modifiable. To illustrate, in 2017 the Danish government awarded 27 million Danish kroners to 11 municipalities, which were to establish initiatives aiming to get citizens who normally do not seek medical attention to be more interested in their health and use preventive health services (Ministry of Health, 2017). The current Minister of Health explains the purpose and the ambition of the health policy:

If the municipalities can detect warning signs of chronic illnesses among a range of people earlier than before, then we can react faster towards the illness if it breaks out. It makes good sense to offer preventive health services to certain groups who are at risk of getting ill. In the long view, it can also reduce the burden on the health system as a whole and give more health value for the money (Ministry of Health, 2017).

The statement links early detection of risk factors, i.e. warning signs, with the potential to decrease the economic burden as well as increase the quality of the health system. The support for preventive health activities is often followed by the argument that the prevention of chronic illness — by means of improving unhealthy lifestyles — will reduce the burden on health systems and the state budget as a whole as well as provide a better life quality for patients (Scambler et al., 2014). More specifically, the statement seeks to construct a causal link between an undesirable future and the necessary means to avoid getting there making such an argumentation difficult to argue against (Peeters, 2013b). Roskilde, one of the cases in this dissertation, is one of the municipalities that received state funding for a health prevention programme. In collaboration with a trade union2, the municipality initiated the project ‘Are you fit and healthy?’ with the aim of inviting all citizens, and specifically citizens at risk of developing chronic illness, to come have a personal conversation about their health in municipal health centres. On the website of the municipality the objective of this collaboration is stated:

If citizens are to have a chance to prevent [illness], it necessarily demands that they get their health checked. To find the citizens, who could benefit from the two health

2 FOA is a trade union for public employees.

1. Introduction

check-ups, everyone first needs to come in to a conversation. That is the first challenge. In collaboration, the municipality and the trade union are to get citizens in the risk group to meet up for a clarifying conversation (Roskilde Kommune, 2017).

The project and the ambitions of the health policy represent an expansive strategy in which the health of all must be checked. As such, the ambition to prevent chronic illness by means of health centres in municipalities extends the gaze of the health system because it becomes necessary to intervene early in the lives of citizens and to take the population as a whole into consideration. This dissertation aims to examine how lifestyle is governed by contemporary preventive health politics and is problematised as both the cause and cure of a range of chronic illnesses. Additionally, the aim is to explore how the problematisations and norms of lifestyle unfold in the exercise of government and the practices of the self-government of health professionals and patients. To illustrate this development of lifestyle as both a precondition and as a means to ensure health, this dissertation makes use of the case of type 2 diabetes (from now: diabetes) in Denmark. Diabetes is recognised as a biomedically-diagnosed illness and still predominantly understood as a biomedical problem both in medical literature and in health strategies. As such, it may be expected that healthcare around diabetes would mainly, if not solely, revolve around pharmacological treatment or curative approaches, such as gastric bypass. However, as this dissertation will demonstrate, treatment and interventions in diabetes care are also aimed at eliminating risk factors and, essential for this dissertation, improving the self- care of patients in the attempt to prevent it from progressing or developing in the first place (Scambler, 2006; Ljungdalh, 2011; Scambler et al., 2014; Seligman et al., 2015). In a Danish context, these risk factors are referred to as KRAM3-factors referring to nutritional habits, smoking, alcohol use and physical exercise. These lifestyle factors become focal elements of health policy that must be monitored and improved not just among diabetes patients but also among the general population. Through this dissertation, I employ a distinction between two forms of self- government: first, a form

3 KRAM: A contraction of the first letters in Danish of Diet (”Kost”), Smoking (”Rygning”), Alcohol (“Alkohol”) and Exercise (“Motion”) and regards the overall focus areas of the health politics promoted by public authorities.

Governing lifestyle of self-government that has to do with a pathological problematisation and the physical behaviour of patients, second, a form of self-government that has to do with a non- pathological problematisation and the conduct of patients, that is the mind, attitudes and considerations of patients. This distinction is comprised in the concept of lifestyle which entails a concern for both the behaviour and the conduct of patients. The overall argument of this dissertation is that a fundamental transformation is taking place not only in diabetes treatment but also in the managing of social risks pertaining to the health and welfare of individuals and populations in liberal democracies. Diabetes is an exemplary case of this transformation in the state’s intervention repertoire and of the shifting roles of responsibility in the state-society relationship, allowing one to study neoliberal rationalities and technologies that assert themselves in the government of health. As I will demonstrate in this dissertation, the fact that public authorities regard certain illnesses as the result of poor lifestyle choices does not necessarily imply divestment of state responsibility and interventions. Rather, the ambition of contemporary preventative health politics in Denmark is to offer a comprehensive form of interventions encouraging and enabling citizens to make healthier choices. Conceptually, the dissertation takes its point of departure in the French scholar Michel Foucault’s notion of biopower — understood as the political ambition to optimise the lifestyle and quality of life of a population (Foucault, 1978, 2003). However, the notions of the dispositive and governmentality, including government and ethics, frame the analyses focusing on modes of government and freedom practices in advanced liberal societies. Following this, the dissertation conceives the societal solution to the problem of diabetes as a lifestyle dispositive: a network or apparatus that represents a specific model of solution. The lifestyle dispositive is at the same time historical, non-determinant and characteristic of its time and with certain effects, i.e. the way society handles a given problem creates an effect for the people living in that society. Empirically, the dissertation aims to explore the implications of lifestyle in various fields of intervention in society, namely the politico-administrative, professional and patient fields, using different methods and data.

1. Introduction

In this dissertation the concept of lifestyle is used both in the common-sense understanding, that is the way a person practices his or her life, but also as a field of political problematisations and interventions aimed at individuals and their surroundings. Moreover, the concept of lifestyle is employed to nuance and renew Foucault’s original concept of biopower in three dimensions to provide a more adequate understanding of contemporary forms of power involved with contemporary preventive health politics. As such, through the exploration of the use of lifestyle and the ways in which health professionals and patients in diabetes care are governed and govern themselves in diabetes care in Denmark, the aim of this dissertation is to contribute to our understanding of the concept of lifestyle in preventive activities in diabetes care. In addition, the aim is to contribute with knowledge on how contemporary preventative health politics can be understood within a lifestylisation of biopolitics. This will be further elaborated in the concluding chapter of this dissertation. In brief, this dissertation seeks to make both an empirical and conceptual contribution to our understanding of contemporary health politics and the government and self-government of lifestyle in advanced liberal societies.

1.2. Objectives and research questions The objectives of this dissertation can be divided in two forms: the immediate and the overall objective. The immediate objective of this dissertation is to critically examine how lifestyle is shaped through the government and self-government of diabetes in the three fields of intervention: the politico-administrative, the professional and the patient fields. To shape means, in this dissertation, not the determination of behaviour but the attempt to structure the fields of government and self-government. The overall objective is to contribute both empirically and conceptually to a critical understanding of the exercise of power and freedom in advanced liberal societies. Empirically, this aim is addressed by analysing diabetes care in Denmark with a focus on lifestyle interventions through three papers (see Part Two of this dissertation for the three papers). Conceptually, this aim is pursued through an exploration of a contemporary version of Foucault’s biopower analysed through the analytics of the dispositive and governmentality

Governing lifestyle focusing on the relation between power and knowledge and practices of freedom in the government of lifestyle in diabetes care. The Foucauldian form of critique entails not only identifying the various forms of power at stake in preventative health politics. It also entails what Foucault terms critical attitude; it is about unsettling existing power relations and ways of thinking by interrogating how we are governed and how we govern ourselves (Foucault, 1997). On the one hand, this kind of critical analysis entails showing that even indirect, and what we often regard as benign, forms of power, such as health promotion and disease prevention, often importantly limits the exercise of freedom. On the other hand, this also entails showing that we are often more free than we think (Foucault, 1988). In other words, we have more room for manoeuvre than is often assumed. The analysis of the exercise of power in concrete institutional and temporal settings may illuminate such unexpected possibilities of freedom. The crucial element here is that this is a non-normative form of critique. Basically, this form of critique does not attempt to tell people what to do or that they suffer from a false consciousness (Triantafillou, 2012). Rather, the critical attitude aims to give the subject the right to question the truths by which she is governed — to enable her to not be governed quite like that, by these people, procedures and principles, and with this objective (Foucault, 1997, p. 29). As famously put by Foucault (1994a, p. 256):

My point is not that everything is bad, but that everything is dangerous, which is not exactly the same as bad. If everything is dangerous, then we always have something to do. So my position leads not to apathy but to a hyper- and pessimistic activism.

To criticise in the Foucauldian sense is linked to a central concept in Foucault’s analyses: problematisation, which is introduced as the overall analytical approach in section 3.1. Critical activity is indispensable for practical transformation of our thought insofar as it problematises thought. Following Foucault’s (2002b) critical endeavour, the analysis in this dissertation does not attempt to search for anything hidden behind the events under exploration. Rather the aim is to bring forward prescriptive events whose effects can be taken at face-value, but at the same time seek to breach the self-evidence that presents itself as obvious and on which the practices and forms of knowledge rest.

1. Introduction

To establish a position for addressing this objective, this dissertation predominantly draws on insights from critical public health literature as well as more loosely on health sociological professional literature and health sociological and medical anthropological literature. These insights, in combination with the analytical framework, inform the research design, which focuses on the three fields of intervention in diabetes care. To explore the objective, this dissertation is guided by a central research question:

How — and under what conditions — is lifestyle problematised and governed in the politico- administrative field, in the professional field and in the patient field of diabetes care?

As mentioned, the dissertation addresses the main research question through three papers. Each paper revolves around a specific research question that focuses on each field of intervention. The first paper focuses on knowledge and power relations, while the last two papers address the relations between power and freedom. The first paper aims to identify knowledge/power relations in diabetes care and critically examine how and why lifestyle interventions became the self-evident and obvious approach to diabetes care. More specifically, paper one examines how problematisations, rationalities and norms of lifestyle inform the political ambitions of diabetes care. Conceptually, the paper employs Foucault’s notion of the dispositive to investigate a lifestyle dispositive in which various elements surround the individual patient to make the choice of a healthy lifestyle easier. Empirically, the paper uses Danish health programmes to examine the explore the concept of lifestyle in Danish diabetes care. The second paper critically examines the government and self-government of health professionals in diabetes care. The point of departure of this study is that the prevention of unhealthy lifestyles not only has implication for the patients but for the health professionals involved with the interventions as well. Conceptually, this paper employs Foucault’s notions of government and ethics to explore the relation between power and freedom in the professional field of diabetes care and the expectations that health professionals are not only to assume the role as medical experts but as facilitating professionals. Empirically, the paper employs document analysis to explore the

Governing lifestyle government practice of diabetes and semi-structured interviews with health professionals in three health sectors (hospitals, primary care and municipalities) to explore the self- governing practice of health professionals. The third paper critically explores lifestyle interventions through an analysis of the self-practices of diabetes patients. More specifically, this paper examines the self- government of diabetes patients in the context of lifestyle interventions in patient schools in municipalities in which a certain form of self-care is imposed on them by health professionals through a balanced approach that presupposes a freedom-based power seeking to optimise individuals’ ability to achieve and maintain health and well-being in general. Conceptually, the paper employs Foucault’s notion of ethical self-formation to illustrate and understand the various self-practices diabetes patients engage in. Empirically, the paper uses semi-structured interviews with patients and observations from patient schools in municipalities. To address these objectives, each paper is guided by a distinctive research question:

P1: How are rationalities of preventive lifestyle interventions in the social surroundings of patients employed in diabetes care in Denmark?

P2: How — and with what implications — do problematisations of diabetes as a lifestyle disease inform the government and self-government of health professionals?

P3: How are diabetes patients practicing their freedom (and shaping their lifestyle) in the context of interventions that seek to optimise their self-caring capabilities?

The research questions allow this dissertation to explore the government rationales and practices as well as the self-governing practices of professionals and patients. These questions are derived both from the literature review of this dissertation as well as the conceptual framework. This will be elaborated in chapter two. Additionally, chapter five further discusses and concludes on these contributions in light of the findings of the three

1. Introduction

papers. The next section elaborates on the relevance of using Danish diabetes care as the setting for this study.

1.3. Research setting The empirical setting of this dissertation is diabetes care in Denmark, where the health system surrounding the chronically ill has undergone significant organisational changes in the last decades. As already suggested, diabetes care represents an interesting case for investigating the proliferation of lifestyle in policy making in advanced liberal societies. The governing of lifestyle captures the emphasis in these societies on the choice, autonomy and responsibility of individuals and groups (Rose, 1999). Danish diabetes care allows for an investigation of the government and self-government of lifestyle and may provide new insights into forms of knowledge, power and freedom in contemporary preventative health politics that can be of relevance to other advanced liberal societies. First, compared to other advanced liberal countries the Danish welfare state has a comprehensive public sector with accessible and universal health care and social systems. Denmark — even among Nordic welfare states — has one of the most fully developed Beveridge-type modern welfare states, with a long tradition of universal health coverage and state regulation. As it stands, Denmark is often emphasised as a country with well- functioning state institutions (Bengtsson et al., 2015). Thus, the health governmental context of Denmark seems a particularly useful setting to explore the scope of government ambitions in contemporary preventative health politics and the ways in which neoliberal rationalities and technologies of government assert themselves even in a highly regulated society. Second, the Danish public sector went through a radical reform in 2007 (which has been labelled the most radical reform of the political administrative system (Andersen and Jensen, 2010)) in which especially the health sector was reorganised. Among other transformations, the provision of preventive initiatives was altered making local government, which traditionally administered social services, responsible for disease prevention in local health centres. This essentially created what is now termed the ‘close to home health system’ (in Danish: Det nære sundhedsvæsen) (Danish Health Authority,

Governing lifestyle

2005). The purpose of this new form of health system is to provide a framework for healthy lifestyles in the population in the local community, thus moving the territory for lifestyle interventions from the health sector to also include the social sector. The structural reform maintained the three-level political-administrative structure at the state, regional and local government levels. Five new administrative regions replaced the fifteen counties and became primarily responsible for the delivery of health care, as the fifteen counties had been before. 98 municipalities replaced the previously 371 municipalities. The structural reform brought municipalities into health care services. As such, the reform added a new layer of treatment on top of the curative treatment in hospitals and primary care as well as an extra actor to collaborate with in the delivery of chronic illness caretaking. The delivery of care is 1), partially taken care of by the hospital ambulatories at public funded hospitals that deliver specialised diabetes care, 2) partially by the primary care sector that consists of private general practitioners (GPs) regulated by the Danish Regions and receiving public funding for the services they provide, and 3) partially by municipalities that oversee, among other services, home nurses, rehabilitation and prevention4. Third, the Danish approach to diabetes care and the emphasis on patient self-care represents an individualising approach, in which the individual agency of patients is mobilised. This approach can be observed in many countries and is perhaps most pronounced in the UK (Armstrong, 2014a). However, in Denmark — and especially since the mid-2000s — a network approach has particularly emerged in the treatment of diabetes and in the health system in general (Triantafillou and Vucina, 2018). The notion of creating and mobilising a network around the patients — often termed cross sectorial care — is legitimised as the natural and efficient way to solve the problems of poor health and lifestyle diseases (Holt et al., 2017). As the structural reform in 2007 introduced

4 In the new Danish health act from 2005 two new concepts were introduced and marked a new distinction between patient and citizen directed prevention. Citizen directed prevention is primary prevention targeted at the already healthy population and is to be managed by the municipalities. The patient directed prevention is targeted patients in the health system and is defined as clinical prevention. It takes place in the health care system with the patient (Vallgårda et al., 2014). However, increasingly municipalities are entrusted with the task of both types of prevention.

1. Introduction

additional actors in the health system, several disease management programs (from now: DMPs) have described the political ideals for working across sectors and the role and responsibilities between the involved health professions. Moreover, a range of self-care management programmes are used in diabetes care and in chronic disease care in general. In Denmark, these programmes are specifically managed by municipalities through patient schools. As such, investigating the ways in which Denmark responds to neoliberal problematics of self-government may be helpful to other modern welfare states striving to adopt some of the elements of the Danish welfare model.

1.4. Research design To examine and answer the main research question of this dissertation, the research design is applied to three fields of intervention that are both distinct and interrelated: a political (specifically, the administrative structure), a professional and a patient field (see figure 1). To be clear, by using the term field I do not mean to imply an analytical concept (e.g. Bourdieu’s concept of fields as structured spaces). Rather, fields in this dissertation are simply applied as levels of analysis. The study of the politico- administrative field entails an exploration of the development of diabetes as an object for political concern in the past decades (1981-2016) through a document analysis of public health programmes and DMPs. It consists of an analysis of the problematisations and rationalities as well as the intentions and ambitions of government visible in these health documents, which informed the exercise of power or of government in diabetes care. To study the professional field, this dissertation employs document analysis of one disease management programme and interviews with health professionals from hospital ambulatories, primary care and health centres in municipalities. This study focuses on one hand on the government and the self-government of health professionals through their own accounts of how diabetes care and lifestyle interventions unfold. To study the patient field, the dissertation analyses patient self-government through interviews with patients and participant observation (i.e. field work) in patient schools in municipalities.

Governing lifestyle

This research is designed to enable a detailed study of the relations between the rationalities of government and how these rationalities unfolds in practice by informing the exercise of government and the practice of freedom.

Figure 1. Sequential design of each study element (method, study object and study period)

1.5. Structure of the dissertation The dissertation is structured in two parts: The first part consists of the introduction and overall framework of the dissertation in five chapters; the second part consists of the three papers and empirical analyses. The dissertation framework in part one serves as an attempt to synthesise the more specific research questions, methods, analytical concepts and empirical studies of the three papers. Chapter one introduces the dissertation, its background and context, objectives and research questions, and the research setting and design. Chapter two reviews critical social science literature on the politics of lifestyle as well as medical literature on diabetes and lifestyle. Chapter three introduces the analytical and conceptual framework of the dissertation. The chapter

1. Introduction

discusses the analytical approach, the analytical concepts and conceptual contributions of the dissertation and the three papers. Chapter four discusses the methodological approach and research process of the three papers and the dissertation in general. Chapter five concludes and discusses the findings and contributions. The second part of the dissertation consists of three papers that can be read independently. However, each focuses on a different aspect of the central issue of the dissertation: the government of lifestyle in diabetes care. While some repetition across the papers and in this dissertation’s framework is thus to be expected, each paper approaches the government of lifestyle from different vantage points, thus drawing on different methods and, to some extent, different literature sources within the field of critical public health and health sociology. Overall, the aim is to present three papers that examine the analytics, contributions and objectives presented in the first part, thereby creating a coherent and meaningful, but not exhaustive, interpretation of the government of lifestyle in diabetes care.

Governing lifestyle

Chapter 2: Literature review

In this chapter, I review studies from the critical social science literature on lifestyle and health as well as medical literature on lifestyle and diabetes. The purpose of this review is twofold: first, to account for studies that ‒ in a similar way to the dissertation’s overall aim ‒ seek to critically illustrate the relations of power at play in the government of lifestyle in preventive health strategies, and second, to account for the scientific discourses in diabetes care. Both purposes are guided by the central research question of the dissertation as well as by the Foucauldian conceptual frame that underpins the dissertation in which scientific discourses about a social phenomenon are intrinsically related to the way in which power is exercised over this phenomenon. Both purposes aim to illustrate the current way of governing diabetes and health in general by illustrating what came before. More specifically, the review attempts to shed light on the relationship between the key concepts of the dissertation: diabetes, lifestyle and self-management. As I will come back to, the notion of lifestyle in this dissertation – following the Foucauldian framework – denotes how diabetes patients and citizens in general are encouraged to govern themselves not only through their behaviour but through their conduct, understood as their mind, attitudes and self-hood. The purpose of this review is not to derive at fixed clarification of concepts such as lifestyle, self-care and self-management but to illustrate how they are used. Accordingly, the review does not aim to report on the effects or benefits of interventions aimed at improving the lifestyle and self-management of people with diabetes or the scientific evidence of the diverse range of techniques used in diabetes care.

2.1 Principles applied in the literature review The review consists of two parts both aiming to illustrate how diabetes is governed through patients’ behaviour and conduct and which forms of practices and concepts are linked to this way of governing. The first part accounts for literature with a critical approach to contemporary health politics and not specifically diabetes. The second

2. Literature review part tracks the theme of lifestyle and self-management in international and Danish medical and related interdisciplinary literature (such as social medicine, health psychology, medical anthropology) on diabetes. This part of the review aims to illustrate how lifestyle and self-management emerged in diabetes from the 1950s up until and through the 1990s and the review of the Danish literature accounts for medical literature up until present time. Using this time period, the review can account for studies published on diabetes, lifestyle and self-management in the decades before the analyses of this dissertation, which illustrate preventive strategies in Danish diabetes care from the 1980s and more substantially from the 1990s. Before presenting the results of the literature review, I briefly introduce the principles applied to the literature review. The first part of the literature review is a selective review. It aims to identify social science literature with a critical conception on public health, including prevention, health promotion, lifestyle intervention and self-management. It identifies literature not specifically on diabetes but on public health in general as the intention is to place the government of diabetes in a more general and critical discussion of the social and political agenda on public health. For this review, I used a chain searching strategy to be able to establish an overview of existing knowledge and research on lifestyle and health. This entailed both backward and forward searches in literature that I had identified through the Foucauldian conceptual literature. Thus, the selected studies consist of scholars drawing in particular, though not exclusively, on Foucault. This part will attempt to identify some of the shortcomings and contributions in the critical literature which will be discussed in the concluding chapter of this dissertation. This review – as well as the Foucauldian framework – has to an extent informed the second part of the review and especially the reading of selected articles by substantiating the themes I have sought to identify. The second part of the review is based on a systematic literature search that was conducted in three steps. In the first step, I formulated search strings based on keywords and conducted three rounds of searches. I used the databases Scopus and PubMed as well as key journals in the field (see Table 2 for further specifications of the search strategy).

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Table 2 Search strategy for international and Danish medical literature

Review Search words Specifications Results Selected Part I diabetes AND lifestyle OR Journals: Diabetes Care; Social Science & 50 16 behaviour Medicine Time period: before 2000 Refined by keywords Database: Scopus diabetes and lifestyle Countries: Denmark, United Kingdom, 165 23 Canada, Sweden, United States Time period: before 2000 Refined by keywords and journals Database: Scopus diabetes AND self- Journals: Diabetes Care; Social Science & 47 12 management OR self- Medicine care Time period: before 2000 Refined by keywords Database: Scopus diabetes and self- Countries: Denmark, United Kingdom, 144 18 management OR self- Canada, Sweden, United States care Time period: before 2000 Refined by keywords and journals Database: Scopus diabetes AND lifestyle OR Journal: Ugeskrift for Læger 71 19 behaviour Database: PubMed diabetes AND self- Journal: Ugeskrift for Læger 16 8 management OR self- Database: PubMed care Diabetes AND prevention Journal: Ugeskrift for Læger 134 16 Database: PubMed Total 627 112

In the first round, I searched for studies of lifestyle and behaviour as well as self- care and self-management in relation to diabetes published in two key academic journals: Diabetes Care (a diabetes-specific medical journal published by the American Diabetes Association ‒ published since 1978) and Social Science & Medicine (an interdisciplinary journal covering a range of perspectives on health from the social sciences ‒ published since 1982). In this search, the term “behaviour” was included to get a broader view on when and how the lifestyle of patients came into view in medicine. In the second round of search, the search was broader (although behaviour was excluded to limit the results) and focused on specific countries (Denmark, United Kingdom, Canada, Sweden, and United States). The aim of this search was to retrieve studies published before the two key

2. Literature review journals existed as well as studies published in a broader collection of journals. These first two rounds of searches were restricted to studies published up to and including the 1990s. The third and last round of search aimed to identify Danish medical papers. The search was restricted to Ugeskrift for Læger (a leading Danish medical journal). I used the same search strings, although I added “prevention” as a keyword. In total, these search rounds returned 627 results in total. These articles are mainly medical literature authored by doctors and nurses, but also psychologists, diabetes educators, anthropologists, sociologists, epidemiologists etc. In the second step, I first screened the results based on abstract and title. This included the deselection of a range of studies focused on measuring the effect of interventions and on other forms of diabetes than type 2. On this basis, I selected 112 articles, which form the basis of part two of the review and are summarised in the following. The third step was of the literature review consisted of reading through the selected studies to identify general themes and conclusions. While reading through, I focused on the following items: (1) how lifestyle is studied, including how lifestyle is problematised; (2) which types of interventions and approaches to lifestyle are in focus; (3) key themes; and (4) references to policy reports and significant conferences and events in diabetes care. These items have been chosen as they contribute in different ways to answering the central research question and links to the Foucauldian conceptual frame. The first item is derived from the overall analytical approach of this dissertation and focuses on how scholars problematise diabetes with a specific focus on lifestyle and behaviour. The second item is closely related to the problematisation of diabetes as it includes highlighting the practices (e.g. interventions and approaches) promoted as a response to the problematisations and as an attempt to govern lifestyle. The third item is used to highlight which key themes can be identified across the studies. The fourth item is used to identify events and developments highlighted by the articles to create an overview of the significant developments and understandings of diabetes, lifestyle and self- management. In this step, I also conducted a backwards chain search in the reference lists of the most relevant studies in order to retrieve earlier publications of relevance.

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In setting up these principles for the two parts of the literature review, I aimed to retrieve studies that shed light on diabetes, lifestyle and self-management from a range of disciplines such as anthropology, public policy, psychology, sociology, epidemiology and medicine as well as interdisciplinary studies. The combination of these reviews can enable the dissertation to illustrate how lifestyle is not just discussed and used based on the specific pathology of diabetes but rather in a wider social and political agenda. In the following sections, I present the results of the literature review. The first part of the review focuses on the literature that is critical towards the concept of lifestyle including the government and self-government of lifestyle. This review links directly to the conceptual contribution of this dissertation that attempts to highlight the relations of power in diabetes care. It is structured according to themes based on the literature. The second part is an empirical review and summarises the international and Danish literature on diabetes. It is structured into sections that will account for literature published first in the 1950s and 60s, second in the 1970s and 80s, and third, up until and through the 1990s, and finally the Danish medical literature on diabetes, lifestyle and self-management but with a specific focus on prevention strategies in Denmark. These sections are divided into themes based on an interaction between the problematisations and key concepts in the literature and the interests and key concepts in the dissertation. A comparison of the decades will be described in the final summary of part two. The chapter will be concluded with a section describing the link between the literature review and the three sub- questions of this dissertation.

2.2 Part one: the politics of lifestyle The section summarises the identified critical social science literature on lifestyle. The focus will be on tracing the theme of lifestyle and the ways in which the literature addressed the government of lifestyle through three themes: (1) lifestyle and health, (2) lifestyle and the social, and, (3) lifestyle and individualisation.

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Lifestyle and health Lifestyle in relation to health is often traced back to the early 1970s and 1980s (Vallgårda, 2009; Pedersen, 2010; Vikkelsø, 2010; Larsen, 2012; Weisz, 2014; Mayes, 2016; Foth and Holmes, 2018) and more specifically to two central policy documents: a working paper, often termed ‘the Lalonde report’5, from 1974 titled ‘A New Perspective on Health’ by the Canadian Ministry of Health (Lalonde, 1974) and the Ottawa Charter of the WHO from 1986 (World Health Organisation, 1986). It is noted how the effects of lifestyle and thereby personal responsibility on health have surfaced and resurfaced throughout time since the ancient Greece and Rome (Larsen, 2010). Accordingly, scholars do not contend that lifestyle politics was invented by these documents; instead, the documents represent a crystallisation of the ambitions of public health in the decades to come in which a range of chronic diseases were linked to self-imposed risks and destructive habits of certain lifestyles (Larsen, 2010). For instance, it is argued that the Lalonde rapport significantly changed the way we perceive illness from something that happened to us to something that has to do with individual risky behaviour (Weisz, 2014, p. 174). It is furthermore advanced how the Ottawa Charter has inspired health policies in a range of countries, including the Danish, from the late 1980s and the decades to come (Larsen, 2010; Frandsen and Triantafillou, 2011). Thus, according to these scholars the need to manage lifestyle gradually becomes a political ambition. Some scholars have explored the focus on lifestyle in health policies following the Lalonde report and the Ottawa Charter under the heading “new public health”. They term this a new governmental health paradigm signalling health systems’ broader conceptualisation of health, which entails a moral enterprise involving prescriptions of how individuals should live and conduct their bodies (Petersen and Lupton, 1996). According to scholars, this health paradigm has gained appeal among professionals and authorities due to its adoption of language adopted from empowerment and social change emphasising the need to overcome social inequalities in health by promoting a holistic approach that emphasises equality, social support and community participation (Petersen and Lupton, 1996; Andersen et al., 2011). Thus, through the “new public health” it is

5 Marc Lalonde was the Canadian Minister of National Health and Welfare from 1972 to 1976.

Governing lifestyle advanced how more territories and objects of public health strategies are being addressed by a broader understanding of health and illness to also include general notions of well- being. Several authors observe that during the 1970s and 1980s the attention to risk factors facilitated a focus on risk factors emerged as a major part of health promoting and disease preventing strategies (Minkler, 1999; Weisz, 2014). Armstrong (1995) suggests that during the twentieth century a reconstruction of the understanding of illness emerges exemplified by a shift from ‘hospital medicine’ to a new ‘surveillance medicine’. In brief, hospital medicine viewed the patient’s body as a three-dimensional object in which illness was understood as a relationship between symptom, sign and pathology within the patient’s body and with the hospital as the primary medical space. The new surveillance medicine entails a focus on “the observation of seemingly healthy populations” (Armstrong, 1995, p. 393). Armstrong describes how the emergence of ‘social’ diseases (such as neuroses, tuberculosis, venereal diseases) required a more comprehensive health care, including community care and surveillance practices such as screening. Moreover, this new medicine dissolves the distinction of health and illness as a person could no longer be understood as either healthy or ill, and aspects of lifestyle increasingly became a concern for health strategies. This blurring of healthy and ill required a focus on the extracorporeal space, in which the medical gaze must leave the hospital and enter into the population. The aforementioned focus on symptoms, signs and illness is substituted with a more general focus on risk factors (Armstrong, 1995).

Lifestyle and the social The social as a territory of health intervention has been explored by several scholars. For instance, Foucault-inspired studies have analysed how technologies of insurance have formed the basis of the conception of risk in the development of the welfare state (influenced by what is termed welfare planning) in especially the 1960 and 1970s (Rose, 1996b; Villadsen, 2004; Mik-Meyer and Villadsen, 2007). Referring to the work of Donzelot and Ewald (see for example Donzelot, 1988; Ewald, 1991), Villadsen (2004) describes how social insurance technologies in the welfare state consider social problems as aleatory in nature and as occasional events rather than as a will of fate or as

2. Literature review someone’s fault. These technologies seek on one hand, to compensate for illnesses and accidents that have already occurred by compensating the individual economically in order for the individual to maintain a certain way of life, and, on the other hand, to calculate the incidence of illness and divide the economic burden among the collective of insured. The idea behind the welfare state is to spread risk, or in other words, to socialise risk through insurance based on social solidarity. This entails that citizens are to view themselves as vectors of the same forms of risk but that different social conditions and social structures mediate their ability to manage these risks. These government technologies emerged with a focus on occupational injuries but were extended to consider among other things unemployment and illness (Villadsen, 2004; Mik-Meyer and Villadsen, 2007). In the same vein, scholars observe how the British health system in the 1950s focused on spreading the movement of social medicine movement promoting the idea that health status was tied to social conditions. The discipline of Social Medicine sought to apply social sciences into medicine to improve both social conditions and health status of the population. Scholars point of that whereas social medicine before the 1950s had a political ambition of creating a universal distribution of health as part of the broader discourse of the Welfare State, the social medicine movement in the 1960s gradually became more institutionalised and less political. It is argued that the meaning of the social transformed in the UK entailing that the major sociological determinants for disease was conceived as manageable components of social behaviour rather than broad structural conditions difficult to act on (Porter, 2002; Weisz, 2014). Thus, health as a social right and a political entitlement ceased to be the main focus; instead the focus was to “reform social behaviour to maximise the chance of health and minimize the threat of disease” through “preventive medicine that looked to reform personal and social behaviour rather than the reform of social structure as the route to a healthy society” (Porter, 2002, p. 76). Following this line of thought, it is argued that the contemporary focus on prevention thus “reframes ‘bad luck’ into ‘blame’ and ‘fate’ into ‘risk’” (Peeters, 2013b, p. 24). In a similar way, Villadsen argues that the contemporary Danish welfare state has moved from focusing on welfare planning and collective insurance technologies based on

Governing lifestyle social rights and structures to a neo-philanthropic social work that predominantly focuses on the citizens’ relation to themselves. Strategies such as empowerment and social contracts between citizens and the state now predominate (Villadsen, 2004, pp. 634–6). Rose (1996b) suggests that the social — understood as a particular sector in which the state in the name of the social governs the nation in the interests of social protection, social justice, social rights and social solidarity — is dead or has mutated into the community. In the community, human beings are conceived as individuals who are active in their own government, changing the division of responsibility between state and citizen (Rose, 1996b, p. 331). To return to the subject of lifestyle, many studies emphasized that not only the health domain but also the social domain has become a territory for disease prevention to shape the choice of lifestyle in the population (Højlund and Larsen, 2001; Bernier, 2009; Ljungdalh and Møller, 2012). For instance, scholars note that lifestyle politics in the last decades are increasingly detached from health in a strict sense as the social is seen as a possible cause for so-called lifestyle diseases (Larsen, 2010; Ljungdalh and Møller, 2012). Moreover, it is argued that when lifestyle inhabits the social, health policy is not only to be regarded as a reactive policy to individuals and their habits but as a proactive policy that seeks to pre-form the social environment and the choices of individuals so that dangerous lifestyles never will happen or their existence will be minimized (Højlund and Larsen, 2001).

Lifestyle and individualisation As indicated earlier, scholars observe how the concept of lifestyle links individual health status with personal behaviour and habits. Many of these scholars – some referring to the new public health – emphasise how public health policies increasingly advocate a withdrawal of the state in favour of a choice agenda and a greater emphasis on the entrepreneurial individual (Petersen and Lupton, 1996; Mol, 2008; Larsen, 2010; Mayes, 2016). More specifically, several scholars argue that contemporary health policies draw on neoliberal rationalities and discourses of shifting the responsibility of ensuring public health from the state onto individuals themselves (Petersen and Lupton, 1996; Osborne,

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1997; Foth and Holmes, 2018). This argument is most significantly illustrated by Rose in the statement: “modern individuals are not merely ‘free to choose’, but obliged to be free, to understand and enact their lives in terms of choice” (Rose, 1999, p. 87). Consequently, in recent studies individualisation processes have been investigated in a vast amount of literature on the new public health. These studies critique how public health strategies tend to individualise risk and lifestyle, which are in fact social problems, and suggest that special attention must be paid to vulnerable groups (Andersen et al., 2011; Henderson et al., 2014) and that a more holistic approach to self-management is needed to incorporate the challenges posed by the social environment and social factors (Morden et al., 2012; Ravn et al., 2016). Mayes similarly finds that one of neoliberal strategies in public health is the crucial focus on responsibility, essentially de-politicising health and reducing the public to the private, which inhibits and neglects the discussion “of the political nature of the structural factors that condition the choices and practices of individuals” (Mayes, 2016, p. 148). Rose contends that presuppositions in the second half of the twentieth century about self-hood are infused with techniques that are not represented or regulated as matters of obligation or conformity to a moral norm but as lifestyle decisions made by autonomous individuals seeking to fulfil themselves and gain personal happiness (Rose, 1999). In this light, more recent studies point out that a new type of rationality has come to the fore in recent health programmes, which not only presupposes the potential resistance and disobedience of citizens but also utilises such resistance to produce health (Bramming et al., 2011; Ljungdalh and Møller, 2012). According to scholars, these programmes imagine a patient-subject that maintains health by working on their lifestyle while at the same time acting as an autonomous human being that can balance pleasure and desire while continuously being attentive to their own well-being (Gudmand-Høyer, 2015; Karlsen and Villadsen, 2016; Kirkland and Raphael, 2018). In the same vein, several scholars have demonstrated that preventive and health promoting activities challenge the traditional role of the doctor as the expert (Karlsen and Villadsen, 2008; Andreassen and Trondsen, 2010; Kjær and Reff, 2010). It is promoted how health professionals are expected to act as facilitators of a patient who is imagined to

Governing lifestyle be autonomous and self-governing (Dahlager, 2005; Armstrong, 2014a; Pii, 2014). Thus, the legitimacy of the health profession increasingly relies on the patients’ recognition of professional knowledge and expertise (Funck, 2012) and less on the specialised knowledge it possesses in the capacity as a medical profession (Järvinen and Mik-Meyer, 2012; Larsen, 2014; Gudmand-Høyer, 2015).

2.2.1 Closing remarks This section has summarised the critical social science studies on lifestyle through three themes. First, the 1970s seems for many authors to mark a significant change in health politics with the introduction of lifestyle. It is noted how health policies increasingly are concerned with how illness can be prevented through an attention to risk and the modification of lifestyles. Second, with regard to the social, scholars promote how the social plays a new role in light of the attention to risk factors. The social is seen as a cause for certain lifestyle diseases instead of social inequalities of which citizens should be compensated. Following this, health policies are attentive to social factors that can cause illness and seeks to modify social surroundings and the choices of individuals. Third, scholars promote how the focus on lifestyle is linked to individualising processes in which the responsibility for health status moves from the state to the self-governing individual who is imagined as autonomous and entrepreneurial. Specifically, it is highlighted how health programmes presuppose citizens who do not act according to established health norms by seeking to install a patient subjectivity that by themselves balance between well-being and healthy behaviour. Moreover, scholars note how not only the patient subjectivity is implicated, as health professionals are encouraged to act as facilitators rather than medical experts in preventive activities. These themes have guided my reading of the medical literature on diabetes which is summarised in the following sections.

2.3 Part two: how did lifestyle emerge in diabetes care? Part two of this literature review will show how lifestyle emerged in diabetes care. The focus will be on highlighting the descriptions made by medical and interdisciplinary

2. Literature review scholars of the key terms lifestyle and self-management in diabetes. Following the previous review, I will attempt to illustrate the difference between behaviour and conduct by drawing attention to when diabetes care is about changing the behaviour of patients, i.e. governing directly through the observable and pathological behaviour of patients, and when it is about optimising the patients’ conduct, i.e. governing indirectly through the non-pathological conduct of patients. First, I will account for the literature in the 1950s and 60s, then the 1970s and 80s and lastly the 1990s.

2.3.1 1950s and 1960s This first section will present literature published in the 1950s and 1960s focusing on, first, the medical understanding of diabetes revolving around the problem of patient behaviour, and, second, diabetes knowledge and education. The sections will illustrate how scholars in this period was especially concerned with a pathological understanding of diabetes in which the focus was on behaviour related to diet and psychological problems.

The medical approach to diabetes: problems of behaviour In the medical literature’s descriptions of the role of patient behaviour in diabetes treatment, scholars noted how problems relating to the behaviour of patients had been a focal point in diabetes care since the seventeenth century (Hinkle et al., 1951b; Surwit et al., 1983). To demonstrate, before the discovery of insulin, diet was essentially the only treatment to offer diabetics (Pedersen, 1987) and it is observed how the relationship between diet and glycosuria (the excretion of glucose in the urine) was documented long before the development of a clinical understanding of diabetes (Hinkle et al., 1951a; Tunbridge, 1953; Treuting, 1962; Heins, 1983). However, according to medical scholars, the discovery of insulin in 1922 revolutionised diabetes care and changed the treatment options for diabetes as patients now died with and not of diabetes (Tunbridge, 1953, p. 894). The problem was now how to ensure that patients could live a normal life with diabetes, intensifying the focus on behaviour, such as diet and psychosocial behaviour (Hinkle et al., 1951b; Surwit et al., 1983). It is important to mention that at this time,

Governing lifestyle scholars were aware of aetiological differences in forms of diabetes6 (i.e. type 1 and type 2). However, they did not report on any significant changes in the treatment methods at the time or make distinctions between the two forms in their studies, often treating them under one heading, i.e. diabetes mellitus. To some extent, this was due to the observation that diabetes mellitus was not well understood at this time (Treuting, 1962; Guthrie and Guthrie, 1983). To return to the subject of behaviour, some discussion existed in the literature of what had been given the most focus in the understanding of diabetes ‒ the physiological or the psychological problems associated with the condition. For instance, some scholars claimed that the discovery of insulin triggered the dominating understanding that the cause of diabetes was to be found in the physiology of patients (such as diet) and less emphasis was given to psychosocial causes (Hinkle et al., 1951a; Beaser, 1956; Treuting, 1962). Nonetheless, American scholars in particular seemed to agree that medical practitioners began to focus more on the psychosocial elements of diabetes during the 1930s. They observed how this focus was followed by an increasing number of studies suggesting psychological, social and cultural causes for diabetes onset (Hinkle et al., 1951a). Accordingly, the focus on psychosocial and emotional factors of diabetes during the 1930s‒1950s developed into a framework termed “psychosomatic medicine” (Treuting, 1962; Surwit et al., 1983), which “regarded prolonged psychological conflict as a primary etiological variable” in diabetes (Surwit et al., 1983, p. 257). In two oft-cited studies, scholars observed that the onset of diabetes was related to “a setting of significant life stress” that not only seemed to cause “overeating behavior” but increased glycosuria (the excretion of glucose in the urine) and hyperglycaemia (high blood sugar) (Hinkle et al., 1951a, 1951b, p. 202). In the same way, other scholars suggested that psychological problems not only seemed to cause the onset of diabetes and

6 According to scholars as well as online databases on diabetes-specific knowledge, the discovery that diabetes could be classified into two types with distinct aetiologies was first made in the 1930s and was developed through the 1950s. Scholars observed significant aetiologically variations in forms of diabetes and several studies noted that a late-onset diabetes (middle-aged adults) appeared to be different from the “natural history” of diabetes that occurred in early childhood or adolescence6 (juvenile-onset diabetes) (Hinkle et al., 1951b; Tunbridge, 1953). In 1959, the terms “type 1” and “type 2” were proposed but they were not adopted before the 1970s (Gale, 2014).

2. Literature review other physiological symptoms, but that psychological stress caused the diabetic patient to have poor control over their dietary habits (Tunbridge, 1953; Beaser, 1956). In the same vein, the complex control and treatment regimen and the responsibility required by the patients to ensure control of their diabetes (often referred to as the maintenance of a stable blood glucose) could cause them to have psychological problems (Beaser, 1956; Treuting, 1962). It is worth noting that the physiological, psychological and social factors given as reasons for causing diabetes or poor diet were to a large extent described as external causes (Hinkle et al., 1951a; Tunbridge, 1953). For instance, it is highlighted that whereas it seemed easy to maintain good dietary control in hospitals, economic constraints often made it difficult for patients to control and follow a dietary regimen in outpatient care where they had to manage by themselves in their homes (Tunbridge, 1953, p. 897).

Diabetes knowledge and education According to medical scholars, there were several causes for poor control among diabetic patients, some of which were social and psychological. It was discussed whether and how adequate control of diabetes could minimise diabetes complications or prevent diabetes altogether. One scholar reported some uncertainty with regard to the benefits of good control (Tunbridge, 1953), while another scholar, a decade later, seemed to state without a doubt that optimal control of diabetes could eliminate serious complications associated with diabetes (Etzwiler, 1967). At any rate, the concern and discussion regarding good diabetes control ‒ and patients’ failure to follow treatment recommendations ‒ was linked to the need for adequate diabetes education to improve patients’ knowledge of diabetes (Tunbridge, 1953; Etzwiler, 1967). It was highlighted by several scholars that diabetes was a lifelong disease requiring lifelong self-care and more participation and responsibility on the part of the patient than most other diseases (Beaser, 1956; Etzwiler, 1967). Therefore, it was not questioned that patients needed to be knowledgeable of their diabetes. Beaser claimed that “the value of patient education has never been questioned, but the degree of success achieved currently has been” (Beaser, 1956, p. 146). According to a later review by Watts

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(1980), Beaser was the first to test the knowledge of patients in a systematic way, and he found that diabetes patients “were distinctly deficient in knowledge of their disease” (Beaser, 1956, p. 147). Scholars agreed that to remedy these failures and ensure good patient education, an individual and personal approach to the patient was required with the inclusion of the patient’s family if necessary as well as continuous supervision and permanent medical supervision (Tunbridge, 1953; Beaser, 1956; Etzwiler, 1967). The content of patient education was not well described, but it was noted that teaching dietary control to patients was a difficult task that demanded the active engagement of the physician with assistance from a team consisting of specialist nurses and dietitians (Tunbridge, 1953; Etzwiler, 1967). Beaser (1956) stated that education was about teaching the patient self-care and too much focus had been given to purely medical facts in diabetes education, which prompted a need for attention to psychological attitudes towards the disease. In the same vein, scholars noted how medical practitioners were often not equipped to manage these psychological and social problems causing poor control (Tunbridge, 1953; Beaser, 1956). Thus, scholars called for practitioners to be more attentive to individual patients, which required an understanding not only of diabetes but of the many personal and social factors making up each patient (Tunbridge, 1953, p. 899).

***

Overall, on the basis of the literature in the 1950s and 1960s it seemed that the problematisation of diabetes was not only concerned with the physiological but with the psychological and social aspects of diabetes. Diabetes was understood as a condition of which the patient was expected to practice responsible self-care according to the diabetes regimen prescribed by medical practitioners. According to the reviewed literature, the focus on patients’ behaviour in the treatment of diabetes patients had been the focus of diabetes treatment for many decades in which the aim seemed to be to relieve the patient of symptoms and complications. Thus, the problematisation of diabetes seemed to be predominantly pathological as it was concerned with medical aspects of diabetes that had

2. Literature review already occurred and needed some form of remedy. The inability of patients to follow the prescribed treatment seemed to be understood as external causes and the structure of their lifestyle that the patient had no control over, such as psychological or economic problems. On the whole, the behaviour of patients seemed to be conceived as caused by underlying structures in the patient’s life and not as something that the patient could immediately modify.

2.3.2 1970s and 1980s This section will account for the medical literature on diabetes in the 1970s and 1980s. This section will show this through four themes, some of which continue from the previous sections. The addition of themes serves as an illustration of how more aspects of the diabetic patient become of interest to medical scholars. Overall, based on these studies there seemed to a transformation in the approach to diabetes in which non- pathological aspects of the patient was problematised. Put another way, patients seemed to be expected to self-govern not only their behaviour in terms of diet and exercise but their conduct in terms of their minds and attitudes.

The medical approach to diabetes treatment: behavioural medicine In the 1950s medical scholars discovered several types of diabetes7. Despite this, the medical literature continued to study both forms of diabetes for several decades without addressing their different manifestations (Jenny, 1986). However, the differentiation of the two forms was significant as it marked a change in the medical understanding of diabetes and thereby in the treatment recommended. For instance, in the 1970s and 1980s it seemed that there was a consensus that both types had a genetic predisposition, but the symptom manifestation of type 2 diabetes was linked to environmental factors, such as dietary change, and decreased energy expenditure due to, among other things, the adoption of a more sedentary lifestyle (Eaton, 1977, p. 44). Although scholars noted that both types of diabetes required complicated self-care

7 To be clear, more recently several types of diabetes have been discovered, e.g. gestational diabetes (pregnancy diabetes), but this review will not go into this.

Governing lifestyle regimens that included similar behavioural components, they concurred that the self-care regimens vary with the type of diabetes (Wing et al., 1986, p. 78). Moreover, whereas dietary management for type 1 was a complex regimen, type 2 diabetes was associated with obesity and the treatment therefore focused on weight reduction. Type 2 diabetics could therefore be treated with any well-founded weight-loss programme as type 2 diabetics often had the same requirements as non-diabetics (Watts, 1980; Heins, 1983; Wing et al., 1986). Thus, whereas the dietary management for type 1 was regarded as complex, the dietary management recommended for type 2 mimicked the one recommended for the entire population. Similarly, and related, the optimal model for diabetes treatment and management was discussed in several studies in the 1970s and 1980s. Some medical scholars noted that a universal agreement on the optimal treatment did not exist in terms of diet, exercise, home monitoring of blood glucose, or patient education. This was mainly due to the failure to obtain evidence of the effectiveness of treatment methods in this period (Lane and Evans, 1979; Wing et al., 1986). This lack of evidence did not make scholars disavow the mentioned elements of diabetes treatment but rather made them call for more systematic studies. For instance, even though it had not been possible to obtain evidence of the effectiveness of dietary treatment or exercise on blood sugar levels, there seemed to be a persistent consensus that in addition to medication, diet and exercise were the cornerstones of diabetes treatment (Thomas, 1976; Heins, 1983; Smith, 1983; Wing et al., 1986). Meanwhile, medical scholars began to problematise earlier decades’ focus on psychosomatic medicine. They acknowledged the importance of studying psychological aspects of diabetes but argued that the old psychosomatic perspective on diabetes overemphasized the psychosocial aspects looking for causal links between psychological problems and diabetes. Moreover, scholars highlighted how the psychosomatic perspective had not been useful in helping patients and physicians manage diabetes (Skyler, 1981; Surwit et al., 1983). In contrast to the psychosomatic paradigm, which only intervened if psychosocial variables could be causally linked to diabetes onset or fluctuations, scholars promoted a new paradigm of behavioural medicine, which had

2. Literature review developed since the 1970s. According to scholars, the benefits of the behavioural model were the attempt to manipulate behaviours through the combination of psychological, biological and social aspects of diabetes, including the optimisation of skills to cope emotionally with diabetes, using the health services effectively and adhering to the treatment regimen (Smith, 1983, p. 586; Surwit et al., 1983). As one scholar noted: “[s]uccessful treatment of diabetes (…) depends entirely on how well the patient can change old behavior and maintain a new pattern of behavior” (Surwit et al., 1983, p. 261). In the same vein, several studies understood the focus on behavioural medicine in diabetes as an important strategy not only in the management of diabetes but in the prevention of diabetes as it attempted to work backwards from “pathophysiology” to identify behavioural interventions that could alter specific behaviour (Lane and Evans, 1979; Watts, 1980; Surwit et al., 1983). Not only did scholars promote behavioural medicine at the expense of psychosomatic medicine, but in some cases the behavioural perspective could also take the foreground at the expense of medical concerns:

(…) from a behavioral perspective, it would be advisable initially to simplify the demands made on the patient—even at the risk of sacrificing some degree of blood glucose control. What would be the advantage of prescribing a regimen for optimal blood glucose control if there were little chance that the necessary behavior changes would occur or persist? (Surwit et al., 1983, p. 261).

This implied an approach to diabetes in which the illness and related health problems were viewed as behavioural as well as medical. A key concern was therefore the patients’ ability to adapt to the necessary behavioural changes. As the quote illustrated, the focus on behavioural modifications was linked to patients’ inability to follow the prescribed diabetes treatment programme, which the next section will elaborate on.

Problematisations of behaviour and conduct Concomitantly with the development of the behavioural paradigm, several scholars during the 1970s-80s dealt with and described the knowledge patients needed to be able to self-care (Foster, 1973; Rosen, 1973; Simon and Stewart, 1976; Thomas, 1976; Miller et al., 1978; Budurowich and Lofton Jr., 1979). In continuance with studies from the last

Governing lifestyle two decades, scholars highlighted how patients had low levels of knowledge and understanding of their condition, which caused low levels of compliance with the recommended diabetes regimen (Simon and Stewart, 1976; Miller et al., 1978). In the early 1980s, studies distinguished between knowledge about diabetes in general and knowledge about how to manage diabetes in practice (Watts, 1980; Speers and Turk, 1981). In other words, they distinguished between knowing about diabetes and having the abilities to perform the tasks expected of them. The latter concern was supported by several scholars who noted that an increase in patient knowledge does not appear to have a significant effect on metabolic control or patient behaviour (Lane and Evans, 1979; Watts, 1980; Strowig, 1982; Hopper, 1983; Prater, 1983). Consequently, medical scholars advocated a focus on patient compliance to understand patient behaviour and non-compliance of patients not following their treatment regimens. Compliance included patients’ beliefs, actions and performance of particular procedures in the management of the disease (Lane and Evans, 1979; Watts, 1980). Thus, the focus on compliance seemed to supplement the focus on behavioural models and was an attempt to reframe the concern over patients not following their treatment regimen into a problem that could be solved. Thus, a critical concern in the diabetes literature was patients’ non-compliance with the diabetes regimen (Simon and Stewart, 1976; Lane and Evans, 1979; Speers and Turk, 1981; Strowig, 1982; Heins, 1983; Hopper, 1983; Surwit et al., 1983; Popkess- Vawter, 1983; Prater, 1983; Strodtman, 1984; Mason, 1985). Across the literature, scholars highlighted a range of causes of non-compliance. Some advanced social and psychological causes, such as socio-economic factors, patients’ social surroundings and psychological barriers, such as grief (Lane and Evans, 1979; Surwit et al., 1983; Brown, 1985). Others advanced the lack of systematised, formal and adequate patient education programmes (Miller et al., 1978; Strodtman, 1984; Leichter, 1986). Again others noted the failure to consider and include individual patients’ needs, abilities and personal resources in their treatment (Strodtman, 1984; Anderson, 1985). It was described how the heterogeneous causes of patient non-compliance in diabetes challenged traditional medical knowledge as compliance in the traditional medical sense implied that patients behaved according to the

2. Literature review prescriptions of physicians regardless of the relevance, understanding or practicality of the prescriptions (Surwit et al., 1983; Glasgow et al., 1985). Although non-compliance had been identified as a problem in the treatment of several serious conditions, scholars highlighted how diabetes specifically was likely to raise compliance problems (Watts, 1980; Speers and Turk, 1981; Surwit et al., 1983; Anderson, 1985; Wing et al., 1986). This was due to the complex self-care behaviour demanded of patients to regulate and achieve good metabolic control, which reached far beyond simple compliance with “doctor’s orders” (Guthrie and Guthrie, 1983; Anderson, 1985; Mason, 1985; Sims, 1986; Wing et al., 1986). The problem of non-compliance was furthermore linked to problematisations of the division of responsibility between patients and professionals in which too much responsibility was placed with the health providers, which also meant that they decided for the patient (Budurowich and Lofton Jr., 1979; Strowig, 1982). Thus, scholars contrasted diabetes with acute illness in which the “sick role” was assumed by the patient. However, in diabetes the patient must assume an “at- risk role” that lasts a lifetime and requires the patient to assume responsibility for managing daily activities (Simon and Stewart, 1976, p. 189), because although the physician could suggest strategies for improving metabolic control, the ultimate responsibility lay with the patient (Wing et al., 1986, p. 78). Thus, the medical literature appeared to understand diabetes as a special condition in terms of the kind of behaviour expected of patients, and patients’ ability to take responsibility was particularly important in diabetes care. In particular, type 2 diabetes was put forward as a problem of modes of conduct, in this case especially patients’ lack of responsibility for their disease. It was not only the patients’ job to own the responsibility, but professionals should divest more of the responsibility to patients. In continuance with the problems of non-compliance, some scholars proposed that more attention was given to the perspective of the patient. Directing attention to a conference on behavioural and psychosocial issues in diabetes held by the National Institutes of Health (NIH) in the United States in 1979, one scholar suggested using the term “adherence” instead of “compliance”. This might seem an insignificant distinction, but the rationale was that whereas compliance referred to a certain management of

Governing lifestyle diabetes, the adherence model recognised the patients’ perspective, including their support systems (i.e. families) and the “socio-environmental milieu” in which they lived (Prater, 1983, p. 284). Thus, this adherence model seemed to be an indication of the ambition to govern through the conduct, i.e. the minds and attitudes, of the patients and not only directly through behaviour. The distinction between adherence and compliance was related to a critique of the traditional medical approach and the emphasis on biomedical factors in diabetes care. Instead, scholars called for more holistic and individualised approaches to the management of diabetes to enable the inclusion of social structures to address their effect on non-compliance and health behaviour (Simon and Stewart, 1976; Lane and Evans, 1979; Strowig, 1982; Hopper, 1983; Popkess-Vawter, 1983; Surwit et al., 1983). For instance, it was problematised by some that the medical world had focused too narrowly on the biochemical processes and physiological factors of diabetes, such as metabolic control, at the expense of a focus on the patient’s resources (Budurowich and Lofton Jr., 1979; Lane and Evans, 1979). As expressed by one scholar, “physical aspects of diabetes have been the central focus of research for many years but it is now time to join our knowledge of the body with knowledge of emotions” (Popkess- Vawter, 1983, p. 777). One scholar advocated a broader meaning of health (which resembled the definition of health given by the WHO in 1948), emphasising that “health is not only absence of disease but the maximization of individual capabilities in accomplishing personal goals and achieving self-expectations” (Strowig, 1982, p. 1295). Similarly, another author framed this illustratively with two distinct descriptions of a person with diabetes: “you have diabetes” versus “you are a diabetic”. The argument was that the former statement maintained the wholeness of the person, i.e. someone who had many attributes, whereas the latter statement made diabetes the predominant description “encompassing all that the person is, has been and will be” (Mason, 1985, p. 1333). This highlighted a view of patients as more and other things than “just” ill as well as an attempt to distinguish between behaviour defined as the patient’s compliance with a specific treatment regimen, i.e. behaviour exclusively related to diabetes, and the conduct of patients in terms of more general notions of health and well-being, i.e. their own reflections of themselves, their condition and their situation. Here it must be clarified that

2. Literature review compliance was often used interchangeably with adherence by medical scholars. Moreover, the term “behaviour” was used differently by scholars. Some seemed to denote observable behaviour, such as exercise, diet and so on, while others seemed to denote behaviour as conduct, that is, the ability to self-manage, i.e. the way patients related to themselves in the disease process became a goal in itself. Thus, the distinction between adherence and compliance as well as behaviour and conduct were not univocal among scholars at the time, but it appeared that what was brought forward was an increased focus on patients’ resources and their ability to manage themselves. Moreover, this attempt to govern via conduct was proposed on the basis of a non-pathological problematisation of diabetes. By this I mean an approach to diabetes that was not derived from a medical understanding. When diabetes was problematised based on a non- pathological problematisation it seemed to be more about the identity of patients and the way they related to and governed themselves, which is somehow detached from diabetes as an illness. In line with this, several scholars promoted an approach in which the focus was to optimise self-management skills that seemed in some ways to be detached from biomedical aspects of diabetes. To demonstrate, some scholars promoted a problem- solving approach to diabetes in which the aim was to optimise patients’ ability to handle a diverse range of situations and not necessarily diabetes-related situations (Speers and Turk, 1981; Armstrong, 1987). This approach “(…) will help the patient deal with unique and difficult situations, especially high-risk situations that may interfere with adherence. Because the patient rarely will be faced with the identical situation, instruction in how to handle a situation should be geared toward generalization” (Speers and Turk, 1981, p. 148). Similarly, another study explored the possibility of developing treatment programmes that focused solely on the optimisation of patients’ self-regulation as an independent aim (Wing et al., 1986, p. 78). So, these approaches seemed not only to seek to transform the conduct of patients in terms of their desires and attitudes towards diabetes but enable them to actively manage any situation that might arise with their diabetes. In this way, scholars promoted patients with a healthier and more responsible conduct by transforming them into agents of their own health.

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Patient education It was pointed out by various authors that the 1970s in particular represented an increased focus on patient education both in diabetes research (Simon and Stewart, 1976; Lane and Evans, 1979; Leichter, 1986) and as a critical health-care resource in practice and not only in theory (Levin, 1978, p. 17). The increased focus on patient education was illustrated by the range of guidelines, programmes and conferences held to strengthen the use of patent education in diabetes treatment highlighted by scholars. For example, in 1972 a conference was held in Minneapolis on the “Education and Management of the Patient with Diabetes Mellitus” with the aim of developing a series of objectives for a comprehensive patient instructional programme. The programme consisted of guidelines on the roles of professionals and patients and outlined the knowledge, skills and behaviours necessary for self-management of diabetes (Miller et al., 1978; Etzwiler, 1980). And in 1976, the American Hospital Association published “Guidelines for Implementing Patient Education Programs in Hospitals” (Leichter, 1986). Finally, it is noted that the US National Health Promotion and Disease Prevention Act of 1976 recognised patient education and health education as a national priority (Lane and Evans, 1979, p. 30), and in 1980, one study reported that it was now the legal responsibility of professionals in the US to provide patient education (Dudley, 1980). Although there seemed to be a strong recognition of the theory of patient education and several authors claimed that it was translated into practice, a more recent study pointed out that at a meeting of the Diabetes Education Study Group (DESG) in Geneva in 1979, a physician delivered a talk entitled “Why is education still the Cinderella of diabetology?” The term “Cinderella” referred to something whose attributes were unrecognized (Hurley et al., 2017, p. 1957). This was corroborated by scholars who argued that only a few effective programmes for educating the diabetes population existed at the time (Prater, 1983; Anderson, 1985). Moreover, the aim of patient education seemed to differ. For instance, it was stated that:

[t]he major goal [of patient education] is to motivate the person to a self-care, self- management program that will achieve optimal control of his blood glucose and a sense of security and well-being. Control is defined as maintaining as near normal blood

2. Literature review

glucose as possible within a regimen that fosters good physical and emotional health. (Thomas, 1976, p. 163)

In line with the focus on governing through conduct, as I have outlined in the previous section, other scholars highlighted how patient education programmes should focus less on instruction on insulin and glucose self-monitoring, and more on enhancing controlled responsible behaviour and an active, independent, self-controlled patient with the aim of promoting and maintaining self-management and lifestyle modifications (Lane and Evans, 1979, p. 36; Glasgow et al., 1989). Another scholar explained the relation between clinical factors and self-managing skills in diabetes education:

Teaching the patient proper techniques in the survival skills needed to manage his diabetes is, of course, the first goal in diabetes patient education; however, equally important is providing the education necessary to help the patient become independent, i.e., to think for himself, to solve problems on his own, and to become more self- managing. Every patient should feel responsible for his own health. When this is attained, diabetic patients will feel like any normal, healthy individuals who accept disciplines in life and are well-adjusted, productive members of society. (Dudley, 1980, p. 128)

This quote illustrated the difference between pathological and non-pathological problematisation of diabetes and two distinct aims of patient education. Whereas the first had a biomedical focus on behaviour, i.e. the optimisation of blood glucose levels, the latter scholars seemed to advocate the enhancement of self-management as an aim in itself not necessarily related to the optimisation of blood glucose or any other clinical aspect of diabetes. These two approaches sum up the literature’s view on self- management at a time in which scholars were not clear on the aim. Similarly, scholars problematised how patient education was still based too much on the traditional biomedical approach. For example, one scholar observed:

Many health-care professionals still make the major decisions about what patients should do, and education is often seen as a means of persuading patients to view diabetes as health-care professionals do and to follow treatment recommendations. (Anderson, 1985, p. 32)

Similarly, others argued that educational approaches often neglected the decision- making process that involved the patient and took his or her overall needs and goals into

Governing lifestyle consideration (Strodtman, 1984). Several scholars emphasised that to individualise and tailor approaches, it was necessary to assess the individual patient’s knowledge, needs, abilities and personal resources before an intervention (Dudley, 1980; Watts, 1980; Speers and Turk, 1981; Strowig, 1982; Wing et al., 1986). The focus on assessing the needs of patients before an intervention indicated that the patients’ needs in terms of diabetes education were to be based on their desires and goals and not entirely on the medical professionals’ assessment. This implied that something within the patient was not immediately visible to professionals but must be cultivated through the patients’ relation with themselves. For some scholars, the focus on the inclusion of the patients was part of what is referred to as a major revolution in diabetes care, which, among other things, was asserted through a battle against the rise in health costs and a rebellion against professional authority (Etzwiler, 1980). The section that follows will illustrate in more detail how the role of professionals was problematised by scholars.

Problems of professionals It was observed by scholars that since the early 1900s the make-up of relevant health professionals in diabetes care and in health care in general had changed. From a health-care system consisting primarily of physicians with little ongoing service required, the emergence of new knowledge had made diabetes treatment more complex and difficult to manage, requiring new medical practices and medical teams of professionals with specific skills (Etzwiler, 1980; Guthrie and Guthrie, 1983). For instance, one scholar questioned the hospital setting as the preferred place for diabetes treatment and education (Miller et al., 1978), and another scholar highlighted the important role of general practice in the management of diabetics and their families (Smith, 1983). In line with this, one scholar promoted a supportive network of professionals, which included social workers, clinicians, nurses and psychiatrists that could provide patients with the ongoing assistance, supervision and education needed to achieve effective self-management in patients’ daily routine (Strowig, 1982). Accordingly, several medical scholars highlighted the role of the nurse in diabetes care (Simon and Stewart, 1976; Thomas, 1976; Hopper, 1983; Popkess- Vawter, 1983; Brown, 1985; Armstrong, 1987). In particular, it was argued that the

2. Literature review problem of non-compliance extended the treatment to nurses ‒ as well as to the community and to long-term care ‒ who were well suited to teaching self-management skills to patients (Simon and Stewart, 1976; Brown, 1985). In addition, scholars addressed the need for professional health educators or diabetes educators or professionals skilled in the teaching of adequate self-management for patients (Simon and Stewart, 1976; Miller et al., 1978; Dudley, 1980; Etzwiler, 1980; Anderson, 1985). According to one scholar, the task of diabetes educators was to improve the total care of the diabetic patient. This included ‒ in addition to teaching patients about diabetes complications and blood sugar levels ‒ an assessment of the patient’s knowledge and educational needs and each patient’s readiness to learn, as well as the optimisation of each patient’s ability to be mentally and emotionally prepared to deal with situations and problems as they occurred (Dudley, 1980, p. 128). Following the demand for professionals skilled in diabetes and self-management education, scholars advocated a change in the role of professionals. As was mentioned earlier in this chapter, medical scholars argued that patients should assume the majority of the responsibility for diabetes treatment as having diabetes required complex self-care measures. Scholars exploring the role of professionals supported this claim and called the traditional division of roles, in which the patient was passive, and the practitioner was the expert, inappropriate (Anderson, 1985; Mason, 1985; Baker, 2006). For instance, one scholar argued that while health professionals were still to be the experts in diabetes, the patient was the expert as regards his or her own life. Accordingly, the problem with non- compliance in diabetes care was not the behaviour of patients but health professionals’ inappropriate expectations regarding the behaviour of patients. To solve this problem, health professionals should focus less on the disease and direct their attention toward the patient (Anderson, 1985). Similarly, other scholars argued that diabetes educators and other health professionals should assume the role of a facilitator in which they attempted to facilitate patients’ self-management skills, understood as competent and autonomous behaviour (Strowig, 1982; Popkess-Vawter, 1983). Thus, these professionals were to teach patients to have a proactive approach to their diabetes.

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***

This section has provided a summary of the medical literature in the 1970s and 80s. On the basis of this literature, it seemed that although medical and psychological aspects of diabetes still took a predominant place, the conduct of patients were increasingly problematised as scholars began to distinguish between behaviour and self- management in itself, i.e. observable behaviour in terms of diet and exercise etc. and the conduct of patients. The distinction was not univocal, as the terms “behaviour”, “self- management”, “self-care” and “lifestyle” were often used interchangeably with different meanings. However, the focus on the conduct of patients seemed to follow a concern and wish to solve problems with non-compliance, i.e. that patients did not follow the diabetes regimen prescribed by physicians. Instead of focusing on patients’ compliance with a certain regimen, the term “adherence” was proposed to denote a concern with the patients’ own goals and needs. Thus, some scholars began to advocate an approach in which the essential element was not the disease or the pathology, or the specific elements of the diabetic treatment, but the person’s relation to her- or himself. Finally, some parts of the medical literature addressed the context and organisation of diabetes care, including the relevant health professionals in diabetes management. In line with the description of non-pathological problematisations of diabetes, scholars promoted professionals who did not have a narrow clinical focus on diabetes education but a focus that reached beyond the clinical factors to deal with the patient’s conduct.

2.3.3 1990s This section will account for four themes in the medical literature in the 1990s, with three of them being continued from the previous section. Overall, this decade to a large extent continued many of the problematisations of diabetes from the 1970s and 1980s but it appeared that the medical scholars intensified the ambition to govern through the conduct of patients and in this regard expanded the field of government in diabetes care. A key theme in this regard, was the prevention and health promotion strategies in the 1990s which entailed reaching beyond pathological/physiological factors

2. Literature review to the psychosocial ‒ factors that seemingly had nothing to do with the pathological ‒ to help patients to govern themselves but also as one element of what it meant to be healthy.

The medical approach to diabetes: problems of well-being Continuing the discussion on patient adherence and compliance from the earlier decades, scholars in the clinical psychological research tradition in the 1990s argued that although the technological development in diabetes had led to more sophisticated techniques for both the management and self-management of diabetes, i.e. provided the diabetic patient with important information about their condition through self-monitoring of their own blood glucose, people with diabetes still did not adhere to the recommendations for optimal care (Rubin et al., 1990; Goodall and Halford, 1991). According to these scholars, one of the reasons for the persistence of low adherence was that optimal care in diabetes had almost only been understood and measured as patients’ ability to achieve good metabolic control, which, although essential, was only one factor (Parrott, 1990; Rubin et al., 1990; Goodall and Halford, 1991). However, scholars argued that “doing everything by the book” did not necessarily lead to good metabolic control and, as had been argued by scholars since the 1950s, the stress of adhering to a complicated diabetes regimen could itself affect both the blood glucose and the self-care of patients. Accordingly, scholars proposed juxtaposing the focus on metabolic control with a focus on patient well-being and self-management skills (Rubin et al., 1990). Others argued that diabetes management should have a positive approach. The central aim should be to educate the diabetic to develop a more successful lifestyle and to deal with the problems typically faced by diabetics (Parrott, 1990). Similarly to this, scholars proposed that “self-management” was a more appropriate term than “compliance” and “adherence” to denote the behaviour of patients. Whereas compliance implied an authoritarian tone and the notion that non- compliance was caused by patients not doing what they were told or a lack of information, self-management suggested “a set of skilled behaviors engaged in to manage one’s own illness” (Goodall and Halford, 1991, p. 1). And in that regard, metabolic control did not provide a good measurement of self-management (Goodall and Halford,

Governing lifestyle

1991). Thus, in a similar way to the 1970s and 80s, a crucial distinction of patient behaviour was brought forward here. The self-conduct of patients had less to do with learning concrete skills to establish good metabolic control, such as blood glucose measurements etc., and more to do with a set of general life and problem-solving skills that in principle could be used in a range of situations other than diabetes. Thus, scholars placed emphasis on changing the way patients related to their diabetes and to themselves. For instance, one scholar focused on helping patients to have a more positive approach to diabetes instead of blaming external circumstances for their situation. This approach was derived from a cognitive-behavioural tradition and consisted mainly of methods to change the negative beliefs of patients to improve their ability to self-care, e.g. learn to live with limitations, keep the faith, and share their difficulties with family and friends (Rubin et al., 1990). Again, another scholar promoted the personal responsibility of patients, arguing that for patients to conduct successful self-care they must accept personal responsibility for having and treating their diabetes. The purpose was to help patients “discover their capacity to make choices that will empower and enrich their lives” (Anderson and Genthner, 1990, p. 278). As discussed above, there seemed to be a distinction in the way these scholars conceptualised the need to modify behaviour and the need to optimise self-management skills. In diabetes-related behaviour, the responsibility for treatment was not placed with the patient but with the physician, whereas when self-management was promoted the responsibility was with the patient. However, there seemed to be an ambivalence in the message of medical scholars. Patients were expected to conduct themselves as empowered patients but at the same time take responsibility for behaving responsibly in terms of self-care. Thus, scholars seemed to send a double message as patients were empowered to be autonomous but at the same time to be healthy in a certain way. However, it was not only the health and clinical psychological literature that focused on the responsible patient. In 1999, the WHO and the IDF (International Diabetes Federation) published a desktop guide to type 2 diabetes mellitus building on previous versions from 1989 and 1993 (World Health Organisation, 1994; International Diabetes Federation (Europe), 1999). By its own standards, the desktop guide had revised

2. Literature review its language to make it more comprehensible for the person with diabetes as “the primary resource for diabetes care is the person with diabetes themselves, supported by enthusiastic and well-trained professionals” (International Diabetes Federation (Europe), 1999, p. 716). In addition to recommendations on the clinical management of diabetes complications and risk factors, the management of diet and physical exercise, the guide emphasised that patient education should enable the person with diabetes to follow their chosen lifestyle. This was to be achieved through empowerment, which was defined as knowledge, behavioural skills and self-responsibility (International Diabetes Federation (Europe), 1999, p. 719).

Diabetes education: self-management as outcome In this decade, patient education continued to be a crucial element in the recommendations in diabetes care (Anderson and Genthner, 1990; Davis, 1990; World Health Organisation, 1994; Clement, 1995). A review study of the diabetes education literature between 1979 and 1999 found that the trends in interventions had gone from only providing education before the 1990s to providing a combination of education and behavioural models in the 1990s. This entailed a focus on empowerment, support groups, counselling, problem solving and contracting (Brown, 1999). Furthermore, authors seemed to make a distinction between educating patients in behavioural strategies and self-management education while at the same time promoting the use of behavioural strategies to promote self-management (Clement, 1995; Brown, 1999). Thus, the study seemed to use the terms “patient education” and “patient self-management education” interchangeably. Similarly, medical scholars denoted patient education with a variety of names and use these names interchangeably. For instance, one scholar termed it “diabetes self-management education” and defined it as: “the process of providing the person with diabetes with the knowledge and skills needed to perform self-care, manage crises, and make lifestyle changes required to successfully manage this disease” (Clement, 1995, p. 1204). Other scholars terming education “lifestyle education” described the content as including physical activity, nutrition knowledge, behavioural modification and self- management of weight (Hamilton et al., 1992). These examples not only illustrated an

Governing lifestyle ambiguous use of terms but also highlighted that even though there seemed to be more focus on the non-pathological problematisation of diabetes, there was still a focus on the pathological behaviour of patients and the attempts to make patients change this behaviour. With regard to patient education, scholars also discussed the outcomes of this approach. Where some studies argued that metabolic control and morbidity rate were the relevant outcomes (as had also been the most used outcomes historically), other studies suggested that indicators of conduct, such as self-management and emotional well-being, beliefs concerning diabetes, potential barriers to self-care, coping skills and patients’ social environment, should function as outcomes themselves and not merely as a means to achieve metabolic control. In other words, not only biomedical indicators should be the outcome of diabetes care and patient education (Rubin et al., 1990; Goodall and Halford, 1991; Clement, 1995). Thus, the outcomes of patient education, but also diabetes care in general, were, according to these reviewed scholars, not only about behavioural modification but also about optimising patients’ ability to self-manage, i.e. govern themselves, and to make lifestyle changes. As described earlier, this could be termed a “non-pathological problematisation” as it was not only the pathology of diabetes that was problematised but increasingly the patients’ selfhood that was problematised and thereby targeted in the literature.

Disease prevention and health promotion: an expansion of government In 1994, a WHO study group published the report “Prevention of Diabetes Mellitus” building on former WHO reports in diabetes that, however, did not have a specific focus on preventive activities (World Health Organisation, 1994, p. 1). According to the WHO study group, only a few studies had been published on the effect of preventative intervention in type 2 diabetes, although preventive strategies in diabetes care had been of interest for several decades. The overall aim of the report was to promote lifestyle change through prevention, such as the prevention of obesity, avoidance of specific high-fat and carbohydrate diets, the cautious use of diabetogenic drugs and increased physical activity. Among other things, the report promoted three types of

2. Literature review prevention. The primary prevention was aimed at individuals who had not yet developed a clinical diabetes diagnosis, so-called “susceptible” individuals or groups or “pre- diabetes”. This type of prevention covered both the modification of environmental and behavioural risk factors or specific interventions. The secondary prevention was aimed at undiagnosed individuals, i.e. individuals who had an undiscovered diabetes diagnosis. The aim was to detect diabetes earlier through screening methods allowing for an effective management of the condition to reverse or halt its progression. The tertiary prevention was aimed at individuals diagnosed with diabetes and included any measure to prevent or delay complications and negative health consequences. This included early detection, effective management, education and metabolic control as well as the reduction of major risk factors (World Health Organisation, 1994, p. 10). The first two forms of prevention were to be directed at so-called high-risk individuals but also at the wider population, for instance in societies with a high susceptibility to type 2 diabetes, thereby representing an expansion of the field of government. The overall aim was to prevent impaired glucose tolerance, which is also known as the “pre-diabetic state”. The literature had addressed early detection of diabetes before but the WHO report seemed to be the first systematic and health political attempt to systematise the early detection of individuals at risk of developing diabetes in the future. Similarly, scholars also promoted health promotion and disease prevention strategies as being important for all patients with type 2 diabetes. For instance, studies discussed screening directed at people at risk of developing diabetes, i.e. people with a family history of diabetes ‒ what the WHO called “primary prevention” in the earlier description (Dellasega, 1990). Moreover, another example of this kind of expansion of government through prevention strategies was three major prevention studies published in the late 1990s and early 2000s. According to a wide range of medical scholars, these studies provided evidence that diabetes can be prevented or delayed by intensive lifestyle intervention with more exercise, improved diet and psychosocial support (Roglic et al., 2002; Beck-Nielsen and Henriksen, 2012). The first was a randomised, controlled clinical trial from China (Pan et al., 1997), the second was from Finland (Tuomilehto et al., 2001) and the third was from the US (Knowler et al., 2002; Diabetes Prevention Program (DPP)

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Research Group, 2002). The three studies had in common the fact that they were concerned with reducing the risk of developing diabetes and thus not aimed solely at people already diagnosed with diabetes. The interventions consisted of weight reduction through diet and physical activity and behavioural modification, which were individually tailored to each person and supervised by experts. was All of them came to the conclusion that lifestyle interventions were more effective than drug treatment. The American study in particular described in detail the use of individual case managers or “lifestyle coaches”’ and the focus on individualised programmes (The Diabetes Prevention Program Research Group, 2002). As described in this review, the focus on prevention and lifestyle was not a new invention, and according to the studies themselves, their interventions built on the framework of other researchers who since the late 1970s had attempted to establish the effect of interventions to prevent the development of diabetes in people with impaired glucose tolerance (IGT), also known as the “pre-diabetic state”. These interventions include both drug trials and diet/exercise programmes (Pan et al., 1997). However, first in the 1990s a range of observational and intervention studies was published that, according to these studies, seemed to indicate that lifestyle interventions “might reduce the risk of developing diabetes” (The Diabetes Prevention Program Research Group, 2002, pp. 1–2). Thus, attention was directed at the pre-diabetic state as a field of intervention due to the seemingly untapped possibilities of preventing diabetes from developing. The preventive measures were essentially health promotion as they were based on lifestyle interventions to promote a healthy lifestyle in high-risk individuals, those who were in the pre-diabetic state. Thus, scholars and the WHO alike explored the benefits of intervening early by means of lifestyle interventions, targeting essentially healthy people (in a biomedical understanding). The expectation seemed to be that if at risk people could be identified and made aware of this risk, they would make the necessary lifestyle changes.

The expanded role of health professionals In the 1990s, scholars described how it was a persistent problem in diabetes care that health professionals such as nurses in hospitals and general practitioners showed

2. Literature review disinterest or lacked access to adequate knowledge to enhance patients’ psychological and cognitive abilities to self-manage diabetes (Davis, 1990; Galuk, 1990; Peyrot and Rubin, 1994; McCord and Brandenburg, 1995; Ahroni, 1998; Brown et al., 1998). Following medical scholars in the previous decades, scholars in the 1990s promoted the role of diabetes educators who could enhance not only the self-care and knowledge of patients but medical practitioners’ knowledge and interest in patient education (Davis, 1990; Ahroni, 1998). By contrast, other scholars directed the question of non-compliance or non- adherence away from patients to focus on the role of practitioners (Brown et al., 1998; Hunt et al., 1998; Larme and Pugh, 1998; Lutfey and Wishner, 1999). Some stated that not only did patients’ beliefs and attitudes towards diabetes inhibit adherence, but also that practitioners’ adherence to diabetes regimens and therefore their attitudes towards diabetes were of interest. They found that the medical system at that time was still mostly geared towards treating acute illness and not long-term conditions such as diabetes, which required the practitioners to act as facilitators of patients’ own self-management (Larme and Pugh, 1998). In particular, scholars emphasised how practitioners were rooted in a clinical context, neglecting the whole-life context from which patients derived their approach to managing diabetes and practising self-care (Hunt et al., 1998). Others ‒ continuing the discussion on compliance versus adherence ‒ highlighted the role of medical practitioners in problems of adherence in diabetes care. They expanded the definition of adherence as the inclusion of the patient perspective from earlier scholars:

The very word ‘compliance’ suggests that patients acquiesce to, yield to, or obey physicians’ instructions; it implies conformity to medical or medically defined goals only. The term ‘adherence’, on the other hand, captures the increasing complexity of medical care by characterizing patients as independent, intelligent, and autonomous people who take more active and voluntary roles in defining and pursuing goals for their medical treatment. The question of why patients might not adhere to regimens necessarily implies a broader social and personal range of issues than just the medical goals implied by ‘compliance’. (Lutfey and Wishner, 1999, p. 635)

The distinction between compliance and adherence was thus further developed in the 1990s as well as the imagined patients that professionals were to foster. Although the compliance term was problematised in the early 1980s, this excerpt indicated that the

Governing lifestyle authoritative practitioner who instructed the non-compliant patient was still viewed as a problem in diabetes care. The patient were to be viewed as having “more autonomy in defining and following their treatment” (Lutfey & Wishner, 1999, p. 635). By reframing the understanding of patient behaviour to a social paradigm, practitioners were enabled to expand the types of explanations and accordingly the types of solutions available for improving patient adherence. The concept of adherence introduced an element of collaboration in which patients could collaborate with physicians on changes to the diabetes regimen. However, it seemed not to change the end goal of improved health care and tighter diabetes control. Although this study criticised the compliance model for a narrow focus on “obeying” the physician’s instructions, the aim of their adherence model was similarly to solve patients’ adherence problems. The solution was “just” to include a broader social paradigm to understand patient behaviour than a strict medical one. This illustrated the difference between pathological and non-pathological problematisations. In this example, the end goal appeared to be the same, but in the latter problematisation more aspects of the patients were problematised to achieve a better understanding of why patients did not follow medical advice. This can be conceived as a double message from medical scholars. As mentioned earlier, patients were expected to conduct themselves as empowered patients but at the same time take responsibility for behaving responsibly in terms of self- care. This double message was illustrated here as the adherence imagined a patient with more autonomy, but the end goal was still adherence to a specific diabetes regimen.

***

This section has provided a summary of the medical literature in the 1990s. On the basis of this literature, this decade seemed to intensify the focus on the non-pathological problematisation of diabetes and the conduct of patients. This is illustrated through four key themes from the reviewed literature. First, the problem of achieving metabolic control continued to be an essential factor in diabetes care, however it was only one factor. This indicated that it was not only diabetes as an illness that was in focus but the

2. Literature review patient person. In other words, the conduct of patients was as important as the clinical factors. To be clear, the patient person that these scholars attempted to bring to life, was a person that suffered from an illness, but was encouraged to relate to herself as an active and responsible individual. Second, the recommended outcome of patient education by some scholars was not only to be a behavioural change but patient mental wellbeing and self-government. Thus, patients were not only problematised because of their diabetes, but because of their ability handle it. Third, the WHO and major prevention studies promoted preventive strategies to target non-diabetic people, i.e. were pre-diabetic or had unrecognised diabetes. This indicated an expansion in the ambitions of government to deal with not only people with diabetes but people who was considered at risk. In the same vein, another example of the expansion of the field of government in diabetes was the expectations of professionals at the time. The task of professionals was not only to get patients to conform to medical defined goals, but the goals should be defined through the perspective of the autonomous and active patient. Finally, scholars seemed to send a double message. On one hand, patients were to be empowered to make their own choices of lifestyle, on the other, they were to conduct themselves in certain ways. The next section describes the promotion of prevention and self-management in Danish medical diabetes literature.

2.3.4 The Danish development: self-care and prevention The purpose of this part of the review is to account for earlier Danish medical papers in the journal Ugeskrift for Læger that promoted diabetes self-care or prevention in relation to lifestyle. The first section focuses on the description of optimising patients’ self-care development of self-management strategies. The second section focuses on the development of prevention strategies in Danish diabetes care and the problematisation of diagnostic and screening practices in diabetes.

Self-care: responsibility and motivation In the late 1970s and early 1980s several Danish medical scholars promoted the view in Ugeskrift for Læger that patients should assume the main responsibility for the

Governing lifestyle treatment of their diabetes in their own homes with the overall aim of ensuring better diabetes regulation. To do this, scholars stressed the transferring of information and knowledge about diabetes to the patient (Bonnevie-Nielsen, 1978; Bøttger and Jørgensen, 1982). However, these scholars problematised ‒ similarly to the international diabetes literature ‒ the feasibility of achieving this due to the common problem of patient non- compliance. For instance, it was observed that an adequate dietary regimen seemed too complex to convey to patients because many patients had difficulties in following a diet regimen due to environmental factors in the patients’ everyday life (Bonnevie-Nielsen, 1978). Similarly, it is highlighted that it was common knowledge that guidance and instruction given in a consultation or ambulatory were often forgotten or misinterpreted by patients (Bøttger and Jørgensen, 1982). According to these scholars, the solution to these problems of non-compliance was to motivate patients and optimise their illness consciousness and ability to self-care. This was to be done by providing continuous instruction and control of diabetes either by providing diabetes education in patients’ own homes or by encouraging patients to more closely observe the progression of their condition (Bonnevie-Nielsen, 1978; Bøttger and Jørgensen, 1982). Almost two decades later, medical scholars were still discussing in Ugeskrift for Læger how best to enable patients to manage their diabetes and the emphasis was still on including the patient in the treatment to solve the problem of non-compliance. In particular, what one author termed a “patriarchal” model had to be replaced by a “partnership” model in which the patient was included as an equal and active decision- maker (Beck-Nielsen, 2000; Pedersen and Gæde, 2000). In line with this, one study claimed that prevention in the Danish health system had been predominantly conceived as persuading patients to do what they were told when in fact a much more pedagogical intervention was needed to enable lifestyle change. Accordingly, a pedagogical intervention could be “motivational interviewing” (based on an American approach to enhance behavioural modification) (Christensen and Lauritzen, 2002). According to scholars, motivational interviewing was disseminated in Danish medical practices through the 2000s (Christensen and Lauritzen, 2002; Vedsted and Christensen, 2007; Aspegren et al., 2008). The purpose of this approach was to promote behavioural change by urging

2. Literature review patients to analyse their own feelings between wishes of well-being and actual behaviour. In this way, the patients could make decisions on changing their lifestyle based on their own considerations instead of being persuaded by practitioners (Christensen and Lauritzen, 2002). Thus, this approach expected patients to navigate between necessary behaviour changes and their well-being.

Prevention: earlier diagnosing and screening A persistent discussion among Danish medical scholars ‒ following international scholars ‒ from the late 1970s until the present day concerned the diagnostic and screening practice of type 2 diabetes. Common for these scholars was the central role of general practitioners as most patients with type 2 diabetes were treated here (Deckert et al., 1979; Bøttger and Jørgensen, 1982; Astvad et al., 1989; Larsen, 1994; Beck-Nielsen and Pedersen, 1997b, 1997a; Moltke, 1997; Olivarius et al., 1997; Astrup and Madsbad, 2000; Pedersen and Gæde, 2000; Christensen and Lauritzen, 2002). Scholars were concerned with preventing or delaying diabetes complications as well as preventing diabetes in general. A study published in the late 1970s on the diagnostic practice in primary care suggested that not only should patients presenting normal and known symptoms of diabetes should be enrolled in screening strategies, but also patients without symptoms but in whom diabetes often occurred (i.e. patients with risk factors such as diabetes in the family, obesity and elderly patients). It is not recommended, however, to screen for patients with glucose-intolerance (later termed the “pre-diabetic state”) (Deckert et al., 1979). A decade later, scholars promoted a more extensive screening practice, which included general health checks of people in general practice to detect unrecognised cases of diabetes. Health checks were to be directed at people between the ages of 50 and 70 within specific risk groups (Astvad et al., 1989). However, other scholars argued that health checks were basically the screening of healthy people and could cause people to feel unnecessary guilt as certain lifestyle were linked with specific disorders. Moreover, not all who exhibited these risk factors developed the disease or were able to undertake the necessary lifestyle changes (Lauritzen et al., 1995).

Governing lifestyle

In the late 1990s and early 2000s, scholars argued that because diabetes was often diagnosed at a late stage, many patients at that time had already developed complications. Thus, an early intervention and screening was needed, and the treatment of risk factors rather than a diagnosed illness was justified (Beck-Nielsen, 2000; Pedersen and Gæde, 2000). Accordingly, scholars suggested a model for systematic screening of people with non-recognised diabetes and people at risk of developing diabetes, i.e. people in the pre- diabetic state (Beck-Nielsen and Pedersen, 1997b, 1997a). By these scholars’ own standards, no scientific evidence existed on the positive effect of either pharmacological or behavioural intervention on blood glucose levels in the early stages of diabetes. Nonetheless, behavioural modification had to be included on equal terms with pharmacological treatment as this was the cheapest and earliest treatment option available and made it possible for patients to obtain good health in general (Beck-Nielsen and Pedersen, 1997b; Beck-Nielsen, 2000; Pedersen and Gæde, 2000). Even though these scholars highlighted the risk of pathologising healthy people, they argued that when patients with diagnosed diabetes were asked to take responsibility for their treatment, the same should be asked of people at risk of developing diabetes. Accordingly, they had an obligation as doctors to inform people of their risky behaviour and provide people with a choice to change it (Beck-Nielsen and Pedersen, 1997b, 1997a). Thus, these scholars advocated an approach in which the responsibility for conducting a healthy mode of lifestyle were not only expected of diabetes patients but also of people at risk of developing diabetes. People were to be informed so that they could make the choice themselves. Other scholars argued that the consequences of such a comprehensive screening strategy must be considered. They opposed the idea of making test results into illness and thereby moving the conception of normality from health to illness. Finally, they argued that not even the US had implemented general screening of asymptomatic diabetes (Moltke, 1997; Olivarius et al., 1997). Some scholars rhetorically asked: “How many healthy people are we to screen to find one sick? How many healthy are we to treat to save one life?” (Olivarius et al., 1997, p. 3186). Although they concurred that lifestyle changes were essential in type 2 diabetes, they questioned whether a pre-diabetic diagnosis would make it easier for the patients to change their lifestyle ‒ moreover, they

2. Literature review highlighted that these lifestyle changes were recommended to all patients regardless (Moltke, 1997; Olivarius et al., 1997). Over a decade later medical scholars and practitioners proposed an even broader screening method as a means to decrease mortality and the financial costs of diabetes. An early detection strategy was proposed in a Danish newspaper in 2012, which entailed the screening of all individuals over 40 years old to detect unrecognised diabetes. In the same manner as a decade ago, this form of expansive screening model was justified by arguing that society could not leave these people in the lurch by denying them the knowledge of a possible diabetes diagnosis and the opportunity to change their lifestyle (Lauritzen and Borch-Johnsen, 2012). Again, other scholars were critical highlighting how this form of population-based screening was not recommended in Denmark or in most other countries and there existed no evidence of its effect. Instead, screening should – as was the then agreement in Denmark – only include people portraying risk factors for type 2 diabetes, i.e. obesity, hypertension, earlier gestational diabetes, a family history of diabetes, and cardiovascular disease (Beck-Nielsen and Henriksen, 2012; Olivarius, 2012). Thus, compared to the late 1970s, there seemed to be consensus on screening people in the pre- diabetic state but the screening of all was still discussed. Similarly and related, scholars from the early 2000s up until the present day have called for politicians and health administrations to develop more comprehensive prevention plans for diabetes (Astrup and Madsbad, 2000; Christensen and Lauritzen, 2002; Drivsholm, 2002; Borch-Johnsen, 2004; Beck-Nielsen and Henriksen, 2012). In their view, the rise in diabetes incidence could only be prevented by a major structural intervention targeting the three most important lifestyle-conditioned risk factors for diabetes: obesity, physical inactivity and diet (Drivsholm, 2002; Borch-Johnsen, 2004). Accordingly, scholars called for a radical reinvention of preventive strategies. For instance, one scholar noted how central policy documents published in the early 2000s by Danish Health Authorities8 and the Ministry of Health9 focused solely on the prevention of complications in already diagnosed patients. Instead, a future strategy should focus on

8 A Medical Technology Assessment on screening, diagnostics and treatment (Danish Health Authority, 2003). 9 The National Plan of Action for Diabetes (The Ministry of Health, 2003).

Governing lifestyle prevention on three levels, two of which were concerned with people who had not yet developed diabetes. First, primary prevention should be directed at healthy individuals through a population-based lifestyle intervention (diet and physical activity) in the public space with the aim of decreasing risk factors. Second, preventive strategies should target individuals in the pre-diabetes state, i.e. high-risk individuals. The challenge here was to identify these high-risk individuals. Third, there should be a prevention strategy aimed at individuals with manifest diabetes to prevent the development of complications through pharmacological treatment (Borch-Johnsen, 2004).

***

This section has provided a summary of the Danish medical literature from the 1970s until present time. In summary, the aim of diabetes care in the reviewed studies from 1970s and 1980s appeared to be to achieve a tight diabetes regulation and the enhancement of patient responsibility. It was promoted that because of the problems with patients’ non-compliance, emphasis should be put on motivating patients as well as optimising their self-care skills by a continuous control of their diabetes in which the patient should participate. In the early 2000s, Danish scholars still promoted the participation of patients to overcome non-compliance problems. However, at this time the goal seemed to be to achieve lifestyle change through pedagogical approaches in which the patients themselves should navigate between their well-being and necessary changes to their lifestyle. The patients were to be motivated to choose a healthier mode of conduct. Thus, in line with international scholars a pathological understanding of diabetes was supplemented with a non-pathological understanding of diabetes in which patients were encouraged to reflect on act on themselves as autonomous and responsible individuals. There existed some disagreement among medical scholars of how best to detect people with unrecognised diabetes and people at risk of developing diabetes. Scholars agreed, especially from the 1990s onwards, that lifestyle changes were crucial to diabetes. Moreover, common for them all was the concern with how and if diabetes and diabetes complications could be prevented by screening more comprehensively and

2. Literature review diagnosing earlier. Based on the reviewed studies, recommended screening and preventive strategies seemed to expand in scope as more people were to be included to be able to detect diabetes earlier – either to prevent diabetes from occurring or to prevent the development to diabetes complications.

2.3.5 Closing remarks The purpose of this review was to illustrate how lifestyle emerged in diabetes care in the international and Danish diabetes literature. In general, the review has illustrated that there were many continuities through the decades that mainly had to do with an expansion of the scope of diabetes care. In particular, how the government of the behaviour of patients was supplemented with the government of conduct. This is illustrated in the review by the addition of themes identified in the literature, which showed how increasingly more aspects fall within the government of diabetes and more importantly within the self-government of patients. The review of literature from the 1950s and 1960s illustrated how medical scholars have been concerned with the behaviour (in terms of diet and physical activity) of patients since before the discovery of insulin in the 1920s. I suggest how this focus on behaviour was based on a pathological approach and almost entirely had to do with diabetes as an illness of which the patient had no control or autonomy over except for being responsible for and learning how to diet and exercise according to the prescribed regimen. Compared to the 1950s and 1960s, scholars in 1970s and 1980s appeared to be concerned with a non-pathological problematisations of diabetes. To be clear, there was a continued focus on patients’ physical behaviour and to increase the knowledge and skills of patients through patient education. However, in addition scholars were concerned with optimising the compliance of patients. The focus on compliance rather than knowledge seemed to supplement the focus on behavioural models reframing the concern of patients not following their treatment regimen into a problem that could be solved. In other words, the apparent disobedience of patients was reframed into something productive. However, scholars also problematised the implications of compliance as it implied that the doctor was the authority and the patient was the compliant. Instead, the approach to treatment

Governing lifestyle and patient education should not only be suited better to the individual patient but include their perspective. The aim seemed to be to equip the patient to solve and adapt to any situation and complication they may encounter by installing in them general self- management skills. Thus, some scholars began to advocate for an approach in which the essential element was not just the disease or the pathology of the person, neither the specific elements of the diabetic treatment, but the person’s relation to themselves. This implied that the medical practice was no longer content simply to treat disease, but increasingly proposed to optimise the patients’ conduct in terms of how they relate to and act on themselves. As such, the focus on non-pathological conduct in the 1970s and 1980s can especially be illustrated by the distinction made by scholars between compliance and adherence. In the 90s three of the themes continued from the earlier decades and the theme of prevention strategies was added. This is not to say that prevention strategies were first thought of in the 1990s (see for instance Weisz, 2014), only that the literature seemed to advance prevention in terms of self-management and lifestyle in diabetes more intensively in the 1990s. It might be suggested that the themes were accompanied with an expansion of the field of government. Where the former decades seemed to be somewhat divided in their approach to behaviour versus conduct, the literature in the 1990s seemed to have accepted the optimisation of conduct as an integrated part of diabetes treatment. For instance, where the 1970s and 1980s showed indications of the non-pathological problematisation through scholars’ concern with including the patient’s perspective and own goals, the 1990s seemed to expect patients to be more autonomous. Again, the description of adherence served as an illustration. The concept of adherence in both time periods appeared to be concerned with the social and personal problems of diabetes patients as well as the critique of the compliance term for being too authoritative. Yet, whereas the adherence model from the 1980s did not describe a patient person as such but stressed that the patient’s perspective should be included along with beliefs and cultural background, the adherence term proposed in 1999 imagined a patient person that was more than just included in diabetes care. This imagined patient was described with a range of characteristics such as autonomous, intelligent and independent and expected to

2. Literature review participate actively in the treatment. It might seem like a small distinction. However, the patient in the 1990s were not only being asked to be responsible for their own self-care but for choosing a healthy lifestyle. Accordingly, the expansion of the field of government in diabetes care equally implicated the professionals deemed relevant and challenged the traditional medical knowledge. The literature especially highlights how this approach to diabetes now included a range of professionals that did not solely have a biomedical perspective on patients. In addition, what could be termed traditional health professionals, such as doctors and nurses, were also to act more motivating and be attentive to the resources and wished of the individual patient to enhance self- management skills, understood as competent and autonomous conduct. In general, the Danish development described by Danish medical scholars seems in general terms to follow international scholars. However, two elements can be mentioned. First the Danish summary show how screening and preventive strategies develop and become more extensive in scope as more people and more risk factors are included. Moreover, in the studies after 2000, the government through the conduct of patients was expanded to also include the patients’ ability to balance between behaviour and well-being both as a means for them to govern themselves better and as part of what it means to be healthy. Thus, based on this review especially two points can be made to draw lines to the overall framing of the analysis. First, the review has distinguished between pathological and non-pathological problematisations of diabetes to nuance the difference between behaviour and conduct. On one hand, when diabetes was problematised based on a pathological approach, the focus seemed to be on the physical behaviour of patients (such as diet and exercise) and the behaviour directly related to medical aspects of diabetes (such as blood sugar levels). On the other hand, when diabetes was problematised based on a non-pathological problematisation it seemed to be more about the identity of patients and the way they related to and governed themselves which is somehow attached from diabetes as an illness. In the non-pathological problematisation, illness is just one factor that contribute to the overall health and well-being of human beings. Thus, based on this review, I suggest that optimising self-government of patients was not only about

Governing lifestyle modifying the behaviour of patients but the conduct. Second, and related, this indicated an expansion of the field of government illustrated by a movement away from dealing not only with the illness and more with a general notion of health and wellbeing. Moreover, the discussion of compliance, adherence and self-management displayed the persistent logic of self-government. By their own standards, medical scholars through these time periods problematised patients’ actions towards adopting healthier lifestyles as well as achieving metabolic control. However, this failure was only taken as an argument for the need for further development and expansion of interventions. This expansion related to a double message from medical scholars that entailed a focus on the fostering of empowered patients who could act more autonomous and at the same time ensuring and expecting patients to practice successful self-care with the aim of achieving health and wellbeing.

2.4 Closing remarks on literature review One of the aims of this review of the critical social science literature and medical literature on diabetes has been to illustrate the relevance of the three sub-questions (stated in chapter one) guiding the empirical analyses of this dissertation. To be clear, the point of departure for the construction of these questions is the Foucauldian conceptual frame. However, this review of both medical and critical social science literature has helped to nuance the questions, the empirical analyses undertaken to answer these questions as well as the contributions of the dissertation as a whole. As shown in the summaries of both the critical social science literature and the medical literature, many elements contribute to the emergence of lifestyle in diabetes care. Thus, lifestyle seems on one hand to be governed by many scientific disciplines and forms of knowledge, and on the other, lifestyle seems to denote different things. The critical social science literature especially advances how the concept of lifestyle denotes the connection of personal behaviour and habits to the individual health condition. Thus, the basic idea of lifestyle is that it is based on the idea that that individual behaviour is an area of self-determination. In the medical literature, lifestyle seems to be employed in a range of different ways by health professionals, doctors, and politicians denoting, among other

2. Literature review this, underlying social structures, concrete behaviour and conduct of patients. Thus, one might say that lifestyle is a tainted concept. However, I employ lifestyle in this dissertation to grasp contemporary forms of biopower (this will be discussed further in chapter 3 and the discussion of the contributions of the dissertation in chapter 5). Based on this literature review, I employ the term lifestyle as entailing both forms of self-government: behaviour and conduct. The term lifestyle incapsulates that diabetes care is, on one hand, about changing concrete behaviour, and, on the other, about governing the conduct of patients to enable them to govern themselves. Thus, lifestyle is used as a governmental mechanism to govern both the health and the identity of individuals. This understanding of lifestyle has informed the central research question and the construction of the three sub-questions. In the following, I will outline how the research questions relate to both the conceptual frame and literature review respectively. In the concluding chapter of this dissertation, it will be discussed how the findings of this dissertation relate to the literature review and the conceptual frame. The first research question (How are rationalities of preventive lifestyle interventions in the social surroundings of patients employed in diabetes care in Denmark?) relates mainly to the critical social science literature as well as Foucault’s analytics of problematisation that enables a critical awareness of present practices that present themselves as facts or universal categories. By exploring how the social surroundings of individuals are employed in diabetes care, I aim to address the claim that contemporary preventive activities often entail a divestment of state responsibility and thereby individualise health problems. Thus, it also relates to the medical literature review as it wishes to explore the normative assumptions of the predominant amount of diabetes literature in which diabetes is termed a lifestyle disease demanding self-reflecting patients. The second research question (How – and with what implications – do problematisations of diabetes as a lifestyle disease inform the government and self-government of health professionals?) is especially derived from both the medical and the critical social science literature. This question especially takes its point of departure in the suggestion that we are witnessing an expansion of the field of government in diabetes care and the double message send by scholars. Answering this question, I aim to explore how health professionals practice the

Governing lifestyle task of empowering patients and include their experiences, knowledge and resources in the treatment together with the aim of ensuring successful self-care for patients and how this implicates the identity and self-conduct of professionals. The third research question (How are diabetes patients practicing their freedom (and shaping their lifestyle) in the context of interventions that seek to optimise their self-caring capabilities?) is informed in particular by the conceptual frame and Foucault’s notions of ethics and the conduct of conduct. However, the question is also informed by the insights from critical scholars who have explored neoliberal forms of government in which human beings through preventive health strategies are subjected as autonomous and self-governing as well as medical scholars who promote patients with more autonomy to participate in diabetes care. Taking this as a point of departure, the central aim of this question is to explore how patients practice self-conduct in the context of patient education programs with the relatively new expectation that patients not only have to adopt a healthier lifestyle but that they can balance between pleasure and health as part of what it means to be healthy and responsible.

3. Conceptual and analytical framework

Chapter 3: Conceptual and analytical framework

Maybe the target nowadays is not to discover what we are but to refuse what we are (Foucault, 1982, p. 785)

This chapter presents the dissertation’s overall analytical framework. The analytics of Foucault and the interpretations made by his followers are a key inspiration to this dissertation’s approach to analysing governing in diabetes care. This chapter makes use of texts by Foucault but will also rely on scholars that are more or less directly inspired by Foucault’s analytics of power, knowledge and subjectivity: in particular, academics focusing on governmentality and biopower in contemporary liberal societies, such as Nikolas Rose, Paul Rabinow, Colin Gordon, Sverre Raffnsøe, Peter Triantafillou, Thomas Osborne, Timothy O’Leary, and Kaspar Villadsen. The application of Foucault’s work as well as the conceptual contributions this dissertation seeks to make will be outlined in several sections. First, I explicate the overall analytical approach inspired by Foucault’s term of problematisation (Foucault, 1985, 1994b) and his approach to a non-normative form of critical analysis. I will also refer to this approach as a critical diagnosis of the present. Second, the next four sections provide an account of the concepts used in this dissertation, including the dispositive, governmentality, the analytics of government and ethics, and finally biopower. I will account for how these concepts are applied and have inspired the analytical frameworks and concepts of each paper. The section on biopower attempts to contribute by clarifying/elaborating the distinction between biopower and biopolitics. Third, in section 3.6, I advance the notion of biopower to answer the central research question and illustrate how the empirical analyses in this dissertation can be seen as a contribution to the existing understandings and use of biopower in contemporary liberal societies. More specifically, I show how this dissertation contributes to the concept of biopower by advancing three dimensions of an extension of contemporary biopower

Governing lifestyle to be able to grasp the neoliberal rationalities and techniques of contemporary preventive health politics. The chapter will provide brief examples from the three papers which are presented in Part two of this dissertation to illustrate the application of Foucault’s analytics in the papers as well as how they contribute in especially two ways to the concept of biopower. The papers were briefly introduced in Chapter one and will be introduced in more detail in Chapter four (section 4.3.1.) and Chapter five (section 5.1.). As mentioned in Chapter one, Foucault’s notion of biopower informs the analytical frame of the dissertation as a whole as well as the three papers. Although biopower is not explicitly mentioned in the papers, the empirical analyses of the papers show the continued relevance of biopower in contemporary preventative health politics — albeit in an expanded form. That is to say, that all papers in one way or another relate to the notion of biopower employed in health policies to optimise the lifestyle and health of the population. However, the notion of governmentality, including the analytics of government and ethics, is used to analyse the relation between knowledge, power and freedom in advanced liberal societies. As I will demonstrate, the papers of this dissertation investigate current forms of power over life within which I argue profound changes can be witnessed in our societies in the way health politics promotes prevention by which people are governed today.

3.1. Analytical approach: problematisation The overall analytical approach of this dissertation is inspired by Foucault’s forms of problematisation, which he discusses with regard to sexual behaviour in Greek and Roman societies as well as in Christianity in the second volume of The History of Sexuality (Foucault, 1985). Foucault points out that the question that has guided his analysis of the history of thought and the techniques of the self has, among other things, been why this problematisation? He contends:

It as a matter of analysing, not behaviour or ideas, nor societies and their “ideologies”, but the problematisations through which being offers itself to be, necessarily, thought— and the practices on the basis of which these problematisations are formed (Foucault, 1985, p. 11).

3. Conceptual and analytical framework

The quote exemplifies two distinct but interrelated aspects of the notion of problematisation that are particularly relevant for a critical analysis of the exercise of power: on one hand, it is applied as an analytical tool to critically problematise the contemporary exercise of power in liberal societies; on the other hand, problematisation is applied as an object of the examination of modern liberal power. More specifically, the object of analysis is others’ problematisations of diabetes and the way that human beings problematise “what they are, what they do, and the world in which they live” (Foucault, 1985, p. 10). These problematisations contribute to the rationalisation and structuring of the exercise of power and arise out of, for instance, social and medical practices (Foucault, 1985). To elaborate on the first aspect of problematisation, following Rose (1996a), this dissertation seeks to problematise contemporary preventative health politics by examining some of the processes through which the self-caring and autonomous ideal of the self have been invented. As an analytical tool, the notion of problematisation can be used to analyse how, for instance, the invention of new rationalities and techniques for governing and exercising power in diabetes care links to the production of a new order of knowledge (Rose, 1996a; Rabinow and Rose, 2003). To analyse power in terms of problematisation can alert the analyst to ask of any system how power operates and how it emerged, in which institutional context and in what historical circumstances (Snyder,

1984). As Gordon’s illustration of Foucault’s way of analysing power puts it:

[…] this type of analysis […] increases our awareness of the role of construction and the constructed in governmental landscapes and institutions, and of the way in which habit leads us to accept these constructions as facts of nature or universal categories (Gordon, 2000, p. xxiv).

Foucault’s problematising analysis of modern power (i.e. modern power exercised in Western European and North American societies after the Eighteenth century) has above all two foci: subjectification and knowledge. Subjectification entails examining how power is implicated in the ways in which we are formed as subjects by others and by ourselves. For instance, when investigating the history of psychiatry, Foucault understands practices, persons and institutions from “their location within a much wider

Governing lifestyle nexus of relations of knowledge, power and the production of subjectivities” (i.e. practices of freedom) (Rabinow and Rose, 2003, p. 8). The purpose of this form of power is to improve and produce certain subjects, not through force or coercion but through the shaping of the actions and the self-hood of free individuals (Mik-Meyer and Villadsen, 2007). This means that power is to be understood as productive as it only works through freedom, i.e. subjectification. Being free, thus, means having the capacity to act in several ways, including the possibility to resist (Foucault, 1982, 1994c; Gordon, 2000). Knowledge is intrinsically linked to power as Foucault understands the exercise of power as directly dependent on the production of knowledge, i.e. knowledge understood as scientific discourses, such as for example the social and human sciences, that is entailed in the production of subjectivities (Mik-Meyer and Villadsen, 2007). Knowledge is “governed by certain rules which establish what can be said truthfully at any one time, the criteria of evidence, the forms of proof and even the very object of which they can speak” (Rabinow and Rose, 2003, p. 7). Thus, to establish an area of intervention, e.g. the lifestyle of diabetic patients, entails, on one hand, relations of power that have established it as a possible target, and, on the other, techniques of knowledge and procedures of discourse that have made it visible as a problem in need of intervention and thus enabled power to target it (Foucault, 1978, p. 98). Rabinow and Rose (2003, p. 3) emphasise how Foucault’s notion of power enables us to visualise in detail the “workings of the forms of thought and practice that shaped our contemporary existence and experience”. This thought and practice are informed by a relation between power and truth in which power is a matter of the production of truth — truth understood not as preceding thought but as bound to and dependent on apparatuses such as the hospital, the clinic, the prison and the school for its production and knowledge (Rose, 1996a; Rabinow and Rose, 2003). These historically specific procedures, rituals and techniques involved in the ability to distinguish between true and false are termed the ‘regime of truth’ (Rose, 1996a; Foucault, 2002e; Rabinow and Rose, 2003). This dissertation seeks to problematise contemporary preventative health politics by examining how the governing of diabetes hinges on the production of knowledge and the production of subjects.

3. Conceptual and analytical framework

The second aspect of problematisation in this dissertation entails an analysis of the problematisations of diabetes made by others and by the self (i.e. health authorities, professionals and patients). Foucault aimed to locate the forms in which a phenomenon is problematised, that is the forms in which a phenomenon becomes “an object of concern, an element for reflection, and a material for stylization” (Foucault, 1985, pp. 23–24). As advanced by Rabinow and Rose: “Like Nietzsche, for Foucault the most profound thought is that which remains on the surface. To analyse problematisations is not to reveal a hidden or supressed contradiction: it is to address that which has already become problematic” (Rabinow and Rose, 2003, p. 13). For instance, Vallgårda (2013) discusses how a phenomenon becomes a political problem. Vallgårda contends that the formulation of a problem already contains half of its solution. For instance, by categorising some diseases as lifestyle diseases, one has already identified the cause of the problem (lifestyle or behaviour), and thereby indicated the solution. Thus, to critically examine contemporary ways of governing, this dissertation looks for explicitly articulated problems that inform government to illuminate the forms of questions and answers that arise when certain phenomena or human behaviours are considered problematic. Problematisation as an analytical tool thus seems to provide a viable analytical framework to grasp phenomena that present themselves as self-evident and understand the relationship among the societal context, policy contents, political processes and political actors (Triantafillou, 2014), without giving an a priori place or significance to a local hotspot from which all events have their origin (Foucault, 1994). The analysis of problematisations is a crucial element in Foucault’s notion of genealogy — that is a practice of investigation that illuminate the “historical contingency of how we have become what we are” (Owen, 1995, p. 491) — as it specifically avoids having a normative or moral point of departure in which it can confirm or reject social practices. As Paul Veyne (1997, p. 181) puts it:

The Foucault-style genealogy-history thus completely fulfills the project of traditional history; it does not ignore society, the economy, and so on, but it structures this material differently—not by centuries, peoples, or civilizations, but by practices.

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It is important to stress that the works of Foucault are not considered general theory — neither by himself or others who have developed these works (Rose, 1999; Kelly, 2013). Instead, as Foucault states in his article ‘The Subject and Power’ (1982, p. 778), critical thought is central to his work:

Do we need a theory of power? Since a theory assumes a prior objectification, it cannot be asserted as a basis for analytical work. But this analytical work cannot proceed without an ongoing conceptualization. And this conceptualization implies critical thought—a constant checking.

Hence, the analytics of Foucault do not “have a distinct methodological inventory at its disposal. It signifies a research perspective in the literal sense: an angle of view, a manner of looking, a specific orientation” (Bröckling et al., 2011, p. 15). Applying the notion of problematisation and the two outlined aspects, it becomes possible to answer the question of how and why lifestyle became the locus of the problematisation of diabetes. Moreover, the fundamental purpose of Foucault-inspired analyses is to critically investigate how we are governed by others and how we govern ourselves. More specifically, the purpose is to analyse how we are made subjects of knowledge, of the exercise power over others and of the power we exercise over ourselves with a view to create more space for the exercise of freedom. As such, the ambition of this dissertation is to unsettle existing power relations and ways of thinking, to disturb and fragment what seems solid and necessary — not to predetermine judgement, but to make judgement possible (Rose, 1996a; Rabinow and Rose, 2003; Triantafillou, 2012). The crucial element here is that this is a non-normative form of critique. This form of critique does not attempt to tell people what to do or that they suffer from a false consciousness (Owen, 1995; Triantafillou, 2012). Accordingly, the crucial characteristic of a Foucauldian form of critique is not just to identify power in preventative health politics as supressing or stigmatising but to critically interrogate how to govern and more specifically “the art of not being governed quite so much” (Foucault, 1997, p. 29). In other words, the approach used in this dissertation aims to give the subject the right to question the truths by which they are governed — to enable them to not be governed quite like that, by these people, procedures and principles or purpose (Foucault, 1997).

3. Conceptual and analytical framework

Consequently, the works of Foucault are used here not as theory in the sense of a more or less universal framework for uttering the truth about society and power but as an analytical and conceptual framework to critically examine the functioning of power relations in a concrete historical and institutional setting. The analytical approach of this dissertation is not a genealogy; instead, the analytical approach adopted here intends to work as a critical diagnosis of the present (an elaboration of diagnostics of the present will follow in Chapter four. Such a diagnosis does not aim to evaluate the validity of a contemporary phenomenon (lifestyle interventions in diabetes care in Denmark) but is concerned with an examination of what is asserted in the political, professional and patient field of intervention following the problematisation of diabetes as a lifestyle disease. More specifically, it is concerned with a critical endeavour in which the truth claims made in contemporary preventive health politics are acknowledged, but their contingent character and practical effects are exposed at the same time (Owen, 1995). This dissertation aims to critically analyse modern government by grasping how the phenomenon of preventive lifestyle interventions turns certain issues in to a problem in need of intervention and how this is asserted in the relationship between the societal and political context and between professional actors and patients with diabetes. Finally, problematisation forms as a point of departure for all the empirical analyses in this dissertation as well as the methodological choices I made when analysing the empirical data. This will be elaborated in Chapter four, but at the most general level, I adopt Foucault’s nominalist approach (Bröckling et al., 2011; Triantafillou, 2012) in the analysis of empirical data (documents, interviews and field notes). That is, I take the actors arguments and mode of reasoning at face value rather than searching for hidden agendas and motives. Having outlined the analytical approach of the dissertation, the following sections will consist of a general account of the analytics of the dissertation including a brief outline of how they are applied as analytical categories in the papers.

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3.2. Dispositive In the text “The Politics of Health in the Eighteenth Century”, Foucault advanced how the development of medicine cannot be separated from what he terms a politics of health, in which disease is considered both a political and economic problem for the collectivity of society. This is not to say that the practice of medicine only is an object for state interventions. Rather, health and illness are problematised by a multiple of social instances and thus become an object for collective control measures that tries to regulate the social body. The state is only one of various actors that seek to address the health of a population (Foucault, 2002d). Thus, in Foucault’s view the practice of medicine is entangled with a politics of health and consists of power relations. To analyse these power relations, Foucault proposes the concept of the dispositive (in the mentioned text, the dispositive is exemplified by the practice of medicine, although Foucault seems to apply the concept to analysis of the relation between rationality and practices in general)10. In its most general sense, Foucault describes the dispositive as a system of relations between a multitude of heterogeneous elements, such as discursive and non- discursive elements, institutions, administrative measures and moral propositions, that surface at various points in time (Foucault, 1980). Foucault alludes to some specifics of the dispositive:

The biological traits of a population become relevant factors for economic management, and it becomes necessary to organize around them an apparatus which will ensure not only their subjection but the constant increase of their utility (Foucault, 2002d, p. 96).

In the same way that Foucault understands the notion of power as both intentional and non-subjective (Foucault, 1985), the dispositive seems to denote a complex, strategic linkage of elements. The dispositive binds all these elements into a network that is to be understood as a relation between rationality and practice. As such, the dispositive is

10 Foucault is never completely clear on the specifics of the dispositive, for which he also uses different terms, such as the apparatus or assemblage. Scholars discuss if Foucault is actually talking about the same analytics when mentioning these terms. Although, the analytics of the dispositive are employed and developed by several Foucault scholars, its application, compared to other elements of Foucault’ work, has received little attention (Rabinow and Rose, 2003; Raffnsøe et al., 2016b).

3. Conceptual and analytical framework employed to analyse “how forms of rationality inscribe themselves in practices or systems of practices, and what role they play within them” (Foucault, 2002b, p. 230). These practices can be analysed as programmes of conduct along two axes: prescriptive effects about what is to be done and codifying effects of what is to be known in the government of others and the government of ourselves (Foucault, 2002b). In other words, he talks of coupling a set of practices and a regime of truth, which forms a dispositive of power and knowledge, making something that does not exist able to become something (e.g. madness, disease, sexuality). Foucault stresses that this does not mean that these phenomena are to be understood as illusions. The set of practices that establishes them is real, thus making them real (Foucault, 2008). As such, a key objective in a dispositive analysis is investigating how forms of knowledge bring ways of thinking and acting upon others and ourselves into existence: in other words, mapping the exercise of power that takes place through forms of knowledge and rationalities and practices of freedom (Triantafillou, 2012). The concept of the dispositive can be further outlined by describing another term, eventualisation, which Foucault presents in ‘Questions of Method’ (a conversation in 1978), linking it to the notion of the dispositive (or the apparatus) (Foucault, 2002b, p. 226). Generally speaking, eventualisation consists of two functions: first, a theoretico-political function, which means breaking with self-evidence, for instance by illustrating a singularity in places where there often is alluded to a historical constant; second, a function of a pluralisation of causes to lift the weight on causality “by constructing around the singular event analysed as process a ‘polygon’ or rather a ‘polyhedron’ of intelligibility, the number of whose faces is not given in advance and can never be properly taken as finite” (Foucault, 2002b, p. 227). In this regard, the analytics of the dispositive are closely related to problematisation (described in the previous section). In his analyses, Foucault does not attempt to search for anything hidden behind events but to bring forward prescriptive events whose effects can be taken as face-value (Rabinow and Rose, 2003). At the same time, he seeks to breach the self-evidence that presents itself as obvious and on which our knowledges and practices rest (Foucault, 2002b).

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As such to impose a dispositive analysis entails an analysis of heterogeneous elements that come together in a form of network serving to render social phenomena problematic and in need of government intervention (Triantafillou, 2014). Rather than analysing the reality as such, it is a way of “demonstrating how different actions (viewed as prescriptive events) mutually eliminate each other, only to collectively outline a pattern and create a new normative level” (Raffnsøe et al., 2016a, p. 279). To clarify, the dispositive does not work in a deterministic fashion but is characterised by a flexibility in which rationalities by themselves can produce effects event though actions are not necessarily being taken or are successful (Foucault, 2002b; Raffnsøe et al., 2016a). In this dissertation, I apply the dispositive to critically examine modern forms of governing in diabetes care. I understand the dispositive as a complex network of heterogeneous elements that bind together forms of knowledge, exercises of power and practices of freedom in a strategic but un-intentional way. I will use the dispositive to analyse various practices within diabetes care and attempt to map these three aspects: 1) the problematisations that render the lifestyle and self-care of diabetes patients problematic and in need of intervention; 2) the exercise of power, by focusing on the government techniques and processes that seek to improve the self-governing capacities of both professionals and patients in diabetes care; and 3) the practices of freedom, in which professionals and patients govern and exercise power on themselves. It should be mentioned here, that although I suggest that the dispositive in this dissertation entails mapping knowledge, power and freedom, the dispositive as an analytical category is only explicitly mentioned in paper one, where I investigate the rationalities and problematisations of contemporary preventative health politics in diabetes care. Yet, in a general sense the dispositive informs all the empirical analyses and is visible in Papers two and three, in which I address the unfolding of power and the concrete practices of freedom – in other words, the self-government of and practices on which the actions of professionals and patients rest form part of the dispositive as well. In the next section, I will expand upon my application of the dispositive as a lifestyle dispositive (most explicitly in the first paper) to examine modern forms of government in diabetes care.

3. Conceptual and analytical framework

3.2.1. The lifestyle dispositive Foucault’s notion of the dispositive loosely guides the analytical frame in the first paper of this dissertation. Mayes (2016) employs the concept of lifestyle in connection with the dispositive and explores the obesity epidemic in Australia as an example of a biopolitical dispositive in which not only medical authorities or government health campaigns target individual lifestyle but also an entanglement of disparate forms of knowledge, exercises of power and practices of freedom seeks to govern the individual’s choice of lifestyle. In a similar manner to Mayes, I attempt to advance how contemporary preventative health politics represent an extension of a government of life informed by a lifestyle dispositive. The example of diabetes is employed to examine the way lifestyle is used as a governmental dispositive that attempts to govern institutions, professionals, communities and citizens according to prevailing health norms (and moral values) as well as how professionals and citizens govern themselves. Through the lifestyle dispositive I attempt to show how forms of government and self-government emerge are informed by a neoliberal problematic of government. The lifestyle dispositive is not determined by any particular health programme or the interests of a certain group of actors. In suggesting the existence of a lifestyle dispositive, I aim to denote a network of power techniques, bodies of knowledge and ethical self-practices that gazes at and seeks to govern the general well-being of the population by optimising the personal capacities and conduct of patients and citizens in general to align with prevailing health standards and moral and political principles of responsible behaviour in advanced liberal societies. To be clear, within the lifestyle dispositive power, knowledge and freedom are combined in a network. This makes diabetes care intelligible as such but only insofar as the dispositive itself is structured by knowledge, power and freedom. Moreover, by this term, I refer to Foucault’s expression “structuring the field of possibilities”. In doing so, I seek to denote an understanding of lifestyle as governed by history, by knowledge, by power structures and by techniques and self-techniques of subjects. Finally, the concept of lifestyle denotes both an analytical category as well as the concrete behaviour as it is talked about by authorities, professionals and patients.

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In Paper one, the application of the dispositive is employed to investigate how diabetes care is surrounded by a network of heterogeneous elements, such as distinct knowledges, connections, practices, instruments and techniques, which are to be rediscovered in order to make visible and breach their self-evident appearance. The main claim of Paper one is that the lifestyle dispositive not only informs a problematisation of the individual’s choice of lifestyle but also a problematisation of the social structuring of choice in diabetes care. The lifestyle dispositive connects the elements of a problematisation of self-care and a government of risk and makes visible how diabetes becomes a prism for neoliberal government, in which the ambition of government is to strategically intervene into the lives of individuals who display certain risk factors to optimise their self-governing capabilities. However, it is not only about transferring the responsibility to the individual but also about mobilising the social surroundings and relations to make the choice of a healthy lifestyle easier. I suggest in the paper that a structural reform acts as a promoter of the lifestyle dispositive. As already mentioned in Chapter one, the structural reforms significantly reorganised the Danish health system and, among other things, relocated the practice of health promotion, disease prevention and rehabilitation from the traditional regional health systems to local health centres operated by local governments. To clarify, it is not the structural reform per se that have brought about the lifestyle dispositive or even changed it. Neoliberal rationales in Danish health care predate these reforms (Højlund and Larsen, 2001; Larsen, 2010; Frandsen and Triantafillou, 2011). However, the local health centres provide an illustrative example of how rationalities as well as forms of knowledge establish diabetes as a condition that not only needs medical expertise but also patient self-care, the involvement and mobilising of lay knowledge and the social surroundings of citizens. Thus, I suggest that the reorganisation of the Danish health system to include a local level following the reform can be seen as a significant shift in the forms of knowledge informing the exercise of power and the practices of freedom in preventative health care. Specifically, I analyse two periods of the dispositive: how rationalities and problematisations unfolded before and after the structural reform. In period one, the dispositive is characterised by problematisations of optimising the

3. Conceptual and analytical framework individual patient’s ability to self-care and to choose a healthier lifestyle. In period two, the lifestyle dispositive is characterised by problematisations of the social surroundings of individuals to make the choice of a healthy lifestyle easier. As mentioned, the lifestyle dispositive is not explored explicitly in Papers two and three, but the lifestyle dispositive is investigated as linked to an extension of biopower in contemporary preventative health politics (please see section 3.6.). This means that in addition to biopower, the lifestyle dispositive comprises the backdrops for all the analyses in this dissertation. Yet, the analytics of Papers two and three are inspired by more recent studies of governmentality to grasp the exercise of power and practices of freedom in practices of diabetes care.

3.3. Governmentality In advancing the notion of governmentality, Foucault, in his 1978 lectures at the Collège de France, Security, Territory, Population, tried to grasp the state — not in terms of an actor or a set of institutions but in terms of the rationalities and technologies informing the exercise of power through and beyond the state apparatus. Governmentality denotes the emergence of governmental practices and their rationalities in which rule becomes a calculated management of the affairs of human beings to obtain certain desirable objectives (Rose, 1996a; Foucault, 2002a, 2007). Within the broad field of governmentality, government is to be understood in the broadest sense as the thoughts about and the practices engaged in the exercise of power over a state, territory and population. The notion of government is taken by Foucault to signify relations of power — i.e. the practice of commanding the conduct of others or of oneself (Foucault, 1982). As mentioned earlier, Foucault’s concept of power deviates from the classical usage within political science. Power in the Foucauldian sense is not a thing or a capacity but a complex set of strategic practices or techniques. Moreover, what differentiates Foucault’s understanding of power is that it is a productive from instead of repressive. As such, government is to be understood as relations of power that aim to structure the actions of others rather than to control, dominate or force them:

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Basically power […] is a question of government. This word must be allowed the very broad meaning which it had in the sixteenth century. ‘Government’ did not refer only to the political structures or to the management of states; rather it designated the way in which the conduct of individuals of groups might be directed […] To govern is […] to structure the possible field of action of others. (Foucault, 1982, pp. 789–90).

This quote represents not only the rationalities of government practices but also the importance of forms of knowledge and subjectivity, i.e. the relation between power, knowledge and freedom (ethics). As such, government is also a concern for a way of living or of life conduct (Gordon, 2000). The notion of government is the practice of commanding the conduct of others or of oneself. More specifically, power as government refers to a mode of action that acts on the actions of others by structuring their possible field of action: that is, the conducting of conduct. Ethics denote the power one exercises on oneself: that is, the conducting of one’s own conduct. Knowledge denotes the way we recognise ourselves and others as particular kinds of selves (Owen, 1995, p. 500). A key insight in Foucault’s notion of government is that power only exists when individuals are free to adopt strategies to modify these relations of power, i.e. power only works when there is freedom (Foucault, 1982, 1994c; Gordon, 2000). According to Gordon (2000, p. xxviii), the analysis of modern government provided Foucault with the true problem in the relationship between freedom and power, the problematic of government. Although the power relation can very often be asymmetrical or out of balance in the sense than one side has all the power, there must always be a certain degree of freedom on both sides for power relations to come into play (Foucault, 1994c). Being free, thus, means having the power to act in several ways and the possibility to resist. More specifically, Foucault suggests in his later writings that freedom cannot be reduced to the struggle against a dominating or supressing form of power (Foucault, 1985, 1994c). Foucault distinguishes between liberty, understood as liberation processes from total domination such as colonisation, and freedom practices that should be analysed as “the relationship of the self to itself and the relationship to others” (Foucault, 1984: 300). While liberation serves as a precondition for the possibility to practice freedom, processes of liberation at the same time pave the way for new power relations that must be controlled by practices of freedom (Foucault, 1994c).

3. Conceptual and analytical framework

3.3.1. The neoliberal art of governing In his ideas about problems of government, Foucault was in particular interested in the analysis of classical liberalism and neoliberalism in the context of modern Europe (Gordon, 2000). Especially in The Birth of Biopolitics (2008), Foucault advances the notion of neoliberalism as a specific art of government that works through freedom and with the aim of maximising freedom (the concept of freedom will be elaborated in more detail in section 3.4.2. in relation to ethical practices). Moreover, freedom is not to be understood as absolute autonomy (Foucault, 2008). Rose argues that liberal democratic governments “seek to govern through constructing a kind of regulated autonomy for social actors” in which individuals are “obliged to be free” (1996a, p. 100). Thus, autonomy is not to be understood as the absence of control or power (Rose, 1999) but as a form of power- freedom relation, i.e. strategic field of relations. Thus, individuals are not free to do nothing or everything but free to do something — they are free to refuse the individuality that is imposed on them (Foucault, 1982). This art of government consumes, produces and organises freedom and seeks to organise “the conditions in which one can be free” (Foucault, 2008, p. 64). Within the production of freedom, Foucault notes that there is always the danger of concomitantly destroying the very freedom this form of government seeks to produce. As such, the neoliberal art of government has a productive/destructive relationship with freedom (Foucault, 2008, pp. 63–4). Thus, following Foucault and others, neoliberalism can be understood as a form of governmental constructivism seeking to facilitate and regulate particular forms of freedom (Osborne, 1997; Rose, 1999; Foucault, 2008; Triantafillou, 2017). As Osborne notes, where classical liberalism seeks to address the dangers of excessive state interventions by acting only indirectly to preserve the natural ability for civil society to govern itself, neoliberal government technologies are direct, and the governing rationalities are fundamentally of a strategic nature concerned with the quest to nurture and direct the self-governing capacities of individuals, groups and organisations in ways that contribute to societal wealth and well-being (Osborne, 1997). The difference between liberalism and neoliberalism is also denoted by Foucault as the difference between two conceptions of the homo oeconomicus. In a classical understanding, that is eighteenth-century liberalism, homo oeconomicus is understood as

Governing lifestyle a self-interested and profit-maximising economic agent that is both the object and subject of laissez-faire, which means that he must be left alone (2008, p. 270). In neoliberalism (Foucault advances this by referring to Gary Becker’s definition), the subject of homo oeconomicus is:

the person who accepts reality or who responds systematically to modifications in the variables of the environment, appears precisely as someone manageable, someone who responds systematically to systematic modifications artificially introduced into the environment. Homo œconomicus is someone who is eminently governable (Foucault, 2008, p. 270).

Moreover, the neoliberal subject is “an entrepreneur of himself” (Foucault, 2008, p. 226). Scholars assert that public sectors in modern welfare states increasingly are dominated by politics of self-governance (Cruikshank, 1999; Dean, 1996; Miller and Rose, 1990; Sørensen and Triantafillou, 2009). Self-governance has become a prevalent or normative ideal that society has to live up to (Bramming et al., 2011). Drawing on Triantafillou, this problematisation of government can be termed constructivist neoliberalism, which denotes a neoliberal rationality that “seems more optimistic about the potential of state intervention” (2017, p. 48). This type of neoliberal rationality promotes the self-government of individuals as the chosen government form. Similarly, scholars — who predominantly, but not exclusively, draw on Foucault’s analysis of modern government — have noted that advanced liberal societies are placed in a permanent and unresolved level of complexity (Andersen and Pors, 2016). This complexity involves a tension between two dominant rationalities: liberty and authority (Peeters, 2013b), to govern or not to govern (Vallgårda, 2015), or in other words, how to intervene to secure life without excessively interfering in the self-governing mechanisms of the domains of government, that is the danger of governing too much and too little (Rose, 1999, p. 70). On one hand, these societies are witnessing public health strategies touching upon social control and a paternalistic state-citizen relationship following an increased wish to optimise the lives of the population. On the other hand, a resentment of excessive regulation by neoliberal governmental logics exists, exemplified by the emphasis on self-government through values such as personal freedom and individual autonomy and responsibility (Villadsen and Wahlberg, 2015; Borovoy, 2017). In this

3. Conceptual and analytical framework dissertation, I attempt to show how government rationales in diabetes care seek to inform the choices of the population so that individuals themselves will choose a certain lifestyle as well as seek to governmentalise the social milieu to promote specific behaviour from diabetic patients and citizens in general. The following section will exemplify how government and self-government (ethical practices) can be understood in the case of diabetes care as well as how the papers of the dissertation explore the relationship between government and ethics in diabetes care.

3.4. Analytics of government Having introduced Foucault’s notion of governmentality, this section will account for the application of the analytics of government and ethical practices, which are used in Papers two and three to examine the government and self-government of health professionals and patients respectively. More specifically, the focus is on how the problematisation of diabetes as a lifestyle disease explored through the lifestyle dispositive informs the relation between the self-government of individuals and the governing practices seeking to structure this self-government. Foucault’s notion of governmentality enables this dissertation to explore the relation between government and self-government and the kinds of agency human beings are capable of when dealing with themselves and others (Foucault, 1994c). As stated by Foucault:

[…] I believe that the concept of governmentality makes it possible to bring out the freedom of the subject and its relationship to others which constitutes the very stuff [matiere] of ethics (Foucault, 1994c, p. 300).

In this regard, governmentality studies are useful as analytical frameworks to examine this relationship without emphasizing either forces of domination or of supressed autonomy (Rose, 1990). Instead, the modern state is something else entirely:

I don’t think we should consider the ‘modern state’ as an entity that was developed above individuals, ignoring what they are and even their very existence, but, on the contrary, as a very sophisticated structure in which individuals can be integrated, under

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one condition: that this individuality would be shaped in a new form, and submitted to a set of very specific patterns (Foucault, 1982, p. 783).

Moreover, Foucault gives primacy to the analysis of practice over the analysis of institutions (Gordon, 2000). As forcefully put by Rose:

[…] far from offering a new theory of power, studies of government offer a perspective which brings into sight a domain of questions to be asked and practices to be analysed. In particular, they seek to interrogate the problems and problematizations through which ‘being’ has been shaped in a thinkable and manageable form, the sites and locales where these problems formed and the authorities responsible for enunciating upon them, the techniques and devices invented, the modes of authority and subjectification engendered, and the telos of these ambitions and strategies” (Rose, 1999, p. 22).

Inspired by this, the analytics of government in this dissertation will address the exercise of power and the practices of freedom, i.e. the relation between power and freedom of the lifestyle dispositive. The next two sections will briefly exemplify how I have applied the analytics of the government practices and freedom practices, drawing attention to Foucault’s model of ethical self-formation, analysed in Papers two and three. Government practices will mainly be outlined using examples from Paper two and freedom practices will be illustrated using examples from Paper three.

3.4.1. Analytics of practice of government In his analyses of practices of government, Foucault focuses on technologies of power that seek to structure the field of behaviour and conduct of human beings towards more or less conscious goals — in other words, seeks to structure the conduct of conduct. As mentioned, for power to function it depends on forms of knowledge that direct and inform the exercise of power. As such, technologies of power function both as specific instruments for governing as well as an underpinning of practical rationality by certain presuppositions and objectives of human beings (Rose, 1996a, p. 26). The second paper of this dissertation analyses the government and self- government of health professionals. The paper argues that modern welfare states increasingly rely on the self-government and self-regulation of individuals and society — not only the self-government of patients but health professionals as well. The government

3. Conceptual and analytical framework of health professionals is analysed through a disease management programme that outlines the organisational forms and expectations of health professionals in diabetes care (the methods will be elaborated in Chapter four). Especially, the notion of a neoliberal problematisation of government is illustrated in this paper through the professional figure, who is called the facilitating professional. This figure is urged by government practices to constantly reflect on her expertise to enhance the self-caring capabilities of patients. Concretely, in this paper I look at the rationalities and technologies promoted by government practice, represented by the disease management programme. These programmes neither prescribe nor determine the conduct of individuals, but self-conduct is always enacted in the context of government practices that provide the possible field of action that attempts to give direction to self-conduct. I focus narrowly on the facilitating professional as a government technology for exercising power over the conduct of health professionals. As illustrated, Foucault’s notion of government is always conditioned on self- government and as such, government can only take place as a shaping or as a framing of self-government. In this way, self-government cannot take place outside of power. As such, government is the governing of others, and ethics is the governing of the self by the self. In the next section, I draw attention Foucault’s model of ethical self-formation to analyse the self-government of individuals.

3.4.2. Analytics of practices of the self I employ practices of the self or ethical self-formation to analyse the self- government of health professionals in Paper two and patients in Paper three. In this section, I will provide examples from the ethical self-formation of diabetes patients. As outlined, in the notion of government in Foucault’s work, power only exists when individuals are free to adopt strategies to modify these relations of power, i.e. power only works when there is freedom (Foucault, 1982, 1994c; Gordon, 2000). Foucault explored these practices of freedom through a history of ethics or self-conduct in the ancient Greek and Roman empire in the second volume of The history of sexuality, The use of pleasure (Foucault, 1985) and in the interview ‘The ethics of the concern for self as a practice of

Governing lifestyle freedom’ (Foucault, 1994c). By ethics, Foucault points to “the considered form that freedom takes when it is informed by reflection” (Foucault, 1994c, p. 284). Ethics then denotes the ways in which human beings are urged to conduct themselves morally in reference to a moral code, i.e. a prescriptive ensemble of values and rules of conduct recommended by various prescriptive agencies, such as health institutions, etc. (Foucault, 1985, p. 25; Rose, 1996a, p. 95). To be clear, ‘prescriptive’ in this context does not mean the prescription of guidelines for specific actions but more a structure of existence (Foucault, 1994a, p. 260). This moral code is sometimes clearly and systematically articulated and sometimes is not (Foucault, 1985, p. 30). As such, Foucault’s notion of ethics is not one of values and actions oriented towards the good and the right. These practices of the self are not invented by the subjects themselves nor are they regulated by the state through coercion or repression. Rather they are imposed, proposed and suggested through the forms of knowledge and exercise of power of the (lifestyle) dispositive (Raffnsøe et al., 2016b, p. 334). It is a code of conduct (reproduced and formed by the self and by others) in relation to which the self turns itself into a subject. Some clarifications are in order as to how these ethical practices derived by Foucault from the Antique are relevant today. As emphasised, this ethical self-formation described by Foucault denotes the power one exercise on oneself in relation to others seeking to give this conduct direction. To clarify, Foucault do not subscribe to an absolute freedom, but a relative form of freedom. This means that human beings are not conceived as autonomous, free and self-conscious, but neither is the action of human beings seen as completely socially determined. Thus, the ethics described by Foucault are to be seen as the freedom to question the historical and social conditions and circumstances that shape the lives of human beings (Clarke and Hennig, 2013). Thus, this understanding of ethics does not subscribe to a certain logic or ideology and must always be seen in the context of social and historical circumstances. In this light, ethical practices are in this dissertation analysed in relation to contemporary preventative health politics and neoliberal technologies of government. In his analysis of the ethical practices, Foucault delineates four principle dimensions of our self-constitution, representing the “different ways to conduct oneself”:

3. Conceptual and analytical framework the ethical substance, the mode of subjection, the ethical work, and the telos (Foucault, 1985, pp. 26–27; O’Leary, 2002, p. 12). Each of these dimensions of self-constitution represents a certain activity by which the subject shapes her relation to the self, which always arises out of the shaping of the self’s relation to others. That is, the ethical self- formation always takes place within a field of constraints (Rabinow and Rose, 2003, pp. xxi–xxii). First, the ethical substance denotes the essence of the self’s conduct, or in other words the object of ethical concern. Second, the mode of subjection concerns the ways in which the self relates to the rule/follows a code and recognises herself as obliged to put it into practice, Third, the ethical work is the work the self performs on herself using various techniques and practices to bring her conduct into compliance with the code and to transform oneself into the ethical subject of one’s behaviour. Fourth, the telos of the ethical subject is the aim of the self’s ethical work, which is not isolated but contributes along with other practices to a mode of being characteristic of the ethical subject (Foucault, 1985; O’Leary, 2002). These ethical dimensions are employed in Papers two and three; however, Paper three will serve as an illustrative example. I have found the interpretation made by Clarke and Hennig (2013) and O’Leary (2002) especially helpful in the application of Foucault’s ethical self-formation. As I have also outlined in Paper three, the four aspects of ethical self-formation are applied in the paper to analyse the self-government of diabetes patients. The ethical substance can denote the different ways diabetes patients practice self-care in terms of problematising their own lifestyle and health behaviours. The mode of subjection can encompass all the reasons why the patients want to engage in lifestyle interventions. For example, diabetes patients can practice self-care and comply with health and lifestyle precepts that are imposed, either because they see themselves as part of a group that accepts it or because they want to live up to an appeal. The ethical work can denote how diabetes patients examine their daily thoughts and actions in terms of changing their lifestyle. Lastly, the telos for diabetes patients can be using lifestyle interventions to strive towards a certain state of well-being or health. These ethical dimensions were never systematised by Foucault himself, to avoid both limiting their potential application or elevating them as essential principles. I do not

Governing lifestyle seek to schematically go through each dimension. Thus, Foucault’s four dimensions of ethical practice are regarded as heuristic tools not as essential principles that must be schematically followed. In Chapter four (section 4.3.1.), I describe how I have analysed the ethical self-formation using interview data. In the next section, I account for the concept of biopower, including a suggestion for the clarification of the distinction between biopower and biopolitics, followed by an account of other scholars who have employed biopower to analyse the contemporary exercise of power and both conceptually and empirically developed the term.

3.5. Biopower Biopower denotes the analytical concept used by Foucault to investigate the introduction of life into politics in Western Europe during the 18th century. The concept was developed by Foucault in the first volume of The History of Sexuality (1976) and in the lectures at the Collège de France, Society must be defended (1975-76). In his analysis, Foucault makes use of the classical theory of sovereignty as a backdrop to understand this new power over life (Foucault, 2003). Sovereign power is derived from the rights of the father in Roman families “to ‘dispose’ of the life of his children and slaves; just as he had given them life, so he could take it away” (Foucault, 1978, p. 135). Thus, one of the basic attributes of sovereignty is a right over life and death. More specifically, it is an asymmetrical and deductive form of power exemplified in “the privilege to seize hold of life in order to supress it” (Foucault, 1978, p. 136), or in other words, the right to take life or let live (Foucault, 2003). In contrast, biopower is characterised by the opposite right, exemplified by the Foucault’s oft-quoted ‘definition’ of biopower: the right to make live and to let die (Foucault, 2003, p. 241). This broad definition denotes how biopower takes life as the object of political strategies and is exercised to govern and encourage specific forms of life (while ignoring others or letting them die). It works to:

incite, reinforce, control, monitor, optimize, and organize the forces under it: a power bent on generating forces, making them grow, and ordering them, rather than one dedicated to impeding them, making them submit or destroying them (Foucault, 1978, p. 136).

3. Conceptual and analytical framework

Foucault traces the transformation of (sovereign) power and, thus, the evolution of biopower to the eighteenth century. By tracing the transformation not at the level of political theory but at the level of the mechanisms and techniques of power, Foucault demonstrates how life begins to be problematised in the field of political thought (Foucault, 2003, p. 141). Biopower develops in two interrelated forms that constitute, on one hand, the disciplines of the body and the regulations of the population: an anatomo- politics of the human body (often just termed discipline) and, on the other, a biopolitics of the population. The first form of power entails technologies directed at the individual bodies to increase their productivity and comprises disciplinary institutions such as hospitals, schools, factories, prisons, barracks etc. Within this power mechanism, the body is presented as a machine that can be disciplined, optimised, extorted and integrated into systems of efficient and economic control based on scientific knowledge, e.g. medicine, to establish the more or less normal (Foucault, 1978, p. 139). The second form targets the population. This power is concerned and invested with the mechanisms of life: reproduction, births, mortality, the level of health, life expectancy and longevity and with all the conditions that can cause these to vary (Foucault, 1978). Where the first technology of power is individualising, this form is massifying and totalising, as it is directed not at individuals but at ‘man’ as a species (Foucault, 2003). More specifically:

Both technologies are obviously technologies of the body, but one is a technology in which the body is individualized as an organism endowed with capacities, while the other is a technology in which bodies are replaced by general biological processes (Foucault, 2003, p. 249).

Foucault highlights three features of biopolitics. First, it is a technology of power that deals with the population as both a biological and political problem. More specifically, the biological traits of a population are essential elements in the economic management of politically-defined territories (Foucault, 2002d, p. 96). Second, biopolitics takes collective phenomena into consideration. This means that these phenomena are unpredictable and aleatory at an individual level but have economic and political effects at the mass level. Third, biopolitics is concerned with mechanisms such as statistical estimates and measures, not to modify the individual but to intervene by means of

Governing lifestyle regulatory mechanisms at the point at which these phenomena are determined. According to Foucault, biopolitics seeks to secure the population from internal dangers, not by disciplining but by regulating and optimising life (Foucault, 2003). Furthermore, Foucault clearly points out that biopower, while not being disciplinary, embeds itself in existing disciplinary techniques. Biopower does not replace discipline but exists at a different level (Foucault, 2003, p. 242). Thus, in Foucault’s analysis of the development of the power over life, three distinct but interrelated power technologies are advanced: sovereignty, discipline and biopolitics. In contrast to sovereign power and discipline, which seek to normatively describe how behaviour should be, biopolitics makes use of security mechanisms to transform the conditions for something to develop. That is, it intervenes upon a hypothetical situation in order to intervene upon a concrete and actual phenomenon (Jensen, 2005, p. 264).

3.5.1. Biopower, discipline and sovereignty There is some uncertainty as to how the technologies of sovereign, disciplinary and biopolitics relate to each other and specifically which technologies are employed in the biopolitical government of the population and how biopolitics deviates from biopower, which Foucault never completely made clear11. However, Foucault describes his notion of biopower as a form of power that seeks to optimise the living population: a power that takes life as the object of political strategies and is exercised to govern and encourage specific types of life (while ignoring others or letting them die). This is the power not to take life or let live (as the was the right of sovereignty) but the power to make (or foster) live and to let die (Foucault, 1978, 2003). Foucault advances how biopower operates through dispersed networks, such as the before mentioned dispositive (Foucault, 2007). Furthermore, Rabinow and Rose (2006, p. 197) suggest that biopolitics is located within biopower and refers to “all the specific strategies and contestations of problematisations of collective vitality, morbidity and mortality; over the forms of

11 It has also been suggested that the distinction between biopower and biopolitics is a forced, binary distinction made for the sake of clarity, as it in practice is difficult to separate the creation and solving of a problem (Walters, 2015)

3. Conceptual and analytical framework knowledge, regimes of authority and practices of intervention that are desirable, legitimate and efficacious”. Following this line of thought, I understand biopower both as the political ambition to optimise the lifestyle and quality of life of a population and as a way of observing the population (often through the aggregation of data and statistics) that in turn creates and makes visible the problems of the population. Biopolitics, then, refers to the means — technologies and knowledge — that systematically review and govern the populations that biopower has created. Moreover, biopower entails that sovereign, disciplining and biopolitical power technologies come to the fore in different ways, sometimes conflicting but also sometimes constituting. In this dissertation, I suggest that these technologies link to systems of knowledge (such as epidemiology and demography but also knowledge of social inequalities and social risk) and political rationalities. The technologies operate within a lifestyle dispositive that in different ways is informed by the truth regime but also makes use of these power technologies to regulate the production of truth to optimise the biological traits of the population and produce certain subjects. More specifically, I adopt a view in which the interplay and continued existence of all three technologies in contemporary society is acknowledged, but the emphasis is on governmental technologies and therefore on biopolitical technologies. These are understood within the field of general problematics of government (this is also mentioned in the introduction in Chapter one) and as such linked to Foucault’s notion of governmentality and liberal government — and neoliberalism (this will be elaborated in section 3.6.). The focus is on the displacement of these technologies in contemporary society and especially on the displacement of forms of knowledge. Foucault stresses that biopower does not replace sovereign power. Rather sovereign power ceased to be the primary form of political power as it was permeated by these new forms of power that emphasised the administration of bodies and the calculated management of life (Foucault, 1978, p. 149, 2003, p. 241). In fact, biopower was often combined with sovereign forms of power in the nineteenth and twentieth centuries. Foucault argues that racism exercised by the state emerged as a version of biopower and inscribed itself in the basic mechanisms of power exercised in modern

Governing lifestyle states. Within a system of biopower the imperative to kill (not understood as murder but indirect forms of exposing individuals to increased risk or to repulsion or rejection) is only acceptable if it results “in the elimination of the biological threat to and the improvement of the species or race” (Foucault, 2003, p. 256). Foucault explicitly mentions extreme political regimes such as the Nazi regime to exemplify how biopower can function through the old right of the sovereign, as the Nazi regime was extremely concerned with disciplinary and regulatory mechanisms (biopolitics) as well as the sovereign right to kill. Moreover, socialist states encompass a fully operational biological racism in its dealings with the mentally ill, criminals etc. in order to “take control of life, to manage it, to compensate for its aleatory nature, to explore and reduce biological accidents and possibilities” (Foucault, 2003, p. 261). As mentioned in Chapter two, this has been further explored by Donzelot (1988) and Ewald (1991), who draw attention to technologies of insurance in the emergence of the welfare state. Thus, the combination of sovereignty and biopower can take extremely coercive and violent forms but can also function much more peacefully. Although powers of sovereignty and biopower are two distinct mode of powers — one is the right of death and the other is power over life — sovereignty does not cease to exist but can be found in a wide range of places in combination with biopower since the eighteenth century. As other scholars point to, this absolute form of health, in which health is both a right and a duty of citizenship, is not only visible in diverse ideologies such as the Nazi regime but also in some of the health programmes of Western liberal democracies (Osborne, 1997; Villadsen and Wahlberg, 2015). Thus, state-racism exercised through biopower is not limited to function in extremes, such as Nazism, Fascism or Stalinism. However, from the beginning of the eighteenth century the biopolitical and totalising techniques of biopower is contested by a liberal rationality of government — liberalism understood as “a way of problematizing the question of government” (Osborne, 1997, p. 329). This rationality promotes a form of government in which health is not seen as a right, but that government is to provide the conditions for the population to have an equal chance of health. Government seeks to act indirectly, not directly, upon health (Osborne, 1997). As such, the totalising procedures of biopolitics and excessive state interventions is

3. Conceptual and analytical framework problematized, emphasising the natural ability of civil society to govern itself (Osborne, 1997; Frandsen and Triantafillou, 2011). Liberalism seems to function as a delimitation of the extensive interventions that follows the ambitions of biopower, introducing a tension between biopolitical regulation and normalisation and the juridico-political emphasis on ensuring individual autonomy. Villadsen and Wahlberg (2015, p. 5) forcefully describe this delimitation:

While biopolitics has a potentially limitless impetus for regulation of the life of populations, in the broadest sense of the term, liberal governmental principles emphasize respect for legal subjects and free enterprise.

Furthermore, the relationship between biopolitics and governmentality has been discussed by scholars12, who argue that Foucault did not abandon biopolitics in favour of the analysis of liberalism and neoliberalism in the framework of governmentality (which is sometimes suggested). Rather, biopolitics and governmentality can only be understood on the background of liberal government (Dean, 1999; Rose, 2001; Collier, 2011; Lakoff, 2015; Larsen, 2015; Villadsen and Wahlberg, 2015). To exemplify, Andrew Lakoff (2015, p. 42) notes:

In contrast to the restrictive and centralizing power of discipline, liberalism was articulated as an ‘art of government’ that emphasized the free circulation of men and things, and which depended for its efficacy on mechanisms of security that could ensure the optimal regulation of such flows.

Thus, biopolitics designates the political management of biological questions and can be said to make use of governmental techniques in which the relationship between individual bodies and the state is regulated through exercise of power and practices of freedom. To sum up, biopower designates a rather broad term that in its most general sense refers to the exercise of power through the state that seeks to optimise the quality of a population in a politically defined territorial state. In particular, according to Foucault’s analysis of this power over life, biopower consisted of two dimensions in the eighteenth

12 Biopolitics in relation to governmentality and liberal government was especially addressed by Foucault in the lectures at Collège de France, Security, Territory, Population (Foucault, 2007)

Governing lifestyle century: discipline and biopolitics. In contemporary liberal societies these dimensions seem to have undergone a transformation, which I will address in the following section, drawing on other scholars that have developed the term.

3.5.2. Biopower and neoliberalism Foucault’s concept of biopower has been used to analyse a range of themes regarding the ways biological and social life are politically questioned in a variety of disparate areas. I will mention two that are particularly relevant for this dissertation. First, scholars have been concerned with how broad biopower is to be understood, that is which objects of government are entailed in the concept. Second, scholars have concerned themselves with which government techniques are entailed in biopower. Scholars inspired by Foucault have argued that biopower is a broad form of power that not only is concerned with illness, pathologies and the regulation of biological life13 but also with the broader management of social and cultural concerns. As outlined earlier, Foucault uses biopower (and governmentality) with reference to quite concrete historical objects, e.g. madness and sexuality, and explicitly with regard to the problematisations of these objects made by the exercise of power and forms of knowledge at a given time. Rose (2001, p. 12) proposes that contemporary biopolitics may instead be termed ethopolitics to denote the broader scope of objects targeted by biopolitical technologies, in which behaviour and the predisposition to risk are crucial elements. In this vein, an analysis of the government of life today should not be restricted to a focus on biological or medical problems but must concern itself beyond the narrow biological existence of human beings (Villadsen and Wahlberg, 2015). Accordingly, biopower has been employed to study a range of disparate issues in which biopolitical technologies seek to govern more than just health and illness. Collier (2011) employs it to study city planning in Russia (which he terms Post-Soviet social), and recently Rose (2017) has linked biopolitics (or more specifically ethopolitics) to a study of authoritarian populism. Moreover, scholars

13 According to Collier, biological at the time of Foucault’s studies does not encompass the biological as it is understood in contemporary societies, but encompassed what would be called economic or social today, that is “trade, patterns of habitation, urban conditions, means of subsistence, and so on” (Collier, 2011, p. 17).

3. Conceptual and analytical framework have suggested an extension of biopolitics to grasp contemporary behavioural politics and proposed the term mindpolitics in their investigation of nudging policies (Peeters and Schuilenburg, 2017). Famously, scholars inspired by Foucault’s biopower have introduced the term biological citizenship or biosociality that, crudely put, denotes the expansion of the use of knowledge on molecular genetics and neuroscience to define the objects of biopolitical government (Rabinow, 1996; Rose, 2001; Petryna, 2002; Rose and Novas, 2005). Thus, contemporary studies seem to define the objects of biopolitical government somewhat broadly and observe how government does not target biological existence (understood as molecules and biology) in a narrow sense but that the object of the government of life seems to be expanded to include a range of phenomena that is perceived as influential upon individuals as living human beings (Villadsen and Wahlberg, 2015). Furthermore, Rose (2001, p. 17) suggests that the technologies of biopower are democratised as the health values of politics and “people themselves” have become entangled during the twentieth century. During this time, the political aspirations for ensuring the health of the population was increasingly linked to personal aspirations for being well, reconfiguring the idea of health:

The will to health would not merely seek the avoidance of sickness or premature death, but would encode an optimization of one’s corporeality to embrace a kind of overall ‘well-being’ – beauty, success, happiness, sexuality and much more (Rose, 2001, p. 17).

Although this new form of biopower takes individual freedom as its programme and defines itself as a break with hierarchical structures and paternalistic authorities, scholars argue that modern society has not abandoned the mechanisms of sovereign and disciplinary power. Rather, scholars observe how these mechanisms have been internalised within individuals and how individuals are urged to discipline themselves (Crawford, 2006; Ayo, 2011; Schrecker, 2016; Jaye et al., 2018). An illustrative account of this form of power is made by Deleuze in the short essay ‘Controlling Societies’ (1992). Drawing on Foucault’s analysis of the disciplinary society, Deleuze argues that disciplinary power relations have transformed themselves into a new form of control, and we have moved from disciplinary societies to “societies

Governing lifestyle of control” (1992, p. 4). This new form of control interlinks sovereignty and discipline, functioning not through enclosed confinements, such as the factory, or through binary codes but through continuous control and communication. Where the disciplinary society functioned within institutions, the control society, according to Deleuze, emerges as traditional institutions — with their spaces of enclosure, such as the prison, hospital, factory, school and family — are in crisis. The control societies that are replacing disciplinary societies entail modulating mechanisms that “like a self-deforming cast […] will continuously change from one moment to the other” instead of disciplinary institutions that are distinct castings (Deleuze, 1992, p. 4). This is exemplified by the replacement of factories with the corporation:

In the disciplinary societies one was always starting again (from school to the barracks, from the barracks to the factory), while in the societies of control one is never finished with anything—the corporation, the educational system, the armed services being metastable states coexisting in one and the same modulation, like a universal system of deformation (Deleuze, 1992).

This transformation, Deleuze stresses, is not only characteristic for the system “under which we live, but also of our manner of living and in our relations with others” (Deleuze, 1992, p. 5). Following Rose’s interpretation of Deleuze, the control is internalised, and individuals govern themselves according to norms, which makes institutions redundant. The crisis of institutions emerges as “conduct is continually monitored and reshaped by logics immanent within all networks of practice” and not limited to function within institutions (Rose, 1996b, p. 344). Biopower has developed from a regulating form of power to security indicating a form of power that seek to maximise and optimise the living’s self-government and self-development. Thus, it has its origin in liberal governmental technologies but is the result of the prevail of neoliberal governmentality (Jensen, 2005). Thus, scholars inspired by Foucault agree on the general level that biopower is a relevant concept to explore contemporary exercise of power. However, to grasp contemporary health and social politics they contend that the concept needs to be expanded. As scholars, especially Rose (2001) have advanced, this expansion is in part due not only to the emergence of new knowledge and techniques to govern genetic risk but

3. Conceptual and analytical framework also governmental techniques of a neoliberal character, emphasising self-governing techniques in the latter part of the twentieth century. In the next section, I will draw attention to other dimensions in contemporary preventative health politics which I suggest need elaboration for the concept to grasp contemporary developments.

3.6. Governing lifestyle through neoliberal politics — an extension of biopower? Based on Foucault’s and followers’ conceptual work on biopower, this section further develops this notion in order to be able to grasp key elements of contemporary health politics in general and diabetes treatment in particular. This entails illuminating the dispersed range of neoliberal government rationales and technologies in health politics dealing with the prevention of diabetes through the three papers of this dissertation. I illustrate the (re-)conceptualisation of and the contribution to biopower in this dissertation in three dimensions: The expectation of the individual to continuously reflect on how to improve their lifestyle and well-being; governing through the social environment; and the expansion of knowledge. Through examples from the three papers comprising the dissertation, I seek to demonstrate how the logic of prevention constitutes and is constituted by a lifestyle dispositive increasingly legitimating biopolitical government intervention in the behaviour and conduct of individuals. I do not suggest that the ambition of biopower has changed per se, but that the forms of knowledge and the governmental techniques in conventional health politics by which the health of the population is governed has changed in the last two to three decades. Preventive health politics can be said to lend itself to a neoliberal form of problematisation of government — understood as a form of governmental constructivism seeking to facilitate and regulate particular forms of freedom (Osborne, 1997; Rose, 1999; Foucault, 2008; Triantafillou, 2017). As Osborne (1997, p. 332) notes, neoliberalism with regard to health embarks from the same problem as that of classical liberalism — namely how to govern the indeterminate concept of health — but problematises it differently. Classical liberalism seeks to address the dangers of excessive state interventions and seeks to act only indirectly to preserve the natural ability for civil

Governing lifestyle society to govern itself. In contrast, neoliberal government technologies are direct, and the governing rationalities are concerned with the quest to optimise the self-governing capacities of individuals, groups and organisations in ways that contribute to societal wealth and well-being. Where classical liberalism has functioned as a taming of the ambitions of biopower to intervene to optimise life, constructive neoliberalism (mentioned in section 3.3.1.) in principle has no political limitations, as we can always govern ourselves better and exercise our freedom in a more effective way (Triantafillou, 2017). So far, this is not new. Among others, Frandsen and Triantafillou (2011), investigate the link between preventive health and neoliberal government in Danish health policy. However, I investigate the emergence of a biopolitical lifestyle dispositive in which this expansive and democratised form of power is especially visible in the realm of intervention practices in the lives of individuals who are diagnosed with an illness and in the form of knowledge that is deemed relevant in the practice of health care. This dissertation employs contemporary diabetes care in Denmark as an example of an extension of biopower in three dimensions in contemporary preventative health politics and in the government of the population in general since the 1980s: A governmentalisation of the social environment, a democratisation of knowledge and an expectation that individuals constantly and continuously reflect on how they can improve their lifestyle and well-being. The first dimension that I suggest makes up the extension of contemporary biopower has to do with the relatively recent political expectation that those citizens suffering from diabetes continuously reflect on how they can improve their lifestyle and well-being14. This extension of biopower corroborates the findings by Foucault’s and others. As I have outlined, the entrepreneurial subject in neoliberal government (the neoliberal homo economicus) is considered as continuously governable, modifiable and entrepreneurial and is governed through freedom (Foucault, 2008). Rose has shown this through the investigation of the ‘enterprising self’ exemplified through what he terms the psydisciplines denoting disciplines that take human beings as psychological subjects (1996a,

14 This imagined autonomous subject is also investigated in Paper two in which it is suggested that the government practices urge HPs to continuously reflect on their own expertise and how to improve the self-governing capabilities of patients.

3. Conceptual and analytical framework p. 151). This enterprising self is, according to Rose (1996a, p. 152), intrinsically linked to central values in present societies: autonomy, responsibility and choice and analysed through technologies of the self (freedom or ethical practices as outlined), which denote the ways in which the autonomous subjectivity “has been embodied in our techniques for understanding and improving our selves in relation to that which is true, permitted, and desirable” (Rose, 1996a, p. 153). As mentioned earlier, self-government has become a persistent ideal in advanced liberal societies in which responsibility, to some extent, is transferred from the State level to the individual level. The individual in neoliberal modes of government is considered as entrepreneurial and as a free agent on the market. Similarly, the health professional is not to be considered as an authority on which the individual patient can rely but as a supplier of health services (Ljungdalh, 2013). As I will demonstrate, this entrepreneurial subject is related to the other two dimensions of this extension of biopower: first, how the subject is modified through the social environment in which it is not only about transferring the responsibility onto the individual; and second, how health professionals are expected to be not medical experts but experts of subjectivity in the quest to guide the self towards a quality of life (Rose, 1996a, p. 151). I attempt to show in this dissertation how contemporary preventative health politics conceives lifestyle as a matter of individual choice and self-care as a capability that must be improved in order to achieve well-being and how the imagined patient or citizen subject is also entrepreneurial, responsible and autonomous. Type 2 diabetes is an illustrative example of these persistent values and the imperative to facilitate an informed and active patient subjectivity. Diabetes is recognised as a biomedically diagnosed illness. As such, it may be expected that healthcare around diabetes would mainly, if not solely, revolve around curative approaches, for instance gastric bypass. Although, diabetes is still predominantly understood as a biomedical problem both in medical literature and in health strategies, my study will show, the treatment and interventions in diabetes care are increasingly aimed at eliminating or modifying risk factors (KRAM factors as outlined in Chapter one) and improving the self-care of patients in the attempt to prevent diabetes from progressing or developing in the future (Scambler, 2006; Ljungdalh, 2011; Scambler et al., 2014; Seligman et al., 2015). Thus, according to contemporary health interventions,

Governing lifestyle diabetes is to a certain extent conceived as a social phenomenon and fundamentally social in its cause and effect (Whyte, 2016). The governing techniques used to treat diabetes is on a general level are the same techniques employed to govern health in the general population (Ljungdalh, 2013). Diabetes, then, illustrates how highly the values of autonomy, responsibility and choice are accorded in society today. Even though diabetes in some cases can be cured (gastric bypass), and despite the technological and pharmacological innovations in Type 2 diabetes treatment that have made significant progress in easing the symptoms of the disease (Mol, 2008), there seems to be an intensified focus on optimising patients’ self-caring capacities. As such, the subjectivity — the will, the motivation and the self-reflection of human beings — has been introduced as a medical concern and figures today as an essential tool in the treatment and fight against the global diabetes “epidemic”. This not only raises pertinent problems to be analysed about how patient subjectivity is envisaged but also questions the professional knowledge and practice deemed relevant in diabetes care. This first dimension is especially investigated in paper three that focuses on the freedom practices, i.e. technologies of the self, of diabetic patients participating in patient education with the aim of improving their self-caring and self-governing capacities. In this setting, the patients are expected to govern themselves in relation to a freedom-based power, which in the paper is termed a balanced approach. In contrast, sovereign, disciplinary or other more direct forms of power may seek to govern through strict guidelines and to some extent involve health professionals to act paternalistically towards patients. In the patient education setting investigated, the aim seems to be to produce a well-balanced patient subject that continuously reflects on how to obtain well-being as well as a healthy lifestyle. This power assumes that everyone has the will to change, that everyone wants to take responsibility for her own life and that no one’s situation is hopeless. The second dimension entails a governmentalisation of the social environment to make the choice of the correct (and healthy) lifestyle easier. The focus on governing the social through preventative health politics is substantially different from the one observed through social insurance technologies by Donzelot (1988) and Ewald (1991). As

3. Conceptual and analytical framework mentioned (please see section 2.1.), social insurance technologies consider social problems as aleatory in nature and events occurring with a certain probabilistic regularity. These technologies seek both to compensate for and calculate the occurrence of illness that has already occurred by socialising risk. In contrast, the governmentalisation of the social environment observed in this dissertation through preventative health politics seeks to minimise risk instead of socialising it. This is linked to a strategic attempt to modify individuals and groups in order for them to choose a certain kind of behaviour (this can also be observed in nudging and behavioural psychology) or through the constant urging of individuals to reflect on how to obtain well-being (this could be termed the neoliberal or psycho-therapeutic model). The individual is no longer considered strictly as homo economicus in the liberal sense, but the individual is considered to be continuously governable and modifiable as well as to systematically respond to modifications introduced into her environment. As such, I draw attention to two ways of governing the social. One seeks to govern trough social insurance, and the other seeks to govern through behaviour or conduct. They are both concerned with the calculation of risk, but the one present in this dissertation works through prevention to seek to avoid certain things from happening in the future, while social insurance technologies seek to compensate for things that have already happened. The governmentalisation of the social environment as an extension of biopower is investigated in Paper one, which addresses the link between biopolitical governmental technologies and the dispositive (although biopower is not explicitly employed as a concept in the paper). The paper analyses how governmental technologies and forms of knowledge were extended following a structural reform of the Danish public sector in 2007 in which new norms for conduct was put forward in a lifestyle dispositive. It is not the structural reform that is the object of analysis per se, but how existing neoliberal rationalities of biopower — problematising the self-care of individuals and using risk as a governing tool — are extended through the reform to systematically target the social surroundings of diabetic patients through preventative (and health promoting) interventions. Through the reform, a substantial part of preventative activities directed towards individuals with chronic diseases are placed in local health centres in

Governing lifestyle municipalities at the local government level. These health centres are run not by doctors but by nurses, physiotherapists and dieticians, and the aim is to reach more citizens than the traditional health centre to practice prevention and health promotion closer to citizens in a non-diagnostic and non-medical setting. The move of prevention activities to local government seems to provide the biopolitical technologies with more surfaces to control in the government of the life of the population. Surfaces the traditional health system cannot seem to reach without interfering with the self-governing capacities of the population (or within the economic limits). Thus, the way diabetes is understood in a Danish context makes it necessary to include organisational forms and professional expertise that have a non-diagnostic focus and thereby also non-medical knowledge. In Paper one, I try to tease out problematisations of self-care and risk as a governing technology as examples of a gradual expansion of the lifestyle dispositive into the social. The quest to improve the lifestyle — of not only people who are ill but the entire population to prevent certain illnesses — problematises individuals in new ways and reconfigures the social surroundings of citizens as both the cause of and solution to diabetes. Thus, it is not just about transferring the responsibility for an unhealthy lifestyle, and the consequences that potentially follow, to the individual, but it is about mobilising the social surroundings of individuals/citizens to make the choice for a healthy lifestyle easier. Although the choice of individuals is emphasised, the healthy lifestyle is introduced as a norm through the focus on the aforementioned risk factors (KRAM). It hinges on a neoliberal rationality that is in principle limitless and intervenes directly into society to optimise the self-governing capacities of individuals. Thus, the conception of diabetes and other chronic illnesses termed as lifestyle diseases as a social problem seems to legitimate more interventions and opens up for more territories to intervene upon. The third dimension of contemporary biopower observed in the dissertation is the claim that contemporary neoliberal biopolitics interacts with new and additional forms of knowledge. This entails a democratisation of (biopolitical) knowledge in terms of what kind of expert knowledge is deemed relevant but also in terms of an inclusion of non- professional knowledge, i.e. citizens’ own considerations of what constitutes a good life for them and how they balance pleasure and health. More specifically, the contemporary

3. Conceptual and analytical framework expansion and democratisation of biopolitics entails a transformation of the form of knowledge that preventative health practice is based upon and thus takes as its point of departure. This third dimension is visible in this dissertation through especially two observations. First, traditional medical knowledge in this period of investigation (the last 20-25 years) is combined with other forms of professional knowledge. As Foucault (2002c) notes, a range of different forms of knowledge (besides medical knowledge) became relevant in medical practice in the beginning of the eighteenth century and merged into what he termed as social medicine, i.e. the kind of medical practices concerned with the body as a social technology and as a productive labour force (Foucault, 2002c), in part developed on the basis of epidemiological and sociological knowledge and studies of geographic areas and social groups that predominantly are affected by illness. For instance, epidemics have commonly been considered as signs of economic, social and political disparities and as characteristic of the health of a population, triggering the expansion of hygienic strategies in the eighteenth century (Foucault, 2002d, 2002c). In the present time, social medicine or, as Osborne argues, socialised versions of health policy (1997, p. 331), does not represent a break with liberal strategies for the government of health. Rather, social medicine sparks the expansion of security mechanisms and gives rise to the government of the environment of certain social groups. Foucault talks of milieu as a specific space planned by security in which a range of uncertain elements can unfold “that will have to be regulated within a multivalent and transformable framework” (2007, p. 35). As I demonstrate in this dissertation, the introduction of prevention and health promotion in local health centres gives rise to a systematic government of the social environment — that is collective norms and values — in order to seek to urge individuals to change their conduct. In the last 20-25 years, other forms of knowledge emerged and are considered relevant in the treatment of illness, making the medical expertise of doctors just one of the relevant forms of knowledge in diabetes care. In addition to knowledge of genetic dispositions and brain sciences, which increasingly informs our understanding of human behaviour (Rose, 2001), forms of knowledge that can be characterised as non-diagnostic knowledge, such

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Governing lifestyle as nursing, psychology, health sociology, behavioural psychology, pedagogy, etc., are paired with traditional medical knowledge. Second, the knowledge of patients themselves is to be used actively in the treatment of certain illnesses. Lay knowledge is included as a crucial element of health politics and supplements the non-diagnostic knowledge, making a range of different forms of knowledge relevant in the government of health. Lay knowledge has played a role before but has also been excluded by the state — for instance the exclusion of quack medicine to ensure the integrity and qualification of the medical profession (Armstrong, 2006). In contemporary biopower, laypersons are urged to talk of their own experiences, knowledge and understandings of their illness, and professionals are urged to include and employ these in the preventative treatment of diabetes. It is not only about making room or including lay knowledge, but the production of lay knowledge is encouraged in order to obtain a true understanding of the patient’s condition and potential for treatment. By this I mean that in the encounter between professionals and patients, the patients’ own experiences and ways of knowing the disease are viewed as equally, if not more, important than expert knowledge. As the professionals are to be the experts of conduct, as Rose (1996b) has pointed to, they must possess skills (pedagogy, psychology, behavioural psychology) that can facilitate self-governing and self-managing capacities of patients that seem to be somewhere within the patient. Traditionally, authorities have possessed an authority legitimated and qualified by specific professional training and ways of understanding and acting on conduct (Rose, 1996a, p. 12). Now, lay knowledge is used as government technology to govern not only the bodies but also the minds of patients. This production of lay knowledge enables the government of the patients and has been brought about by the extensive focus on the lifestyle and self-care of individuals, as a range of illnesses now are understood and problematised as conditions caused by individuals themselves. Thus, lay knowledge is both a central mode of intervention and a product of that intervention. Rose has forcefully demonstrated how human beings have emerged as psychological subjects. These subjects are disciplines — often denoted by the prefix psy, like psychosciences, psychology, psychiatry, etc. — that developed in the last half of the

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3. Conceptual and analytical framework nineteenth century in contemporary societies in Western Europe and North America and brought certain ways of thinking of and acting upon oneself into existence (Rose, 1996a). More recently, Wahlberg and Rose (2015) have explored how the social and personal consequences of and experience with illness becomes knowable through the collection, collation and tabulation of knowledge and data about living with a disease, and the patient perspective is essentially quantified through aggregated health levels. Although the psydisciplines still inform the government of self and others, I suggest that the notion of knowledge now includes non-scientific knowledge, lay knowledge, which brings new ways of acting and thinking into existence. The democratisation of knowledge is investigated in Paper two (and to some extent in Paper three). In Paper two, the democratisation of professional knowledge supplementing medical knowledge with non-diagnostic knowledge and lay knowledge is investigated through a professional figure, the facilitating professional. I suggest that this professional is urged not to approach diabetic patients as an authority but to continuously seek to install and facilitate self-reflecting and self-governing capacities in patients. It is not so much the biological body that needs governing, but the mind of the patient (Rose, 1996a). Moreover, the facilitating professional is not to rely strictly on scientific knowledge — understood quite concretely as the knowledge that is recognised and identified in societies as resting on a scientific foundation (Foucault, 2002e, p. 112; Pedersen, 2014) — but expected to always be able to adapt to the specific patient and the specific situation. For example, lifestyle interventions taking place in the municipal health centres is less schematic than the practice of GPs and ambulatories. During my field work, I asked the professionals which programme they followed in health education courses. One health professional told me that they did not use a specific programme, but the current practice was inherited from the former schools and developed based on their own experiences and the participants’ feedback on what worked for them and what did not (field notes). I first regarded this as a problem for the empirical foundation of my work, but it became an analytical point that demonstrates how the practice in municipalities (and the other sectors are urged to do the same) relies upon and organises the courses on the basis of a continuous elaboration and inclusion of the knowledge

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Governing lifestyle produced in the everyday practice — both in the concrete practice at health centres in the interaction between citizens and professionals and from the experiences from citizens themselves. Through examples from the three papers I have suggested how an extension of biopower can be useful to grasp contemporary preventative health politics in which a dispersed range of neoliberal government rationales and technologies in health politics deal with the prevention of diabetes. I have suggested that this is a contribution to biopower along the lines of three dimensions: the expectation that individuals constantly and continuously reflect on how they can improve their lifestyle and well-being; governing through the social environment; and the democratisation of knowledge.

3.7. Closing remarks This section serves as a summary for this chapter as well as a brief restatement of the three conceptual contributions of this dissertation and how these relate to conducting a critical analysis. Paper one examines the rationalities and problematisations of the lifestyle dispositive. Although the dispositive is only explicitly explored in Paper one, it serves as an overall framework in the dissertation to analyse the problematisations and rationalities of contemporary preventative health politics directed towards the practice of diabetes care. As accounted for, the dispositive works along the lines of knowledge, power and freedom. Paper two and Paper three address the exercise of power and practices of freedom by health professionals and patients. I have attempted to clarify the distinction between biopower and biopolitics. In short, this dissertation employs biopower as the political ambition to optimise the lifestyle and quality of life of a population and as a way of observing the population that in turn creates and makes visible the problems of the population. Biopolitics refers to the governmental technologies and forms of knowledge that systematically review and govern the populations created by biopower and the relationship between individual bodies and the state is regulated through exercise of power and practices of freedom. While this dissertation predominantly focuses on biopolitical technologies, both sovereign and

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3. Conceptual and analytical framework disciplining power technologies still exist and continuously come to the fore in different and sometimes conflicting but also mutually constituting ways. I suggest that an extension of the concept of biopower is needed to grasp contemporary preventative health politics. As mentioned – and as I will get back to in the concluding chapter – the concept of lifestyle is employed to nuance and renew Foucault’s original concept of biopower to provide a more adequate understanding of contemporary forms of power involved with contemporary preventive health politics. As outlined in the chapter, the power at play in contemporary preventive health politics can be said to be placed within a neoliberal problematic of government. Rather than employing disciplining and sovereign forms of power to address public health problems, this power seeks to enhance the agency and self-governing capacities of health professionals, patients and citizens in general. This form of power is well-meaning, but also difficult to question. As Rose points out: “The injunction to activity here limits the possibilities of resistance” (Rose, 1996b, p. 348). Obviously, individuals always have the possibility to resist, as this is not a dominating form of power (cf. Foucault’s notion of power and freedom). Furthermore, Kelly (2013, p. 101) notes that to this day, the political struggles around biopower do not demand that biopower be abolished but rather that there be an expansion of the rights to be subjected to the protections and services of biopower: people demand the right to life, to their body, to improved health. What Kelly observes is that this form of power seems to be widely internalised in the population. I have accounted for three dimensions that I suggest is part of this expansion of biopower. In brief, although, diabetes is still predominantly understood as a biomedical problem both in medical literature and in health strategies, this expansion entails a governmentalisation of the social environment, a democratisation of knowledge and an expectation of individuals to continuously reflect on how to improve their lifestyle and well-being. These dimensions of an extended biopower are investigated through the three papers (though they are not mentioned explicitly in the papers). Instead, — given the analytical framework and the focus on the dispositive as well as the analytics of government — the empirical analysis in the papers critically examines how these three dimensions structure the possible field of action for the freedom practices for groups and

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Governing lifestyle individuals in diabetes care. Following the critical approach of this dissertation (which has been outlined in section 1.2. and will be briefly addressed in section 4.1), I seek to avoid investigating objects as historical constants but instead focus on problems, i.e. how lifestyle interventions have become the self-evident mode of treatment and the processes surrounding this exercise of power. Moreover, the focus is on the different elements comprising the lifestyle dispositive: that is what forms of power are exercised, how are they exercised and under which conditions and processes are they exercised. More specifically, I answer this question by describing the exercise of power as well as the processes and conditions surrounding it. Thus, the aim is not to analyse diabetes as such, or to assess whether lifestyle interventions are good or bad, but to analyse the practice of preventing unhealthy lifestyles in the government and self-government of patients and health professionals in the politico-administrative field, the professional field and in the patient field of intervention in diabetes care.

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4. Methodology

Chapter 4: Methodology

This chapter presents the methodological considerations and choices made to address the research questions, defining how knowledge is acquired and produced in this dissertation. The Foucauldian perspective has implications for how this can be done and what knowledge can be acquired. In the first section, I present the strategy for the methods used in this dissertation. The next section accounts for the cases of this dissertation followed by a section that outlines the methods and data employed (to address all three research questions), including the research process of all three papers. Finally, the last two sections of this chapter will briefly discuss some methodological- ethical considerations. Table 3 provides an overview of the research design across the papers.

Table 3. Overview of the research design across the three papers

4.1. Strategy and approach: a critical diagnostic of the present How should one study the way lifestyle is governed and self-governed (by politics, professionals and patients) in diabetes care in a contemporary liberal society? Before

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Governing lifestyle delving into the data and methods used to address this methodological question, some further remarks on what it means to critically analyse are useful. As explained in the analytical framework in Chapter three, one of the messages from Foucault’s analytics of power and of government was “that the apparent neutrality and political invisibility of techniques of power is what makes them so dangerous” (Gordon, 2000, p. xv). I follow Raffnsøe et al.’s (2016b, p. 455) diagnostic of the present which, in the same vein as genealogy, “does not aim for a clear yes or no to the validity of contemporary phenomena. Rather, the perspective shifts from the usual evaluation of what should be valid for us to an examination of what asserts itself here”. As such, the task of an analysis that draws on Foucault’s analyses of modern government is to critically diagnose the present and taken-for-granted truths that asserts themselves in a society in a given historic period. Such a critical diagnosis points beyond the immediate context and brings forward a previously implicit or inarticulate normativity. This does not mean that this dissertation can distance itself from its context and move beyond its normativity. Rather this dissertation can attempt to relate to normativity by rendering the norms and truths of a given practice or society. This means, however, that in this process the dissertation indirectly adheres to a new kind of normativity. As such, the diagnostic of the present, although situated, has no determinate start or end point. The researcher in a diagnosis of the present cannot fully know the context of the analysis or the presumptions of her work. Consequently, the conclusions of the analysis are contingent and always revisable. In turn, they can always be different (Raffnsøe et al., 2016b). Thus, in order to analyse the government of lifestyle and the more or less systematic relationship between knowledge, power and freedom practices in diabetes care, this dissertation performs a diagnostic examination. It examines not only of the phenomenon of lifestyle but also to some extent why and how lifestyle has become relevant in diabetes care and in health politics in the last three decades as well as under what conditions and how the concept of lifestyle seems to obligate both professionals and patients. As mentioned, genealogical practice has served as powerful tool in Foucault’s work emphasising the historical contingency and derivation of today’s practices. This dissertation aims to conduct a genealogically-inspired but essentially ahistorical analysis,

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4. Methodology that is, a study of present power, knowledge and freedom practices based not on historical data, but data produced in present day for this specific purpose. Combining a Foucauldian diagnostic of the present with ahistorical empirical data has implications for the knowledge produced in this dissertation and the methodological tools employed, which I will account for in the following sections.

4.2. Case study This study received funding from Roskilde University as well as from two municipalities (Roskilde and Lejre), Holbæk Hospital and a research collaboration between Roskilde University and region Zealand (in Danish: Region Sjælland). This study is thus co-financed, and the funding was contingent on using region Zealand, the municipalities and hospital as research sites for the study. Hence, this study consists of cases that I, as researcher, have not chosen myself but were chosen for me. There are some clear benefits of a co-financed PhD study, one of which is the fairly easy access to the field of study as the studied cases had already agreed to participate. However, there are also some clear challenges, one of them being on what basis the specific cases enter into the study. I will attempt to advance how these cases, while pre-selected, still serve as exemplary for the investigation of the exercise of power and practice of freedom in in contemporary health politics and diabetes care. As mentioned, this study consists of several cases that also served as sites for collecting data15. The settings include the region of Zealand, two hospitals (Køge Hospital [which did not contribute financially] and Holbæk Hospital) and two municipalities (Lejre and Roskilde) within this region, and finally four primary care practices located in the two municipalities. As I investigate the institutional network of professionals in relation to diabetes, it was central to the study to include cases or institutions that collaborate in this institutional network. Thus, I chose to include Køge Hospital as they collaborate with the municipality of Roskilde and primary care practices located in Roskilde. In the same way,

15Paper one analyses national health programs and is therefore, to some extent excluded from these methodological considerations. The paper’s empirical foundations serve as a point of departure for the analysis of the two other papers.

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Holbæk Hospital collaborate with the municipality of Lejre and the primary care practices located in Lejre. Despite the fact that they are pre-selected, these cases can serve as examples of the exercise of power and practices of freedom. The aim of this study is to analyse the technologies and rationalities of government and self-government. More specifically, I attempt to illuminate the links between forms of rationality and technologies of government and self-government (Bröckling et al., 2011, pp. 11–12). This entails unfolding how problems are defined, how subjects are urged to conduct themselves in certain ways and how government technologies attempt to govern and control this conduct. As described in the previous section, a diagnosis of the present does not assume to ever come to know the full context or the presumptions of the analysis and does not claim to comprehensively describe and explain social phenomena. The aim is not to rationalise in the sense of determining a definite outset and goal for analysis from which the analysis can be legitimised. This involves not taking the immediate context for granted but seeking to transcend it (Raffnsøe et al., 2016b, p. 457). Thus, according to Raffnsøe et al. (2016b, pp. 458–9), representativity its not necessarily an explicit aim in Foucauldian analyses. In this sense, it is not an objective to select cases for study that proclaim to certain ideals or meet some pre-determined criteria for selection. This essentially reflective approach raises some difficult challenges that relate to traditional epistemological issues of how one can gain knowledge of certain events and phenomena. Among other things, how can it be argued that the analysis does in fact represent the treated events and on what basis can the researcher argue the treatment of certain events on the expense of others? (Raffnsøe et al., 2016b, p. 459). In order to meet some of these internal challenges of Foucault-inspired diagnosis of the present, I will reflect on the selected cases to justify the research object of the study, even though it is not possible to overcome these internal challenges. I treat the municipalities, primary care practices, hospitals and their practices revolving diabetes care as examples of the exercise of power in preventative health politics in which technologies of government and self-government can be explored. The municipalities are different in terms of demographic parameters such as geographical size

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4. Methodology and population size. Roskilde’s population is larger than Lejre, with a population of 87,490 compared to Lejre’s population of 27,579 (Statistics Denmark, 2018a). In contrast, Lejre is predominantly comprised of rural area and is slightly larger, with its 238.90 km2 compared to Roskilde’s 211.80 km2 (Statistics Denmark, 2018b). Moreover, the two municipalities are different in terms of the prevalence of diabetes. According to an annual health profile published by the region of Zealand, Roskilde has a significantly higher prevalence of diabetes (6,7 pct. of the population) than the region average (6,5 pct.), whereas the prevalence in Lejre (4,4 pct.) is significantly lower than the region average (Blaakilde et al., 2017, p. 86). On a general level, the two municipalities share similar characteristics with regard to socio-economic status as they are both categorised in social group 116 by the before mentioned annual health profile (Blaakilde et al., 2017). This means that both municipalities are considered by authorities as more or less affluent when compared to other municipalities. Obviously, on the national level some municipalities are more affluent, and many are less affluent. Large municipalities such as Copenhagen (the capital) or Aarhus (the second largest city) are distinctive. As such, the two municipalities share both similar and distinctive characteristics and can thus serve as examples of the diverse composition of municipalities in the region of Zealand. Based on this information, it may be fair to assume that the technologies of government and self- government in diabetes care and the attempt to govern the lifestyle of the population found in Lejre and Roskilde also can be found in many other municipalities. However, affluent municipalities may be more ambitious in their approach to disease prevention and health promotion than less affluent municipalities. Additionally, Holbæk Hospital in 2013 established — by their own account — an ambitious and expanded diabetes ambulatory to provide patients with a better and more cohesive course of treatment (Region Sjælland, 2013). Thus, the hospital represents some of the most recent rationalities and ambitions in diabetes care and thus serves as an exemplary case of the attempts to optimise the institutional and professional approach to

16 The municipality social group is based on the inhabitants’ level of income, education (only primary school) and occupation. Group 1 is made up of the municipalities whose citizens have the highest gross income, lowest levels of citizens with primary and lower secondary schools and lowest levels of citizens outside the labour force (Blaakilde et al., 2017). There are three levels 1-3 in which 1 is the highest.

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Governing lifestyle diabetes. As already mentioned, Køge Hospital is included as part of an institutional network of referral and collaboration with the municipality of Roskilde. The cases are nonetheless interesting cases for analysing the technologies and rationalities of government and self-government in diabetes care and in contemporary preventative health politics in general in spite of being preselected and having a specific interest in the treatment in and organisational measures surrounding diabetes. I assume that the institutional settings included in this study in some way or another are informed by dominant discourses and rationalities in a given society that seek to govern the conduct of conduct and thus represent examples of technologies of government and self- government. However, I want to stress that based on the (limited) empirical material of this dissertation, the findings of this case study are rather a local narrative about specific patterns of government and self-government in diabetes care. This does not mean that the significance of these findings is local or limited. Following the diagnosis of the present (described in section 4.1), genealogy, or genealogy-inspired work, may be considered an exemplary form of critique as it “motivate[s] resistance to contemporary complexes of power/knowledge relations” (Owen, 1995, p. 490). More specifically, Foucault’s genealogical practice entails rendering the given cultural judgement on which our practices rest and exposing its contingent character and the effects of these practices (Owen, 1995). Even though this study is not a genealogical study, it is inspired by the genealogical practice in the sense that it does not aim to make causal claims, i.e. it is not concerned with causality in the traditional sense. As mentioned in the account of the analytical perspective of the dispositive (see section 3.2.), the aim is to lift the weight on causality. The study is especially concerned with answering the questions of ‘what’ and ‘how’ through an analysis of the different elements comprising the lifestyle dispositive, that is what forms of power are exercised, how are they exercised and under which conditions and processes are they exercised in diabetes care. In this perspective, to answer the question of how must be conducted not through an exploration of how power manifests itself but how power is exercised (Foucault, 1982). In doing this, the study is also concerned with ‘why’ these forms of power are exercised. Yet, the account of why is

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4. Methodology achieved not through a traditional causal exploration of dependent and independent variables but through a description of the exercise of power and the processes involved in this. The study derives from the notion that the practices and forms of knowledge involved with diabetes care can serve to teach us something about the practices and forms of knowledge involved in other health settings. Moreover, it assumes that the practice of prevention in diabetes care is linked to a historical contingency and broader and various form of knowledge and ways of exercising power and freedom: specifically, the lifestyle interventions aimed at diabetic patients often take the forms of health advice given to the general population to seek to promote their health and prevent future illnesses, social problems and so forth. The forms of knowledge deemed relevant to managing diabetes do not only relate to diabetes as a biomedical illness, and diabetic patients are to continuously reflect on their lifestyle and health-related behaviour as moral conduct. The research on diabetes enables conceptualisations about the prevention of unhealthy lifestyles in diabetes care in Denmark. It combines propositions about health care with propositions of prevention and lifestyle in health care. This dissertation may address the prevention of unhealthy lifestyles in relation to illness, but it also touches upon the government of lifestyle more generally that points beyond Danish health care. Thus, this dissertation seeks to illuminate if we can learn something about government and self-government in contemporary liberal societies from the case of Danish diabetes care. The next section will account for the methods and data employed in this dissertation as well as the research process of all three papers.

4.3. Methods and data In order to address the objectives and research questions, the selected methods and data in the dissertation need to be able to address both the government rationales and problematisations attempting to govern both professionals and patients (and institutions) as well as the considerations and practices of professionals and patients. For this purpose, the dissertation employs various methods and empirical data, which are presented in this section. To be clear, while studies within the governmentality approach are informed by a

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Governing lifestyle common analytical perspective — the art of government — they do not follow a stringent and coherent disciplinary orientation or empirical object and are therefore not associated with one distinct method (Bröckling et al., 2011, p. 11). Consequently, each paper combines methods and data differently. Table 4 presents an overview of the empirical data collected for this study across the three papers. In the following sections, the methods and data of each paper will be accounted for.

Table 4. Overview of all data across the papers

Data N Period of time Papers Documents (health programmes, policy 13 (12+1) 1981-2016 Paper two, Paper documents, DMPs) three Interviews (health professionals) 15 2015-2016 Paper two Interviews (patients) 15 2015-2016 Paper three Participant observation (patient schools) 13 (26 hours) 2015-2016 Paper three

4.3.1. Research process This section will present the papers in the order they appear in Part two of this dissertation, which also reflects the order I started working on them. The purpose is not to present findings, as they are presented both in the papers and in Chapter five, but to present the methods and data used to address each research question. More specifically, the section will account for the application of methods and data in the three papers. Concomitantly, I will address the methodological and ethical considerations of the methodological choices (document analyses, interviews and observations) made in the research process. The Foucauldian perspective informs how I employ all the methodological instruments in this dissertation. This will be addressed along the way as I describe the research process. The presentation of the data and methods is structured after each paper and research question. There will be some overlaps in the methods used for each paper, as interviews, for instance, are used in both Papers two and three. The section will serve as an elaboration of some of the methodological choices made in the papers as well as an account of the research process (the gradual progression of the dissertation in the period of study). As the papers were framed for and submitted to specific journals along the way, the insights, knowledge and objectives of the dissertation

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4. Methodology have developed along the way, making it relevant to illustrate this progression. In some ways, this section is, therefore, characterised by being more reflective in its language and style.

“Lifestylisation of the Social” — outlining the research process for Paper one To address the first research question in Paper one, a document analysis of health programmes from Danish public authorities is employed. The first paper argues that Danish diabetes care is governed through a lifestyle dispositive. To illustrate this, a document analysis of the lifestyle dispositive is employed. The dissertation draws on the notion that, documents are seen to form part of a process in which they both reflect their institutional context of production and contribute to performing organisational activities in that very same context (Prior, 2003; Mik-Meyer, 2005). As stressed in the paper, a document analysis cannot address the full scope of the lifestyle dispositive as the concrete unfolding of the relation between government practices and ethical practices cannot be studied through documents from public authorities. Hence, documents are employed in Paper one to examine the rationalities and problematisations of government in contemporary preventative health politics. To ensure a representative sampling of documents, Platt (1981) suggests that the researcher work with principles for choosing documents and establishing a sampling frame. These principles can be determined in different ways. The paper followed Foucault’s nominalist approach to select and analyse documents, which implies searching for transformations in the organisation of society and then asking what the basis for this transformation is (Foucault, 2002d). This approach is not concerned with value judgement or searching for hidden agendas (Rabinow and Rose, 2003; Bröckling et al., 2011). Rather it deconstructs truth claims and take actors’ arguments and modes of reasoning at face value through an investigation of what is said and what is done (Falzon, 2013, p. 293). In this regard, textual sources present themselves as a relevant method to examine the rationalities and problematisations of contemporary preventative health politics in Danish diabetes care and the strategic and contingent relation between power and knowledge (Triantafillou, 2017). Thus, the aim is to map and

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Governing lifestyle contextualise problematisations and rationalities of government by explicating the arguments given by public authorities in these documents. Inspired by this, the document analysis and research for this study aimed to account for how a particular transformation of the Danish health system came about and in which way the phenomenon binds and obliges the exercise of power and the practices of freedom. In my investigation of the development of the Danish approach to diabetes care, the structural reform of the Danish welfare state in 2007 seemed to be of consequence, as it added an extra layer of treatment upon the traditional treatment. The health-related tasks the municipalities are expected to perform can be said to not solely be targeting individuals with a diagnosis and are thus not strictly linked to a biomedical understanding of health and illness (Møller, 2016). For instance, as part of the reform so- called prevention packages are developed. The prevention packages include recommendations for the municipal approach to health promotion and disease prevention, in which the aim is to address certain areas of intervention based on societal risk factors to the health of the population (such as packages on alcohol, physical activity, hygiene mental health, obesity, sexual health, etc.) (Iversen, 2014). As such, the reform of 2007 served as a determining time frame for the search for documents. Documents were collected before and after the structural reform to account for how the lifestyle dispositive unfolded in major health programmes. To clarify, I do not argue in this paper that the structural reform in itself triggered or invented the lifestyle dispositive. Rather, I used the reform as a juncture in which the lifestyle dispositive became visible not only in preventative health politics but also in the attempts to systematically govern the social environment of certain individuals to make the choice of a healthy lifestyle easier. The collected documents consist of publicly available key health programmes published between 1981 and 2016, including disease management programmes (DMP), health technology assessments (HTA), recommendations, guides, etc. First, an initial search on articles published in Ugeskrift for Læger (a leading Danish medical journal) was conducted to get a sense of what health professionals were talking about in relation to diabetes and the organisation of diabetes. Especially emphasized were which health programmes were referred to when discussing the treatment of and approach to diabetes.

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Next, to identify relevant governmental health publications, a manual search was conducted on the web pages of the Danish Health Authority and the Ministry of Health on the subject of diabetes. A total of 43 documents were selected. Of those twelve policy documents were chosen that were deemed particularly significant to illustrate governing rationales of diabetes care based on three principles: 1) they were specifically mentioned in in the articles from the initial search in Ugeskrift for Læger; 2) they were referred to in other central health programmes in this period, allowing me to account for the whole body of literature during the study period; and 3) they were selected based on their publishing date in order for the analysis to represent the entire period. As mentioned earlier, the analytical strategy of analysing documents is inspired by a nominalist approach. Thus, as a first step, the analysis focused on the rationales employed by documents when describing prevention in diabetes care and chronic care. Two rationales seemed to be emphasised especially: the self-care of patients and the need to be more attentive to risk factors in order to detect people with undiagnosed diabetes or at-risk of developing diabetes. These rationales also aligned well with the elements highlighted by the critical public health literature. This approach has some implications for the knowledge production in this dissertation. When focusing explicitly on elements derived from the body of literature of this study, the analysis can be criticised as simply confirming the existence of what I am searching for. Therefore, in the next step of analysis, I coded the documents in chronological order using Nvivo software. First, the documents were open-coded based on a semi-structured approach to allow other descriptions and rationales of diabetes and chronic care to emerge from the data. Second, the analytical framework of the dispositive was used to refine the codes, focusing on descriptions of problematisations, forms of knowledge, government techniques and interventions. Accordingly, the document analysis identified other central rationales of diabetes care. For instance, the economic costs of the increased occurrence of diabetes were often used as an explicit argument for improving the self-care of patients as well as for relocating health promotion and prevention to municipalities to save resources in hospitals. Furthermore, the documents’ descriptions of preventive strategies were

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Governing lifestyle interwoven with descriptions of curative strategies, such as pharmacological treatment, emphasising their mutual interdependence. Thus, and as mentioned in Paper one, economic rationales and curative strategies could also be analysed as central elements of diabetes care. However, the rationale of improving the self-care of patients as well as preventing complications of diabetes by focusing on the management of risk factors seemed to be emphasised as key elements of diabetes care. For instance, an influential study in Science has demonstrated that gastric bypass procedures can improve glycaemic control in type 2 diabetes and, in some cases, cure diabetes (Saeidi et al., 2013). Thus, such a curative procedure could in principle solve both the problem of economic resources and patients’ lack of self-care. Yet, even with the availability of such a cost-effective curative procedure, self-care management is promoted in the analysed documents as the most important approach in diabetes care.

“The facilitating professional” — outlining the research process for Paper two This section will focus on Paper two, in which the analytics of the government practice are used in relation to analytics of the practices of the self by the self (ethical self- formation). Therefore, it addresses power/freedom relations. For this purpose, I use both documents and interviews to analyse the rationalities of government and the practice of self-government of health professionals in diabetes care. However, as the specifics of analysing documents and interviews are described in the previous (research process for Paper one) and following section (research process for Paper two) respectively, this section will mainly outline the research interests underpinning Paper two as well as the selection of empirical material. My initial research objective for focusing on health professionals in diabetes care was to illuminate how one treats (or governs) a disease that is emphasised as a lifestyle disease by media, public authorities and society in general. The point of departure of this study was that the conception of diabetes as a lifestyle disease, and the emphasis on lifestyle interventions in preventative health politics, not only has implications for the patients but for the professionals involved with the interventions as well. In total, the analysis for Paper two is based on one document and 15 interviews with health

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4. Methodology professionals. The data collection was carried out in 2015-2016 in the region of Zealand in Denmark. The setting for this paper has thus moved from the national level to the regional level in diabetes care. The document under study is the most recent DMP published by the region of Zealand. It is based on the national DMP by the Danish Health Authority (Danish Health Authority, 2012). By its own standards, the DMP describes the comprehensive, interdisciplinary, cross-sectoral and coordinated efforts towards citizens with diabetes, with a specific focus on preventive and health promoting activities in region Zealand. Moreover, the DMP encompasses the administrative and political rationalities of both the national and regional health authorities (Region Sjælland, 2016). As such, the DMP reflects the most recent rationalities of the governing practices seeking to manage diabetes care and health professionals. Interviews were conducted with health professionals from all three health sectors: the hospital, primary care and municipalities. In total, 13 semi-structured interviews (with 15 respondents) were conducted across the region of Zealand with four GPs and one nurse in primary care, two doctors and four nurses in two diabetes hospital ambulatories, and four health professionals, i.e. nurses, in health centres in two municipalities (see table 5). All interviews lasted .5–1.5 hours. Two of the interviews had two participants as two nurses in one of the hospitals were interviewed together. The same was the case for the nurse in primary care who was interviews together with the GP. The remaining 11 interviews were conducted as solo interviews17.

Table 2. Overview of interview respondents for Paper two

Setting Professionals Total Hospital ambulatories 2 doctors 4 nurses 6 General practice 4 doctors (GPs) 1 nurse 5 Municipalities 4 nurses 4

17 It is a limitation for the collected empirical data that four of the respondents were interviewed together as it limits the variety of statements in the interview. However, these interviews were still informative and fruitful as the respondents discussed some of the questions among themselves providing the data with additional information and insights that the solo interviews did not provide.

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The selection of respondents informs the research question and argument of this study in two ways. First, health professionals form part of the treatment provision in the institutional network surrounding the patient and represent insights from all three relevant health sectors in diabetes care. Second, the main aim was to gain a deeper insight into the complexity of how health professionals in three sectors describe their approach to patients and self-government in relation to governing practices — in this paper represented by the health authorities in the DMP. At first, the intention with interviewing health professionals for this dissertation was to gain insight into their reflections on the DMPs, including the emphasis on the network approach, often termed cross-sectorial collaboration, which has come to play an essential role in the administrative government of the field of chronic illness (cf. interview guides in appendix 1-3). However, it became clear that many of the health professionals (mainly health professionals in ambulatories and primary care) did not have that much to say about DMPs and cross-sectorial collaboration, because it became evident that these elements did not in particular figure in the health professionals concrete and daily approach to patients18. The health professionals were much more willing to talk of the individual patient and how health professionals relate to the needs and condition of individual patients. First, this seemed like a limitation, because it confirmed the suspicion that health documents are not used in practice but are just produced for political purposes. However, the DMP is produced on the basis of a much broader set of considerations, rationales and knowledge from health politics. As such, the governing ambitions analysed through the DMP are not just present in the DMP but also in other tools and documents and guidelines that seek to govern the practice of diabetes care. Moreover, it became clear that health professionals were aware of expectations for them to make use of a network approach and collaborate with the other health sectors if the condition of the individual patient required it. Thus, that health professionals only reluctantly relate to the DMP became an analytical point that illustrated the attempt to promote health professionals’ entrepreneurial and autonomous capabilities.

18A similar point is made in section 3.6. The HPs in municipal health centres did not follow a strict program in health education but relied on former practices and the inputs from patients.

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The analysis of the document aims to illustrate the government practice seeking to give the self-government of health professionals direction. The approach to document analysis in Paper two mimics the research process already described in the previous section and will not be elaborated here. Similarly, this paper employs the analytics of ethical practices in this paper to explore the self-government of health professionals. In the next section, in which I account for the research process of Paper three, I will demonstrate how the ethical self-practices of individuals can be studied through interviews. Moreover, the analytical strategy for coding interviews for Papers two and three has been the same which also will be described in detail, using the patient interviews as examples as well as articulating the challenges of combining Foucauldian-inspired work with interviews and observations.

“Self-government of diabetes patients” — outlining the research process for Paper three In this section I will outline the research process of Paper three. I will focus on the methods used to gather data, the challenges of combining Foucault-inspired work with interviews and observation, and how ethical practices can be illuminated through the analysis of these data producing techniques. Paper three explores the self-practices of diabetes patients and how they pursue lifestyle transformation through patient education to create particular versions of themselves. My initial objective for including the patient perspective in this dissertation was to explore the self-government of individuals who are diagnosed with a ‘lifestyle disease’ that often is framed as an economic burden by common discourses and norms in society. More specifically, diabetes is framed, on one hand, as disease in which the individual can act autonomously and entrepreneurial to secure their well-being, and, on the other, as a disease that can be treated by following somewhat general health advice that is also recommended to the population at large. The setting of this study is two patient schools in health centres in two municipalities within the region of Zealand. The main methods of this paper consist of observational studies and semi- structured interviews. 13 observational studies covering 26 hours as well as 15 interviews

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(each interview lasting approximately one hour) with patients in two patient schools were conducted in total (see table 6).

Table 3. Overview of interview respondents and observations for Paper three

Setting Patient school (Roskilde) Patient school (Lejre) Total Interviews (patients) 8 patients 7 patients 15 patients Duration of observation 2 hours x 8 2 hours x 5 26 hours

11 of the interview respondents participated in the patient schools. Four of the respondents declined participation. While these four patients cannot speak directly of how the patient school urged them to reflect on their lifestyle, these patients received an individual intervention at their home by one of the nurses from the patient school in which they were given advice on how to measure blood glucose as well as urged to reflect on how to improve self-care in their daily life. Thus, all interviewed patients have been included in a government practice seeking to optimise their self-care and choice of lifestyle. The patient schools consisted of two-hour sessions with the participation of health professionals (nurses, physiotherapists, visits from the Danish Diabetes Association), patients with diabetes and relatives. The observations were supplemented by informal chats between me and the health professionals, patients and relatives. To recruit interview respondents, I approached the respondents while I was at the patient school doing my observations studies. First, I made an oral presentation of my research and handed them a brief information sheet in which I encouraged them to contact me if they would like to participate in an interview. Following this, some respondents approached me to sign up for interviews while I approached others. The four respondents that did not participate in the patient school were approached by one of the nurses. Observations served the purpose of gaining insight into the self-practices of patients in patient schools in relation to health professionals and other patients. During my observations at the patient schools, I openly jotted down notes by hand. I wrote down dialogues, statements and expressions regarding the different issues and themes that were discussed in the patient schools. These notes have been rewritten electronically and appear in the body of the text as general analytical descriptions and, to a limited extent, as

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4. Methodology direct quotes. Initially, the focus was on observing the interactions between health professionals and patients to gain information on the relation between the two. On one hand, I was interested in how health professionals as representatives of government practices attempted to give direction to the patients’ self-practices in the light of the patient schools’ objective of optimising self-caring capabilities and patients’ lifestyle. On the other hand, I was interested in the self-practices and interactions of diabetes patients in the light of the government practices. However, during my field work, I began to notice how the different self-practices being employed by patients related in different ways to government practice. Whereas my initial interest had been in illuminating the relations between health professionals and patients, I began to focus much more on these different practices by patients. Although self-government is never practiced in isolation, I started to focus specifically on the self-practices of patients. These self-government practices became visible both in the individual patients’ responses to the health professionals and in their reactions to other patients’ interactions with professionals. These responses were something they openly pointed out at the school but also subsequently discussed in the interviews. All interviews followed a semi-structured interview guide to ensure that all interviews would to some extent touch upon the same themes (see interview guide in the appendix 1). First, I asked open-ended questions that led the participants to explain the issues that seemed important to them, for example: “Can you tell me about having diabetes?” and “When did you learn that you have diabetes?”. Then, I would ask follow- up questions that were more close-ended for clarification or to get clear information on different themes, for example: “Why did you (not) participate in the patient school?” and “Who referred or told you about the patient school?”. To an extent, the interviews for this paper served the same purpose as the interviews for Paper two: to gather information and illustrate the reflections and practices of the respondents. However, while the purpose of interviews for Paper two was to gain knowledge of the self-practices of health professionals, the aim in this study was to gain insight into the self-care practices of the patients, in which the patients reflect and act on themselves in context of the attempts to govern them. The interviews were recorded and later transcribed.

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To use interviews and observations as data-producing instruments in Foucauldian- inspired work requires some clarifications. Followers of the perspective of genealogy have argued that research interviews may not be an appropriate method for Foucauldian- inspired research (Fadyl and Nicholls, 2013). As in all research, using interviews and observations as a data producing technique poses a challenge to how the knowledge produced through these techniques is to be considered. It is especially important to mention that I partake in establishing the context that I am investigating. The Foucauldian perspective views knowledge and power as being intrinsically interrelated, as is the knowledge I produce in interviewing respondents. The use of interviews can be said to be especially problematic when the purpose of interviews is to illuminate respondents’ ethical self-subjectifying reflections and practices — as is the case in this dissertation. For instance, the process of data collection for this dissertation consists of interviewing patients and professionals and asking them to relate to my problematisations of their situation. In this way, interviews as a method of data collection contribute to power relations, have a normative element and are essentially a subjectifying or confessional technique. In other words, the interaction between the researcher and the respondent in interviews can be said to introduce the respondent to problematisations of themselves that they perhaps not had before (Triantafillou, 2005). Thus, the use of interviews as well as observation poses a challenge in this dissertation. In an attempt to minimise this problem (though the challenge cannot be fully overcome), I have used interview guides consisting of open-ended questions to make room for a diversity of reflections from the respondents and to seek not to add certain assumptions and expectations of the answer given. However, open-ended questions do not solve the problem. One way of trying to overcome the challenge can be to combine other data producing forms; thus, interviews with patients are combined with observations. To some extent, the problematisations patients made in the interviews corroborated both the observations I made when participating in patient schools and the reflections made by the nurses in my interviews with them. Again, this does not solve the problem, but it may be argued that instead of producing power relations, I (just) contribute to existing power relations already

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4. Methodology established by the health professionals, the patient schools and the health system in general. In the observational studies, it was similarly difficult not to participate in the existing power relations. For instance, in my observations, I attempted to take the role of participant observer: a role in which I openly participated in the schools but only as an observer, who was not to meddle too much in the course of the patient school. However, as a researcher being drawn into the concrete course of the patient schools is almost unavoidable, as field work often puts the researcher in positions where she feels out of place (referring to Mary Douglas, Tea Torbenfeldt Bengtsson (2012) accounts for this very well in her dissertation). Even though the field work conducted for this dissertation is not as extensive as studies from the ethnographic tradition, there are some situations worth mentioning. For instance, at one of the patient school sessions, the health professionals asked me (in front of the patients) to participate as a facilitator of group work between the patients, because the health professionals were short staffed. On the one hand, it was difficult for me to decline, as I would draw attention to the fact that I was in fact out of place in the patient school setting. On the other, it was problematic for me to take the role as facilitator of the groups work as I would in a very direct way participate in the government practice that was taking place at the patient school. Furthermore, in several sessions, the patients would often refer to me when making a point of the difficulties of having a healthy lifestyle. They would often distinguish the choices they made to the ones they believed I made, because I was not a diabetic patient. In this way, the patients often tried to distinguish themselves from me, while the health professionals would often position me as one of the staff. Although the challenges of both observations and interviews are not easily overcome and can perhaps never can be, I attempted (but did not fully accomplish) to create an in-between role in which I was neither a professional nor a patient. I attempted at all times to be transparent in the data collection and illuminate my role as a researcher when interacting when the field of study. One way of doing this was to openly sit with my notepad and take notes as well as to interact with both patients and professionals in the patient schools.

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The analytical strategy for coding all the empirical data in Papers two and three followed the described strategy employed in my document analysis. In brief, this entails that the aim is not to uncover some hidden truth or to come behind the façade. Rather, the aim is to decentre the “knowing subject” and focus on the discursive formation of technologies and self-technologies that inform the conduct of individuals (Clarke, 2009). Following this strategy, the analytical point of departure was loosely inspired by Nanna Mik-Meyer’s (2016) interpretation of the grounded theory approach and Clarke’s (2009) combination of grounded theory and situational analysis19. One of the core features of grounded theory is its iterative process between the material and two or more stages of coding as well as its heuristic character (Bryman, 2012). Grounded theory and situational analysis have been used to study illness and self-understandings (Charmaz, 1983, 1990) as well as combined with Foucault’s discourse formation (Clarke, 2009). To clarify, I was guided by the conceptual frame and the research question but at the same time sought to avoid conducting a deterministic analysis by keeping an eye on contradictions and things that cannot readily be explained or interpreted by the dissertation’s conceptual frame. Moreover — as described in section 3.6. — I suggest an extension of the concept of biopower to grasp contemporary forms of preventative health politics. This analytical strategy for coding the data has allowed for topics to emerge that I, based on my initial conceptual work and framework, had not expected. Thus, following this approach, I first conducted open coding followed by systematic, focused coding across all interviews20. I began the analysis by reading the interviews in their entirety without having formulated specific hypotheses before the coding process. In doing this, I aimed to allow for issues and themes to emerge from the data that I did not expect as well as gain an in-depth understanding of the data. During this open coding, I grouped the issues the respondents talked about in themes. These themes included — among others — “shame or guilt when talking about diabetes and lifestyle”, “referencing to other problems than diabetes” or “requesting more clear-cut

19 A mentioned, this analytical strategy was also employed to code the interviews with HPs in Paper two, but the strategy will only be accounted for here explained in depth using the patient interviews as examples. 20 To be clear — and as Mik-Meyer (2016) stresses — an open reading of interviews is an utopian ideal as the researcher is always informed by prior research of the topic.

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4. Methodology instructions from health professionals”. Thus, these themes have subsequently been employed as analytical categories and are central to the analysis of Paper three. Next, a focused coding was used in which I focused on these themes in relation to the practices of the self along the lines of Foucault’s four-dimensional ethical model. Thus, the second stage of coding entailed focusing on the problematisations made by patients, reasons given, and techniques employed for engaging in changing their lifestyle as well as the overall aim of engaging in lifestyle interventions. During these two steps of coding, I became interested in the respondent’s different practices of self-government and the ways in which these linked to the technologies of power: that is, the ways the self-government of patients reflected the message and dominant discourses from health professionals and the health system in general. I went back to the empirical material and read the material again, in a bit less detail, with a specific focus on the two forms of self-government: the ways in which the respondents differ in their self-government and opting for forms of power and the ways they explicated common traits. To clarify how the ethical self-formation can be analysed through these interviews, I provide a few examples of the analytical process. These examples also serve to illustrate that, although self-government is central to my conceptual frame as an analytical focus, I have not searched for a certain form of self-government. In my search for forms of self- government at play among patients, I have looked for statements and the context of these statements to exemplify how patients govern themselves in relation to the ethical dimensions. In doing this, I am inspired by Clarke and Hennig (2013) who have provided a thorough and detailed account of how Foucault’s ethical self-formation can be applied empirical analyses. The following excerpt of one of the respondents’ (Anna, who I suggest opts for more direct forms of power) statements illustrates the second dimension, the mode of ethical subjectivation:

They could have looked at you more seriously and said: ’You have to lose weight, you have to stop eating candy’. That could have been nice. […] [I]t is something about them being more concrete saying: ‘You have to lose weight! Come back every 14th day and be weighed. We will send you to a dietician and get control over your diet’ (Anna).

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Following, Clarke and Hennig, the second dimension of ethical self-formation entails all the reasons why the respondents decided to engage in lifestyle transformation by focusing on the values and beliefs they attached to transforming their lifestyle. In this sense, Anna’s desire to change her lifestyle hinges on her self-subjectification as a pathologised human being who with the help of the health system could have avoided becoming a diabetic. Yet, she requests concrete guidelines to be able to govern herself, in this example to be able to control her weight and her consumption of candy. In the paper, I suggest that this is a form of resistance towards the freedom-based power in the balanced approach. Prior to and following to this statement, Anna talks about having been diagnosed with pre-diabetes: “I had pre-diabetes first […]. And if I had been told how serious that was, then I might not be a diabetic today”. After Anna states: “That investment had maybe cost them X amount of money [kroners], now I cost this much [she shows a lot] the next many years”. These examples highlight that Anna, in order to conduct herself in line with values of self-management and autonomy (values promoted by the nurses in the patient school and reproduced by herself), she requests more direct government from the health system. Moreover, Anna links the prevention of her diabetes with how much she costs society, thus reproducing not just the norms proposed for them by the nurses but also certain societal discourses of diabetes as an economic burden on the health system and society as a whole. Yet, the aforementioned quote could also be interpreted as Anna’s attempt to place the responsibility of diabetes on the health system. In relation to this, she would often state that she wished that a pill existed that could make her lose weight, because she had little belief that she would ever get around to it herself. She states:

I try to think more about it [diabetes]. I try to take it more seriously. But then again, the current season is not your friend. It is Christmas. So, it is a difficult, but we [her family] try to keep away from [unhealthy] stuff, and I try to eat healthier (Anna).

My aim is not to illustrate a dualistic understanding of the self-practices of individuals as either good or bad, effective or ineffective, but rather how the individual

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4. Methodology acts within the social context and that the self-practices and agency can take different forms within this context (Clarke and Hennig, 2013). Thus, informed by both observations and interviews I identified two forms of self- government: one group opts for a freedom-based power and the other group opts for a more direct form of power requesting clear cut guidelines and instruction from the health professionals. Others have worked with this kind of patient profile (Ockleford et al., 2008; Mathar, 2010). The distinction between the two groups is ambiguous, and the emphasis is much less on the identification of two groups per se and more on two forms of self- government.

4.4. Ethical considerations In addition to the ethical and methodological considerations accounted for in the research process in the previous sections, some brief reflections on anonymity and confidentiality, informed consent and transparency are in order. Throughout the research process I have tried to ensure the privacy and anonymity of health professionals and patients. First, in my empirical analysis, I have used concrete observations or quotes from patients and health professionals. In the reproduction of these, I have attempted to make sure that it is not possible to recognise who has said and done what. However, as described in section 4.2., the cases of this study are pre-selected, and it has not been possible for me to disguise the identity of hospitals and municipalities in which I have conducted this study. Instead, I have ensured the anonymity of all patients and professionals by giving all participants pseudonyms and changing characteristics that are not relevant to the analysis. Moreover, I have made it clear that all data produced in interviews and observations are handled confidentially, and I have been careful not to disclose information from interviews and observations to other persons. As also clarified in the papers, the study undertaken in this dissertation has been approved by the Danish Data Protection Agency (in Danish: Datatilsynet). Second, in the course of my study I at times observe the interaction between health professionals, conversations between patients and health professionals, and visit patients’ homes and the workplaces of professionals. In most cases, patients and

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Governing lifestyle professionals have given their (informed) consent for me to visit their homes or visit their workplaces. In more general cases, where I stay in health centres, permission may be given at a higher level of management, where the observed, in principle, have no influence on whether they participate in the study. Furthermore, I cannot guarantee that even if patients and health professionals give their consent to participate, that they do so on the basis of full and open information on what my study contains (Christians, 2000). Third, as Mik-Meyer (2004) points out, a research process is by definition is a reducing process, in which I as researcher have chosen which perspectives and objectives I want to focus on. It is likely that the perspectives I have chosen to investigate, and the approach chosen will be criticised by management, health professionals and patients in the institutions I am studying. However, I have aimed for openness and transparency in interviews and observations. For instance, as mentioned earlier, I have presented my research to the participants as well as provided a brief information sheet in which I informed them of the purposes and aims of the study (Christians, 2000). Moreover, I have made it clear to the participants that they at any time can decline to participate in interviews and/or to answer individual questions. The next chapter will discuss and conclude the findings of the dissertation framework as well as the three papers.

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5. Discussion and conclusion

Chapter 5: Discussion and conclusion

This dissertation sheds light on the government of lifestyle in contemporary preventative health politics and in the everyday practice in diabetes care in Denmark. On the basis of the analytical framework and methodological reflections presented above, each of the three papers examines how lifestyle has crystallised into a dispositive of contemporary neoliberal biopower to optimise the self-governing capabilities of citizens in general and of diabetes patients in particular to make the choice of a healthy lifestyle easier. Each paper demonstrates how and under what conditions lifestyle is shaped, i.e. how the possible field of action is structured, in the government and self-government or patients and health professionals in the politico-administrative field, the professional field and in the patient field of intervention in diabetes care. In brief, the dissertation critically examines certain key aspects of the proliferation of interventions seeking to prevent unhealthy lifestyles in patients with diabetes in Denmark. It aims to make intelligible what can be learned from the case of diabetes about government and self-government in general. I assume that the forms of knowledge and practices of power and freedom involved with diabetes care can serve to teach us something about the practice and forms of knowledge involved in other settings. This assumption is derived from the dissertation’s overall conceptual inspiration, namely Foucault’s analytics of knowledge, power and subjectivity. Despite the fact that this dissertation does not purport to undertake a genealogy, I contend that the practice of prevention in diabetes care is linked to a historical contingency and broader and various forms of knowledge and ways of exercising power and freedom. This dissertation explores this as a critical diagnosis of the present by focusing on the rationalities and practices of Danish diabetes care. In doing this, the analysis is not concerned with how individuals are emancipated fully from power relations, but instead focuses on how the existing power relations can be unsettled, their self-evidence breached, which by implication creates more space for the exercise of freedom. The aim is not to look at diabetes care as an institution but to look at the practice of diabetes care. To analyse regimes of practices means to analyse programmes of conduct, which have both

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prescriptive effects regarding what is to be done and codifying effects regarding what is to be known — the relation between forms of knowledge and the exercise of power. Moreover, I look at the practices of the self, the practices of freedom in which individuals possess the freedom to change the way we have been made by power structures, history and forms of knowledge. The dissertation takes its analytical point of departure in the notion of biopower — understood as the political ambition to optimise the lifestyle and quality of life of a population and as way of observing the population that in turn creates and makes visible the problems of the population — to grasp ways of governing in contemporary preventative health politics. Moreover, this dissertation is inspired by governmentality studies and examines how health professionals and patients are governed by others through the exercise of power and by themselves through freedom practices. This objective and approach led to the following central research question:

How — and under what conditions — is lifestyle problematised and governed in the politico- administrative field, in the professional field and in the patient field of diabetes care?

5.1. Main findings Having briefly outlined the objectives of the dissertation, I proceed to demonstrate the main findings of each paper. Whereas the first paper focuses on the ambitions and rationalities of contemporary preventative health politics, the two last papers focus on governing technologies and self-technologies among health professionals and patients. The first paper entitled ‘Lifestylisation of the social’ investigates the question of how rationalities of preventive lifestyle interventions in the social surroundings of patients have been employed in diabetes care in Denmark in the last two decades. The paper illuminates knowledge/power relations in diabetes care and critically examines how and why lifestyle interventions became the self-evident and obvious approach to diabetes care. As the title indicates, the paper investigates a lifestylisation of the social exemplified by a gradual extension of a lifestyle dispositive that promotes particular norms of conduct in the practice of diabetes care. It is argued that preventive lifestyle interventions seek to govern not only the individual’s choice of lifestyle but also the social structuration of

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5. Discussion and conclusion choice. Moreover, this government of lifestyle was intensified and institutionalised by a reform of the Danish Welfare state in 2007. This reform transferred prevention practices to local government and intensified the government of the social surroundings of patients. Paper one demonstrates that the relation of knowledge and power here is exemplified by two interrelated elements within the lifestyle dispositive: problematisation of self-care and government of risk (factors). The paper exemplifies how the problematisation of self-care not only transforms from focusing on the body to focusing on the conduct of the patients — understood as the patients’ ability to reflect on their lifestyles and self-caring capabilities — but also to focusing on the social surroundings and relations of patients as a problem for the prevention of unhealthy lifestyles. The government of risks transforms, from not only focusing on ensuring patients a normal life by trying to minimise the biomedical symptoms and effects of diabetes, to also focus on the whole life of patients, understood as the medical, psychological and social elements of the life of the patient. The gaze at the whole life conceives of a larger part of an individual’s life as being at risk. This paper highlights how new tools for governing risk and detecting diabetes emerged alongside local government’s increased responsibility for preventive lifestyle interventions. While these tools were mainly directed at patients who were regarded as not having the capabilities to manage themselves properly, problematisations of self-care and government of risk formed part of a continuous gaze that is applied to the general population. These elements illustrate — in contrast to the common perception (in much critical social science literature) that interventions into citizens’ everyday life emphasise individual choice and responsibility and a divestment of state activities — that the case of diabetes care in Denmark may be interpreted as a new socialised model of diabetes and lifestyle interventions in general, in which citizens’ choice of lifestyle is being systematically pursued through state interventions into the social surroundings of citizens — in turn expanding the ambitions of health authorities both at state, regional and local levels. Danish contemporary preventative health politics promote a comprehensive and systematic model in which lifestyle intervention is not only

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about transferring responsibility to the individual but as much about a mobilisation of social relations and surroundings. The second paper entitled ‘The facilitating professional’ explores the question of how and with what implications problematisations of diabetes as a lifestyle disease inform the government and self-government of health professionals across three health sectors: the hospital, primary care and municipal health centres? While Paper one examines the rationalities of contemporary preventative health politics in diabetes care, Paper two analyses the power-freedom relations in diabetes care. The relation between freedom and power is illustrated through an analysis of the practices of government and self- government of health professionals. The emphasis on preventative activities — including an individual approach in which the individual patient must be empowered to choose a healthy lifestyle and a network approach in which the health system is organised to surround the patient to make the choice easier — enables an extension of the self- government of health professionals. In contrast to substantial parts of the health sociological literature of professions, the paper seeks to demonstrate how health professionals are urged to govern themselves not with less autonomy but with a new form of autonomy. The findings of this paper highlight how the extension of self-government can be exemplified by the role of the facilitating professional. This professional is promoted by the health authorities (the government practices), who seek to structure the possible field of action of health professionals by especially two dimensions. First, health professionals are expected to democratise their expertise to be able to not only facilitate the knowledge and experiences of patients but also the self-care and active agency of patients. Second, they are expected to continuously reflect upon the ways in which they can improve the self- caring capabilities of patients through the institutional network. The government practice urges health professionals to not only concern themselves with diabetes as a biomedical illness but also with the life, resources and knowledge of the patients. The patients’ capability to engage in treatment and in self-care is the main problem that health professionals must relate to. The findings further suggest that health professionals, to some extent, govern themselves in accordance with the facilitating professional with

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5. Discussion and conclusion regard to expectations of the democratisation of expertise. As such, they focus on improving the self-caring capabilities of the patient. While health professionals in all three sectors conceive diabetes as a lifestyle disease that demands the knowledge and agency of the individual patient, health professionals in hospitals and primary care conduct themselves as biomedical experts in some ways. They seem more reluctant to practice the network approach in which they are expected to continuously reflect on improving the lifestyle of patients. They call for a more structured and formal network setting: not a network that determines when to collaborate with other sectors but one that provides more formalised pathways between each sector, making it easier to communicate within the network about the individual patient. Thus, health professionals in municipal health centres seem to act as facilitating professionals in a more comprehensive way than those in ambulatories and primary care. The third paper examines the question of how diabetes patients are practicing freedom (and shaping their lifestyle) in the context of interventions that seek to optimise their self-caring capabilities. This paper investigates the self-government of patients in the context of patient education schools managed by municipalities that in practice seeks to optimise the self-care of patients. The analytic focus here adds to the analysis of power- freedom relations but focuses explicitly on the ethical freedom practices of diabetes patients. It is highlighted how these patient schools try to adopt a so-called balanced approach, employing a freedom-based power in which patients are urged to conduct themselves as individuals that can balance between health and pleasure and can reflect on how to optimise their lifestyle. The norms and practices imposed by such self- management programmes are appropriated differently by the diabetic patients. The findings of this paper are an illustrative example of self-governing practice. The self-governing practices of patients are to a great extent linked to the attempts of municipalities — and dominant norms in national self-care management programmes in general — to structure the patients’ possible field of action. These attempts by municipalities directly mimic existing norms and practices prescribing how diabetes patient ought to act and reflect on themselves — norms and practices that align with neoliberal rationales of the entrepreneurial and autonomous individual. However, the

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appropriation of these norms of conduct unfolds in a somewhat surprising way. Broadly speaking, the findings demonstrate how the appropriation of the imposed norms of practices can be divided into two distinct modes of self-government: those who opt for freedom-based power and those who opt for more direct forms of power. The latter mode of self-government may seem paradoxical, as it seems to be practiced by patients who have no trouble with conforming to the self-care regime supported by the public health programme. Rather than resist or reject intervention in their lives, they call for more direct intervention to govern themselves, voluntarily govern themselves according to existing norms and practices and objectify themselves as pathological individuals. Overall the findings of this dissertation suggest that the fact that public authorities regard certain illnesses as the result of poor lifestyle choices does not necessarily imply divestment of state responsibility and interventions. Rather, the ambition of contemporary preventative health politics in Denmark is to offer a comprehensive form of welfare that supports citizens to allow them to make healthier choices. Moreover, the findings indicate that the Danish approach to diabetes entails both an individualising aspect — the empowerment of the individual to optimise their self-caring capabilities — and a network aspect, in which the health system seeks to organise a network around the citizens to promote health, making the choice of a healthy lifestyle easier – i.e. persuade them to choose a healthy lifestyle.

5.2. Contributions This section discusses the empirical findings in the light of the existing critical studies of public health prevention and the dissertation’s conceptual framework. It points out three dimensions of the lifestylisation of biopower that contribute to the critical, academic understanding of the governing of diabetes. I have employed the concept of lifestyle both as an empirical term and as a conceptual term. Empirically, I study how the notion of lifestyle is employed by practitioners, politicians, some scholars, and many patients as a way of describing, judging and reforming their behaviour and conduct within the common-sense understanding of diabetes as a lifestyle disease. Conceptually, I use the

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5. Discussion and conclusion term lifestyle to grasp the historical specificity of the kinds of power exercised in contemporary attempts to prevent and treat diabetes in Denmark. To explore what form of power is entailed in the lifestyle concept, I draw on Foucault’s concept of biopower. As described in chapter 3, biopower in Foucault’s work consists of two interrelated axes, discipline and biopolitics. The first is an individualising power targeting the individual through disciplinary technologies, and the second is a totalising power targeting the population through life mechanisms such as mortality and health status. There is a discussion within Foucault studies of the continued relevance of the concept of biopower as state interventions targeting the vigour and health of the population in terms of regulating racial quality and a general cleansing of the social space disappeared after World War II (Fullagar, 2002; Petryna, 2002; Rose and Novas, 2005). Conversely, others have suggested that public health interventions attempting to optimise the lives and life quality of individuals and groups have not weakened. Rather public health interventions appear to be strengthened as preventive interventions has been added to curative treatment strategies in the attempt to minimise the risk of illness (Frandsen and Triantafillou, 2011; Pedersen, 2014; Triantafillou and Vucina, 2018). Following the latter insight, I propose that biopower continues to be a relevant concept, provided that it is updated and modified for contemporary purposes. The notion of lifestyle may be used to bring about a relevant modification of the notion of biopower enabling it to grasp the modalities of power at stake in a wide range of contemporary public health interventions, including diabetes treatment. Accordingly, I advance three dimensions contributing to the understanding of lifestyle and diabetes in this dissertation, which I suggest all have to do with a lifestylisation of biopower. In advancing these contributions, I seek to illuminate that Foucault’s original conception of biopower as the state’s right to make live and to let die is still relevant, albeit with significant modifications. Firstly, while Foucault was adamant that individualizing techniques were crucial to biopower, he was focusing on disciplinary technologies seeking to create a productive and docile body. The present dissertation and several other critical studies have shown that the governing of individuals is predicated not so much on disciplinary techniques seeking to render their bodies docile as on

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interventions seeking to enhance their self-steering capacities. Hence, the current focus is not only on behaviour but above all on conduct of conduct. Secondly, while Foucault’s emphasis on the regulatory interventions targeting the vigour of the population also pointed to environmental controls, the latter were above all focused on physical measures, such a hygiene, sewage systems, and the creation of an institutional network of public health institutions. Foucault’s notion of biopower did not envisage how the social environment too would become a target of governmental interventions too. Finally, while the original notion of biopower did a lot to point to the democratization of sovereignty by addressing not only the emergence of universal suffrage and civil rights as well as the ways in which the vigour of the population became an end in itself, Foucault’s concept of biopower did not envisage the democratization of medical expertise and authority that I have tried to expose in the case of the present governing of diabetes. Through the following dimensions, I seek to nuance how biopower can be made relevant through the concept of lifestyle, I propose an extension of the concept of biopower to grasp (neo)liberal ways of governing. This form of biopower works not trough disciplinary or normalising mechanisms but through the structuring of an institutionalised space of self-government. It entails not only classical notions of a neoliberal power divesting responsibility to the individual but a constructive form of neoliberalism in which the state is regarded as responsible for facilitating and structuring the self-governing capacities of society. These dimensions correlate with the three sub- questions that have informed the empirical analyses of this dissertation. The first dimension of the extension of biopower has to do with the self-government of diabetes patients and the political expectation that citizens suffering from diabetes constantly and continuously reflect on how they can improve their lifestyle and well- being. In reviewing the medical literature, I illustrated how patients with diabetes have been expected to govern themselves through behaviour for several decades. However, the form of self-government expected of individuals appears to have shifted from a focus on behaviour to also include conduct. This shift correlates with the move from an almost exclusive pathological problematisation of diabetes to the inclusion of a non-pathological one. Undoubtedly, the diabetic patient is still conceived as ill in a biomedical sense, but

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5. Discussion and conclusion the patients is encouraged to relate to themselves as an active and autonomous individual that can balance between behaviour and well-being both as a means for them to govern themselves better and as part of what it means to be healthy. Empirically, this dimension is illustrated predominantly in the third paper and the research question set out to explore how diabetes patients are practicing their freedom and shaping their lifestyle in the context of interventions that seek to optimise their self- caring capabilities. The paper analyses how diabetes patients in two municipal patient education programs are expected to govern themselves according to a balanced approach that presupposes a freedom-based power in which patients are expected to continuously reflect on how to balance between health and pleasure and reflect on how to optimise their lifestyle in their everyday life. What is problematised is not so much their diabetes diagnosis, but their ability to handle their disease. The paper illustrates how diabetes patients practice various forms of self-government that challenge the prevailing form of power in lifestyle interventions. Moreover, I suggest that diabetes schools are an illustrative example of techniques developed by constructive neoliberal and individualised rationales that governs through a freedom-based power instead of a disciplinary power to bring the autonomous and entrepreneurial patient subjectivity to life. The distinction between behaviour and conduct as well as the expectation that individuals constantly reflect on their lifestyle and well-being corroborates with Foucault- inspired analyses of the neoliberal subject, which is governed through norms of autonomy, responsibility and choice. This neoliberal form of government through autonomy and self-government is widely recognised in the critical social science literature (Rose, 1996a; Dahlager, 2005; Mol, 2008; Danholt, 2012; Armstrong, 2014a; Pii, 2014; Mayes, 2016; Vassilev et al., 2016). The contribution of the present dissertation to this dimension is, thus, to show that the norms of autonomy and self-government also seem to prevail to citizens deemed pathological. At least, I show how these neoliberal rationales of government are employed on persons who objectively and in a biomedical understanding do not have the capability of self-government because they regarded as ill by prevailing biomedical knowledge. If governing through self-government is assumed to work even on persons who are widely regarded as incapable of self-government, then

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where are the limits to the neoliberal dictum of rule through (individual) freedom? By showing how this neoliberal conduct is not only concerned with ‘normal’ people or, more precisely, persons who are not regarded as ill, the dissertation shows the sturdiness of this logic. For instance, other scholars illustrate how this logic also is to find within the area of mental illness (Gudmand-Høyer, 2015; Triantafillou and Vucina, 2018). This logic also refers to the double message in public health policies in which earlier preventive interventions are proposed if the previous did not yield the desired effect. Therefore, the extension of biopower understood as lifestylisation entails that the study logic of neoliberalism and individualism is translated from the healthy and normal domain to the pathological domain. The second dimension refers to a governmentalisation of the social environment of patients and citizens in general to make it easier to choose a healthy lifestyle. In the review of the medical literature, I illustrate how scholars have been concerned with the living conditions and social factors, such as socio-economic position, of patients prompting some to call for a more holistic approach to diabetes. This follows the discussion of compliance versus adherence and the solutions to this problem. Although diabetes continues to be recognised as a biomedically diagnosed illness with several pharmacological treatments available, scholars located the multiplicity of causes to this non-compliance not only in medical factors, but also in social forces. Thus, instead of conceiving diabetes patients as ill in a narrow biomedical sense only, they should also be considered at risk to enable a multi-factorial approach to diabetes. In this approach the concern is not so much to get patients to comply but to include the patients’ perspective and resources to optimise their self-managing skills in their everyday life. Empirically, this dimension is illustrated in the first paper (and to some extent in paper 3) and the research question sought to explore how rationalities of preventive lifestyle interventions in the social surroundings of patients are employed in diabetes care in Denmark. This paper shows how Danish preventive rationales through municipalities represent an expansion into the social surroundings of patients and citizens in general to make the choice of a healthy lifestyle easier – especially in to the lives people who do not have the capabilities to self-manage according to prevailing social norms and therefore are

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5. Discussion and conclusion at risk of developing so-called lifestyle diseases. This means that it is the relation patients have not only with themselves, but also with their families, workplaces and social surroundings in their everyday life that is governed. The rationale is that municipalities by their presence in the local environment can provide a conducive framework, enabling and encouraging citizens to adopt a healthy lifestyle. The rationale of governing risk factors through the social is visible both in the medical and the critical social science literature. For instance, Nikolas Rose and other scholars emphasize that not only the health domain but also the social domain has become a territory for disease prevention to encourage healthy behaviour in the population (Rose, 1996b; Højlund and Larsen, 2001; Bernier, 2009; Ljungdalh and Møller, 2012). However, these scholars tend to argue that preventive health policies evolving around the notion of risk regard the responsibility of health problems as an individual one and tend to neglect or ignore how risks are shaped by economic and social structures. Conversely, the findings of this dissertation indicate that the rationales of Danish health strategies encourage quite ambitious and extensive interventions in the area of diabetes and in the social surroundings of citizen. Here it should be stressed that the governmentalisation of the social environment observed in this dissertation through preventative health politics seeks to minimise risk instead of socialising it. Thus, it is substantially different from the perspective on the social advanced by Donzelot and Ewald in their analyses of social insurance technologies. The self-government advanced by the governmentalisation of the social is not based on compensation but based a logic of self-government in which the social milieu is governed. A few other scholars have pointed out that the health responsibility of Danish municipalities can be viewed as an expansion of government into the social and personal aspects of individuals. For instance, Gudmand-Høyer (2015) advances how the health responsibility entrusted with Danish municipalities is an example of a transformation of interventions directed predominantly at the pathological aspects of the disease to interventions that are directed to the non-pathological (the “normal”) aspects of the everyday life of the patient. These rationales existed before but are exuberated by the health centres in the municipalities. In the same vein, Triantafillou and Vucina (2018)

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show how contemporary health policies in England and in Denmark in the areas of obesity and mental illness have mutated since the 1980s. In a similar way to this dissertation, they argue that the municipal responsibility for health activities such as health promotion and prevention following the structural reform of 2007 created an “institutional web” in which local authority teamed up with families, schools, workplaces and sports clubs to encourage individuals to adopt a healthier lifestyle. Moreover, they illustrate how this institutional web in Denmark seemed more dense than similar attempts in England to promote healthier lifestyle for obese people (Triantafillou and Vucina, 2018, p. 135). The findings of this dissertation in many ways illustrates the point made by these scholars albeit on another area of illness. Moreover, the contribution of this dissertation is to empirically substantiate the claim (both through paper 1 and paper 3) that this form of self-government – as mentioned earlier – now include people with diabetes or are at risk of being affected by diabetes who objectively seen are unable to govern themselves properly according to prevailing social norms and therefore are in need of intervention. The behaviour of these individuals is not the key object of intervention but their conduct, i.e. the minds, self-hood and attitudes. The third dimension entails a democratisation of knowledge, both in terms of what kind of expert knowledge is considered relevant and the inclusion of non-professional knowledge. The latter form of knowledge can be termed lay knowledge, that is patients’ considerations of what constitutes a good life and well-being and how they balance pleasure and health. In the review of the medical literature on diabetes, I have in particular highlighted how the distinction between compliance and adherence has challenged medical knowledge. This distinction indicated that the roles of the authoritative professional and the compliant patient was to be substituted with a more facilitating professional and approach that could include the patients’ perspective as well as an autonomous patient that was equipped to solve and adapt to any situation and complication, they may encounter by installing in them general self-management skills. The medical literature highlights how this approach to diabetes now included a range of professionals that did not solely have a biomedical perspective on patients. In addition, what could be termed traditional health professionals, such as doctors and nurses, were

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5. Discussion and conclusion also to act more motivating and be attentive to the resources and wished of the individual patient to enhance self-management skills, understood as competent and autonomous conduct. Empirically, this dimension is illustrated in the second paper, which examines how and with what implications problematisations of diabetes as a lifestyle disease inform the government and self-government of health professionals. The paper illustrates how professionals in practice conduct themselves in relation to the expectation that they must democratise their expertise with the inclusion of lay knowledge as well as continuously reflect on how best to optimise the self-governing capabilities of the patients. The study suggests that health professionals are governed through their own self-government guided by the rationality of the self-caring patient. As accounted for in the literature review, critical social science studies have explored the changing role of health professionals and illustrated among other things that health care encounters no longer are based solely on the specialised knowledge that professionals possess in their capacity as a medical profession. To my knowledge, not many have explored this as a democratic aspect in which lay knowledge is almost juxtaposed with medical knowledge in the relation between professionals and patients or the way professionals are subjected to the same governing technologies as patients within a pathological area as diabetes. In an exploration of preventive health and health promoting interventions targeting obese children and their parents, Pedersen (2014, p. 196) illustrates how civil society organisations as well as public administrations are expected to adapt to new knowledge and roles that lies beyond traditional work to provide an environment that makes it easier to choose a healthy lifestyle. She illustrates how health professionals are subjected to the same governing technologies as the children and, therefore, expected to conduct themselves through positive self-reflection and self- engineering capacities. In the same vein as Pedersen (2014), the present dissertation suggests that health professionals are expected to continuously enhance the self-caring capabilities of patients. I attempt to show how this dimension contributes with knowledge of how practical knowledge is democratised in a diabetes setting. That is, the management of diabetes is

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not solely based on medical knowledge or even biologically, psychological or social knowledge but the lay knowledge of patients. The knowledge that is deemed relevant is the knowledge that can be directly applicated in the quest to optimise the behaviour and conduct of patients. Gaining knowledge about patient is still a prerequisite for utilising their capacities. However, not only knowledge about individuals is central, but the knowledge of individuals. By this I mean that patients own knowledge of how they are able to change behaviour and conduct themselves responsibly are to be utilised in order for professionals to encourage patients to choose a healthy lifestyle. In summary I will return to the point of a lifestylisation of biopower. The contribution of this dissertation to the body of knowledge of diabetes and lifestyle is to expose how contemporary diabetes care entails and extensification and intensification of the exercise of governmental power. I have tried to show how ideas about self- government and lifestyle changes articulated in medical circles at least since the 1970s have crystallised into a lifestyle dispositive in which diabetes patients are above all governed through behaviour and conduct. I have attempted to illustrate this by pointing to the reforms and the establishment of health centres in Danish municipalities as well as exploring how these rationalities have implications for the identity and self-conduct of both professionals and patients in practice. Obviously, the lifestyle dispositive is not invented by the Danish 2007 Structural reform, but the latter gave rise to an expansion of the ambitions of governing rationales in diabetes. While we should be careful not to exaggerate the novelty of the lifestyle dispositive, the dissertation does point to significant changes in diabetes care in terms of the expectations of individuals to govern themselves in the quest to adopt healthier lifestyles. I have tried to highlight how the three dimensions in various ways corroborate with other literature and empirical findings but also constitute some novelty and thereby contribute to the knowledge of diabetes and lifestyle.

5.3. Ethical and methodological considerations In this dissertation, I have advanced how a critical diagnosis of the present can be conducted. Foucault showed how past ethical practices can be studied. The benefit of

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5. Discussion and conclusion such an approach is that the data used is not produced for research purposes. Thus, in many ways such an approach — in terms of methodological considerations — avoids dealing with the problems of reproducing already existing power relations. However, to study present practices as they unfold simultaneously with the research process and to illuminate the experiences of professionals and patients, I have chosen to make use of interviews and observations despite their inherent problematic relation to relations of power between the researcher and the researched (outlined in section 4.3.1.). In brief, these data producing techniques contribute to, if not produce, (existing) power relations and present the persons under study with problematisations of their self-conduct that they may not have problematised themselves. I have attempted to overcome this challenge in different ways, although it is not possible to completely avoid the problem. The study has employed interview guides with rather broad and open-ended questions to allow for a diverse number of responses. Additionally, I combined interviews with other data producing techniques such as observations. The findings of these practices resonated with how the health professionals talked about the diverse self-governing practices of patients as well as findings from observational studies. Moreover, any form of research may raise questions of which important patterns and complexities may have been overlooked, silenced, obscured or neglected in the research by focusing on certain study objects and certain patterns (Ringer, 2013; Pultz, 2017). I will focus on one example, although in practice there may be others. I have sought to illuminate the complexity and somewhat broad patterns of the problematics of government and self-government in each research setting and thereby may have silences or obscured more local patterns and complexities. I have explored ways of governing and attempted to illuminate technologies of government and self-government in a range of settings: in national health politics, in a region, in two municipalities, in two hospitals, and in the everyday practices of patients. Even though differences do exist across these settings, for instance, between the two municipalities or between the two hospitals, I have treated these settings as examples of the same form of approach to diabetes care. This is in part due to the consideration that this dissertation has not aimed to compare the settings to produce knowledge regarding which setting may be better at practicing

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diabetes care. Nonetheless, the broad focus of this dissertation’s analytical and methodological perspective may have overlooked complexities and important local patterns that could have provided the analysis with additional understandings of the practice of diabetes care. As outlined in Chapter four, the Foucault-inspired analytical perspective entails that the researcher cannot know if she has covered the full context, or fully take account of the presumptions of the work undertaken. Regardless, this dissertation is undertaken with the notion that it always makes sense to stop and ask what is going on and where is this going on. As Foucault has nuanced, one cannot necessarily say that something is better or worse but that everything is potentially dangerous.

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English summary

This dissertation entitled “Governing lifestyle” examines government and self- government in diabetes care in Denmark. The dissertation critically explores how and under what conditions lifestyle is governed and problematised in diabetes care, inspired by Michel Foucault’s analytics of knowledge, power and subjectivity as well as notions of governmentality and biopower. Overall, the dissertation finds that Danish diabetes care are witnessing a proliferation of interventions seeking to prevent unhealthy lifestyles. These interventions represent a transformation in the mode of governing in which public authorities consider certain illnesses as the result of poor lifestyle choices. Yet, this does not necessarily imply divestment of state responsibility and interventions. Rather, this dissertation shows how the ambition of contemporary preventative health politics is to offer a comprehensive array of interventions that seek to encourage and enable citizens to make healthier choices. Lifestyle has crystallized into a government dispositive in which diabetes can be seen as a prism for contemporary neoliberal biopower seeking to optimise the self- governing capabilities of citizens in general and of diabetes patients in particular. The implications are that healthy lifestyle choices rather than a curative and pharmacological treatment are viewed as the great panacea to what is often termed the diabetes epidemic and lifestyle interventions have become the self-evident and obvious approach. This dissertation contributes conceptually with an extension of the concept of biopower in three dimensions to grasp ways of governing in contemporary preventative health politics and to illuminate the relevance of Foucault’s original conception of biopower as the state’s right to foster live and to let die. The first dimension concerns the relatively recent political expectation that citizens suffering from diabetes constantly and continuously reflect on how they can improve their lifestyle and well-being. The second dimension refers to a governmentalisation of the social environment to facilitate the choice of a healthy lifestyle. The third dimension entails a democratisation of biopolitical knowledge in terms of what kind of expert knowledge that is considered relevant in diabetes care but

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Summary also an inclusion of lay knowledge, i.e. patients’ considerations of what constitutes well- being. The dissertation is comprised of three papers drawing on a combination of different methods and data, including document analysis of health programmes, interviews with health professionals and diabetes patients as well as observational studies in a patient education setting. While the first paper sheds light on the knowledge/power relations, paper two and three examines the power/freedom relations in Danish diabetes care. Specifically, this dissertation offers three main conclusions across the three papers. First, the empirical analyses show the government rationalities attempt to govern lifestyle by intervening into the social surroundings of patients and citizens in general through health centres in local government. The governing ambition is to optimize the self-caring capabilities of citizens and to strategically intervene into the lives of individuals who display certain risk factors of unhealthy lifestyles. These lifestyle interventions are not only about transferring responsibility to the individual. They represent an environmental or institutional approach to lifestyle in which the social relations and surroundings of patients and citizens in general are mobilised to make the choice of a healthy lifestyle easier. Secondly, this dissertation demonstrates that health professionals in diabetes care are urged to govern themselves not according to authoritative medical knowledge, but according to a democratised form of knowledge in which the rationality of the self-caring patient is the guiding principle. This entails an extension of their self-government in which health professionals are expected to not only facilitate the knowledge and experiences of patients but the self-care and active agency of patients and reflect upon the ways in which they continuously can improve the self-caring capabilities of patients. It is however not all professionals who conform to this democratization of their expertise. Instead of renouncing the attempts to govern their conduct they require more formalised structures to be able to facilitate patients’ ability to self-care. Thirdly, the dissertation shows how diabetes patients engage in lifestyle interventions attempting to optimise their self-care in various ways which challenge the prevailing form of power in lifestyle interventions. The analytical findings show that

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patients’ self-conduct can be divided into two distinct modes of self-government: those who opt for a freedom-based power and those who opt for more direct forms of power. Somewhat surprisingly, the latter mode implies that rather than resist or reject intervention into their lives, patients voluntarily objectify themselves as pathological individuals calling for more direct forms of intervention.

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Summary

Danish summary (Dansk resumé)

Ph.d.-afhandlingen ”Styring af livsstil” undersøger styring og selvstyring i diabetesbehandling i Danmark. Med afsæt i Michel Foucaults analyser af relationen mellem viden, magt og subjektivitet i moderne samfund samt hans begreb om governmentalitet og biomagt er afhandlingens formål kritisk at undersøge, hvordan og under hvilke omstændigheder livsstil bliver styret og problematiseret i diabetesbehandling. Samlet set viser afhandlingen, at dansk diabetesbehandling oplever en udbredelse af interventioner, der søger at forebygge usund livsstil. Disse interventioner repræsenterer en transformation i styringsformer, hvori visse sygdomme betragtes af offentlige myndigheder som resultatet af dårlige livsstilsvalg. Dette indebærer dog ikke nødvendigvis en afvikling af statsansvar og -interventioner. Denne afhandling viser snarere, hvordan ambitionen i nutidens forebyggende sundhedspolitik er at udbrede interventioner, der søger at tilskynde og give borgerne mulighed for at træffe sundere valg. Livsstil har således krystalliseret sig til et styringsdispositiv (styresystem), hvori diabetes kan forstås som en prisme for nutidig neoliberal biomagt, der søger at optimere de selvstyrende egenskaber hos borgere generelt og især hos diabetespatienter. Implikationerne ved denne udbredelse er, at sunde livsstilsvalg snarere end en helbredende og farmakologisk behandling opfattes som universalmidlet til ’diabetesepidemien’, hvori livsstilsinterventioner er den selvindlysende og åbenlyse tilgang til diabetesbehandling. Denne afhandling bidrager konceptuelt med en udvidelse af biomagtbegrebet i tre dimensioner for at indfange nutidens forebyggende sundhedspolitik og for at illustrere den stadige relevans af Foucaults originale forståelse af biomagt som statens ret til at fremme livet og lade dø. Den første dimension af denne udvidet biomagt handler om den relativt nye politiske forventning om, at borgere, der lider af diabetes, konstant og løbende reflekterer over, hvordan de kan optimere deres livsstil og velvære. Den anden dimension refererer til en governmentalisering af det sociale miljø for at gøre det lettere at vælge en sund livsstil. Den tredje dimension indebærer en demokratisering af biopolitisk viden i forhold til hvilken form for viden, der opfattes som relevant i diabetesbehandling,

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samt en inklusion af lægviden i behandlingen, dvs. patienters egne overvejelser af hvad velvære er for dem, og hvordan de balancerer nydelse og sundhed. Afhandlingen består af tre artikler baseret på en kombination af metoder og data, herunder dokumentanalyse af sundhedsprogrammer, interviews med sundhedsprofessionelle og diabetespatienter samt observationsstudier i en diabetesskole med patientundervisning. Hvor den første artikel har fokus på viden/magt-relationer, undersøger artikel to og tre magt/friheds-relationer i dansk diabetesbehandling. Særligt bidrager afhandlingen med tre centrale konklusioner. For det første viser de empiriske analyser, at staten i stigende og mere systematisk omfang søger at styre livsstil ved at intervenere i patienters og mere generelt i borgeres sociale omgivelser gennem kommunale sundhedscentre. Styringsambitionen er både at optimere borgernes evne til at drage egenomsorg samt at intervenere i livet hos personer, der udviser risikofaktorer for usund livsstil. Disse livsstilsinterventioner handler ikke kun om at overføre ansvaret for en sund livsstil til den enkelte. De repræsenterer en miljøorienteret eller institutionaliseret tilgang til livsstil, hvori både patienter og mere generelt borgeres sociale relationer og omgivelser søges mobiliseret for at gøre det sunde livsstilsvalg lettere. For det andet demonstrerer afhandlingen, hvordan sundhedsprofessionelle tilskyndes til at styre dem selv ikke i forhold til autoritativ medicinsk viden, men i forhold til en demokratiseret form for viden, hvori rationalet om en patient, der udøver egenomsorg, er det styrende rationale. Dette rationale indebærer en udvidelse af de professionelles selvstyring, hvori de tilskyndes til ikke kun at facilitere inddragelsen af patientens viden og erfaringer, men også patientens evne til at yde egenomsorg og deltage aktivt i behandlingen og til at reflektere over, hvordan og på hvilke måder de konstant og løbende kan optimere patientens egenomsorg. Det er dog ikke alle professionelle, som tilpasser sig denne demokratisering af deres ekspertise, men i stedet for at frasige sig styring, efterspørger de sundhedsprofessionelle i stedet mere formaliserede stukturer, der kan gøre dem bedre i stand til at facilitere patienternes egenomsorg. For det tredje viser afhandlingen, at diabetespatienter engagerer sig forskelligt i disse livsstilsinterventioner, der forsøger at optimere deres evne til at drage egenomsorg,

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Summary hvilket udfordrer den fremherskende styringsform i disse interventioner. Analyserne viser, at patienternes selvpraksisser udfolder sig i særligt to selvstyringsformer: Dem som vælger en frihedsbaserede magt, og dem som vælger en mere direkte form for magt. Måske overraskende indikerer den sidstnævnte selvstyringsform, at i stedet for at modstå eller afvise intervention i deres liv, objektiviserer disse patienter frivilligt sig selv som patologiske individer og efterspørger mere direkte former for intervention.

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Appendix 1: General practice interview guide (in Danish)

Baggrund 1. Kan du fortælle lidt om din baggrund? (Alder, erfaring, erfaring med T2DM) 2. Hvor mange patienter har I med T2DM?

Behandlingen 3. Hvad er det vigtigste i behandlingen af patienter med T2DM? 4. Er der noget særligt der kendetegner denne patientgruppe i forhold til andre patienter? 5. Hvilke værktøjer bruger du i behandlingen af patienterne? 6. Mener du, at du har mulighed for at give patienterne den nødvendige behandling? a. Har du værktøjerne (både tid og konkrete redskaber)? b. Hvad kan gøre, at ikke kan give den nødvendige behandling? 7. Synes du, at behandlingen af patienterne har ændret sig i de år, du har været læge?

Organisering 8. Hvordan fungerer den nuværende organisation af T2DM patienter i det danske sundhedsvæsen, efter din mening? a. Udfordringer? Fordele? 9. Hvad er opgaven for almen praksis, efter din mening? 10. Hvilken rolle skal almen praksis spille i forhold til patienter med type 2-diabetes? a. I forhold til sundhedscentret i kommunen? b. I forhold til ambulatoriet på hospitalet? 11. Skal I være bedre til at snakke sammen om behandlingen af patienterne? a. Er der nogen, der skal inddrages mere? 12. Kender du til forløbsprogrammerne for Type 2 diabetes? a. Hvis ja: Er det noget, som du forholder dig til i praksis?

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13. I programmet er der beskrevet et stratificeringsværktøj, som skal være med til at fordele patienterne til den rigtige behandling. a. Kender du til det? Bruger du det? 14. Hvornår henviser du en patient til ambulatoriet eller patientundervisning?

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Appendix 2: Hospital ambulatory interview guide (in Danish)

Baggrund 1. Kan du fortælle lidt om din baggrund? a. Alder osv. b. Erfaring som læge c. Erfaring på diabetesområdet

Behandlingen 2. Hvad er din tilgang til patienterne med diabetes, som kommer her i ambulatoriet? a. Hvad er vigtigt? b. Hvad er vanskeligt? c. Hvad kunne være bedre? d. Hvilken type patienter får I her? 3. Hvad er hovedformålet med den behandling, som I giver her? 4. Synes du jeres tilgang til patienter med diabetes har ændret sig (siden du startede med at arbejde på området)? 5. Kan du beskrive, hvilken betydning forløbsprogrammet har i dit arbejde? 6. Har forløbsprogrammet ændret på noget? a. Tilgangen til patienterne? b. Typen af patienter? c. Dine arbejdsopgaver? d. Samarbejdet med kommuner, almen praksis andre…? 7. Der er en stratificeringsmodel i det nye forløbsprogram fra 2010 – kender du til den model? a. Hvis ja, kan du sige lidt om dens formål? b. Bliver den brugt? c. Hvorfor er det nødvendigt?

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Organisering 8. Samarbejder I med almen praksis/kommuner? a. Hvordan? b. Hvorfor har I brug for det? c. Hvorfor ikke? 9. Hvordan opfatter du almen praksis’/kommuners rolle i organiseringen af Type 2 diabetes? 10. Hvordan opfatter du jeres rolle? 11. Hvordan fungerer den organisering, som I har nu?

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Appendix 3: Municipality interview guide (in Danish)

Baggrund 1. Kan du fortælle lidt om din baggrund? (Alder, erfaring, uddannelse, erfaring med T2DM) 2. Hvilken stilling har du her i kommunen, og hvad indebærer denne stilling? 3. Hvilke tilbud har I her i kommunen i forhold til forebyggelse af sundhed? 4. Hvad lægger I vægt på?

Sundhedscentrets/kommunens rolle 5. Hvilken rolle, mener du, Sundhedscentret/kommunen skal spille i forhold til borgere med Type 2 diabetes – men også forebyggelse generelt? 6. Har Sundhedscentret/kommunen en særlig forpligtigelse ift. denne målgruppe? Hvorfor? 7. Hvordan varetager I bedst denne rolle, efter din mening? 8. Hvilken rolle har sundhedscenteret/kommunen i forhold til almen praksis? 9. Hvad er kontakten mellem sundhedscentret/kommunen og almen praksis? 10. Hvilken rolle har sundhedscenteret/kommunen i forhold til hospital/amb? 11. Hvad er kontakten mellem sundhedscentret/kommunen og hospital/amb? 12. Samarbejder I på tværs af kommunale afdelinger? 13. Hvorfor har I brug for at arbejde tværsektorielt? 14. Hvilke udfordringer er der i det tværsektorielle samarbejde? 15. Hvordan forholder du dig til forløbsprogrammerne? 16. Er der andre programmer som er vigtige? 17. Hvad tænker du, om de nye anbefalinger til kommunal forebyggelse – Fx opfølgning og opsporing i kommunerne? 18. Borgerne skal/skal ikke henvises til jeres tilbud – hvorfor ikke? a. Hvordan kommer de så?

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Om selve diabetesskolen 19. Kan du ikke fortælle lidt om, hvad formålet er med jeres sundhedstilbud – og specifikt diabetesskolen? 20. Hvad er dine forventninger til deltagernes udbytte af undervisningen? 21. Har forventningerne ændret sig siden I startede med at tilbyde undervisningen 22. Hvordan håndterer man borgere som har svært ved egenomsorg? 23. Hvad tror I at patienterne får ud af, at det er gruppeundervisning? 24. Hvilke udfordringer har I? 25. Hvad fungerer godt?

Om målgruppen 26. Hvilken baggrund har de borgere, der kommer i Sundhedscenteret? 27. Ved du noget om, hvordan det går borgerne efter skolen? 28. Ville I gerne gøre noget andet for dem?

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Appendix 4: Patient interview guide (in Danish)

Baggrund 1. Kan du give mig en kort beskrivelse af dig selv? a. Alder? b. Familieforhold? c. (Tidligere) arbejde? i. Hvis stoppet – hvornår/hvorfor? d. Uddannelse? e. Hvad kan du godt lide at lave i din fritid? 2. Kan du fortælle lidt om, da du fik diagnosticeret diabetes? a. Hvornår? b. Hvordan blev det opdaget? c. Hvad tænkte du? 3. Kender du andre, der har diabetes? a. Hvis ja, er det noget I taler om? b. Vidste du noget om diabetes, inden du fik diagnosen? 4. Har du andre diagnoser/sygdomme?

Hverdagen 5. Kan du fortælle lidt om, hvordan det er at have diabetes? a. Hvad mærker du til din diabetes? b. Hvad er sværest? c. Hvad betyder det for din hverdag og i dit sociale liv? d. Hvis arbejde og diabetes, har du haft nogen udfordringer med dit arbejde ift. arbejde? 6. Er der sket nogen ændringer i dit liv, siden du fik diabetes? 7. Hvad er vigtigt for dig i forhold til dit helbred? a. Hvad gør du for at opnå det? 8. Får du medicin (medicin ift. selvstyring)?

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a. Ja: hjælper det dig? b. Nej: hvorfor ikke?

Om diabetesskolen 9. Kan du sige lidt om, hvorfor du meldte dig til diabetesskolen? a. Blev du henvist, frit valg, opfordret? b. Havde du tænkt over inden, hvordan det ville være at deltage? a. Hvad ønsker du at få ud af at deltage? 10. Har du deltaget i andre lignende kommunale eller frivillige tilbud? a. Fx også de personlige samtaler? 11. Kan du sige lidt om, hvordan det er at være på skolen? a. Hvad er godt/dårligt? b. Kan du bruge det, som de har fortalt jer til noget? 12. Efter din mening – skulle noget være anderledes? a. Er det noget, som du gerne ville have hørt mere om? b. Skulle formen have været anderledes? 13. Hvad betyder det, at I er et hold? 14. Hvad synes du, var det bedste ved skolen? a. Hvad var det vigtigste? b. Hvad tager du med dig? 15. Har det ændret noget for dig?

Interaktion med sygehus, kommune og læge 16. Kan du sige lidt om, hvem du har kontakt til i forhold til din diabetes? a. Har du eller har du haft nogen kontakt til sygehuset, dvs. ambulatoriet? Hvis ja, kan du beskrive den kontakt? 17. Hvordan er din kontakt til egen læge? a. Hvor ofte er du hos egen læge? Til kontrollerne? Mere? Også ikke diabetes- relaterede ting? 18. Hvordan oplever du den kontakt du har til sundhedsvæsenet? 19. Har du være indlagt på sygehuset i forbindelse med din diabetes+

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PART TWO: The three papers and empirical analyses

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Paper one

Lifestylisation of the social: the government of diabetes care in Denmark

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Lifestylisation of the social: the government of diabetes care in Denmark

Sine Grønborg Knudsena a Department of Social Sciences and Business Studies, Roskilde University, Denmark

The paper is being revised for a resubmission to Health.

Abstract Since the 1970s, the public authorities of many OECD countries have emphasized the need for preventing lifestyle diseases and promoting the vigour of their populations. On the basis of public health documents and the Foucauldian analytics of dispositive, this article critically addresses some of the normative implications of the preventive interventions in the area of diabetes care. It is shown that the government of lifestyle was extended and institutionalised by a reform of the Danish public sector in 2007. Following that reform, rationales of public health policies sought to prevent unhealthy lifestyles not only through individual behaviour but through the social surroundings of citizens. In contrast to the claim that we are seeing a retraction of state responsibility and interventions in the area of public health, this article suggests that we are witnessing an expansion in state ambitions expressed through a lifestyle dispositive. These ambitions are less about transferring the responsibility to the individual and more about governing and mobilising the social relations and environments of diabetes patients and citizens in general to make the everyday choice of a healthy lifestyle easier.

Keywords: Lifestyle, prevention, diabetes, Denmark, Foucault, dispositive

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Introduction

Since the 1970s, conditions often regarded as lifestyle diseases have become a major health problem in OECD countries, and there have been multiple attempts to tackle these conditions on the epidemiological, clinical, and public health level (Armstrong, 2009). The Lalonde report published in 1974 (Lalonde, 1974) and the Ottawa Charter published by the World Health Organisation (WHO) in 1986 are often referred to as major sources of inspiration for the focus on lifestyle diseases. For instance, Larsen (2010) observes that the WHO promotes a focus on certain lifestyles that are associated with self-imposed risks and destructive habits. Consequently, several scholars note how public health policies have put particular emphasis on the prevention of unhealthy lifestyles in the population (Larsen, 2010; Vallgårda et al., 2014; Mayes, 2016). Although it may seem obvious to try to change unhealthy behaviour, we need to critically address the normative implications of the policy emphasis on lifestyle as the cause and cure of certain diseases. In critical social science studies on health promotion and disease prevention, the current political emphasis on lifestyle is often explored under the term the new public health. These studies suggest that we are witnessing a governmental health paradigm based on a broad concept of health in which a range of aspects of everyday life seem to pose a risk to the well-being of the population (Petersen and Lupton, 1996). The advent of this political approach is essentially what Armstrong (1995) has termed the shift from hospital medicine to surveillance medicine. Armstrong and others point out how new ways of thinking about illness emerged as health-related behaviour is linked to individual agency, thereby making the behaviour of everyone a goal for preventive strategies (Armstrong, 2009; Larsen, 2010; Mayes, 2016). Other critical social science studies have examined the shifting territories and objects of government in public health strategies. A range of studies — notably Rose (1996) — have pointed to the various ways in which both the health domain and the social domain have become territories for preventive activities (Højlund and Larsen, 2001; Bernier, 2009; Ljungdalh and Møller, 2012). These understandings — drawing in particular, though not exclusively, on the French scholar Michel Foucault — emphasise how the reorientation of government is characterised by neoliberal rationalities

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in which the locus of governing is moved outside the state in favour of the choice and the self-governing capacities of individuals (Petersen and Lupton, 1996; Cruikshank, 1999; Rose, 1999; Mol, 2008). In contrast, others observe a transformation in OECD countries that points to an increase in the repertoire of governing interventions (Collier, 2011; Peeters, 2013a; Triantafillou, 2017). Specifically, Vallgårda (2011) argues that the governing ambitions of public health seem to address more areas of people’s lives, obliging citizens to be both obedient and autonomous. A range of scholars, especially from critical sociology, go a step further and become explicitly normative. They argue that the emphasis on self-government and risk factors in health policies tends to neglect or ignore the challenges posed by social structures and call for a holistic approach to include these structural challenges (Lindsay, 2010; Morden et al., 2012; MacGregor and Wathen, 2014; Ravn et al., 2016). Notwithstanding variations in their critique, they tend to share the same normative point of departure: the self-government and lifestyle of individuals should be enhanced. This article draws attention to the treatment of type 2 diabetes in the Danish welfare state. First, in 2007, a structural reform reorganised the Danish public sector and made local government responsible for disease prevention and health promotion. The strategy was, among other things, to provide a local framework for promoting healthy lifestyles in the social surroundings of citizens, especially among those who portray risk factors for illness (Danish Health Authority, 2005). Second, diabetes is an illustrative case for examining the normative implications of the emphasis on lifestyle, as it is a condition that, more than other chronic illnesses, is considered by health policies and medical scholars as a lifestyle disease that can be prevented by the self-management of patients (Mol, 2008; Danholt, 2012; Scambler et al., 2014). Although the focus in this article is predominantly on Danish diabetes care, the issues addressed here are likely to be of relevance to the range of countries that have adopted the WHO Ottawa Charter. For example, in the U.S., local government seems to gain more responsibility for public well- being (Lobao, 2016), while in the Netherlands, collaboration between local government, local health and social care organisations is emphasised to create effective self-care in the population (Wensing et al., 2014). In Japan, public health strategies seek to support

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Paper one citizens to make healthier choices (Borovoy, 2017). The Danish case thus broadly resonates with public health strategies in a range of countries. What makes this context special is the implementation of preventive lifestyle interventions through local government in a highly regulated and comprehensive welfare state (please see the methods section for a description of the Danish case). Drawing on Danish diabetes and public health documents and building on insights from the critical studies from the social science literature, this article explores the question: How are rationalities of preventive lifestyle interventions in the social surroundings of patients employed in diabetes care in Denmark? The argument in this article is twofold: First, the underlying rationales of diabetes care have undergone a transformation in which not only the individual lifestyle choice is problematised but also the social structuring of that choice. Moreover, this approach governs not only through the behaviour of patients but through the conduct, i.e. patients’ minds, consideration and choices. Second, government of social surroundings and the conduct of diabetes patients were already emphasised in public health policies in Denmark and OECD countries during the end of the twentieth century, for instance in form of the choices and consumption habits made in the everyday life (Ljungdalh and Møller, 2012). This article argues that the problematisation of choice was reconfigured and the governing of the citizens’ social surroundings was institutionalised by the reform of the Danish public sector in 2007. Thus, lifestyle interventions promoted through local government represents an expansion of preventive strategies targeting patients with diabetes and citizens in general. As I will demonstrate, the fact that Danish health authorities problematise certain diseases in terms of the poor lifestyle choice by individuals does not necessarily imply divestment of state responsibility. This study suggests that the Danish approach to prevention through local government portrays rationales of an enabling state that increasingly legitimates state intervention — especially in the lives of people who do not have the capabilities to self-manage according to prevailing social norms. As such, the present article contributes to knowledge of the government of lifestyle in preventive health strategies and on the management of socially structured risks in diabetes care.

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In the following sections, I first present the analytical framework and methodology of the study, after which a critical analysis of the rationalities of diabetes care is presented in four sections, followed by a conclusion.

The lifestyle dispositive

To explore the rationalities of lifestyle in Danish diabetes care, I draw on Michel Foucault’s analytics of the dispositive. Foucault (1980) describes the dispositive as a system of relations between a multitude of heterogeneous elements, such as discourses, institutions, administrative measures, and moral propositions, that surface at various points in time. It was used by Foucault to analyse “how forms of rationality inscribe themselves in practices or systems of practices, and what role they play within them” (Foucault, 2002, p. 230). These practices can be analysed as programmes of conduct along two axes: prescriptive effects about what is to be done and codifying effects of what is to be known in the government of others and the government of ourselves (Foucault, 2002). To be clear, the notion of government is taken up by Foucault to signify relations of power — i.e. the practice of commanding the conduct of others or of oneself. Thus, power is detached as a synonym with a state or with a uniformly process from the top downwards and as something associated with a negative or juridical meaning (Foucault, 1982). Rabinow and Rose (2003) advance how the dispositive enables analysis to cut reality in a different way than existing social theory by dissolving common beliefs. This does not mean that concepts, such as social class, do not exist within these analytics, but that through the dispositive new relations, problems and associations come to view. Thus, practices such as public health “gain their sense only from their location within a much wider nexus of relations of knowledge, power and the production of subjectivities” (Rabinow and Rose, 2003, p. 8). Similarly, Raffnsøe et al. (2016, p. 279) emphasise that rather than analysing reality as such, a dispositive analysis demonstrates “how different actions (viewed as prescriptive events) mutually eliminate each other, only to collectively outline a pattern and create a new normative level”. Thus, the analytics of the dispositive attempts not to search for anything hidden behind events. Rather, the aim of the

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Paper one dispositive analysis is to bring forward prescriptive events which effects can be taken as face-value (Rabinow and Rose, 2003), and to breach the self-evidence that presents itself as obvious and on which our forms of knowledge and practices rest (Foucault, 2002). Notably, Mayes (2016) applies the dispositive to illuminate how obesity (in Australia) is problematised as a social phenomenon to which an urgent strategic response is needed. Mayes advances how lifestyle serves as dispositive or as an enabling network in which not only medical authorities or government health campaigns target individual lifestyle, but disparate forms of knowledge, power and subjectivity seek to govern the individual choice of lifestyle. In accordance with Mayes, this article conceives of lifestyle as a dispositive in diabetes care. As indicated earlier, diabetes is problematized as a lifestyle disease to which an urgent response is needed to secure the population from its personal, medical, and economic consequences. Consequently, the logic of targeting unhealthy lifestyles presents itself as the obvious solution. Applying the dispositive, the analysis seeks to breach the self-evidence of this logic to pin down the rationalities invested in governing the choices of individuals. More specifically, it examines the lifestyle dispositive as a network between two elements that, in part, make up the dispositive: problematisations of self-care and risk as a tool of government (for an elaboration of the identification of elements, see the following section). These elements are analysed according to the two axes of what is to be known (the rationalities of specifying and creating that which is governed) and what is to be done (the regulations, tools or techniques) in the government of diabetes. The term lifestylisation (applied in the title and in the analysis) is lent from a recent study by Lucivero and Prainsack (2015). They apply lifestylisation to denote the emergence of health technologies that not only go beyond-the-clinic toward a bio- medicalisation of everyday life but also take various social factors of citizens into account and personalise treatment to the lifestyles of individuals. The present article employs lifestylisation in a similar way to illustrate how rationalities of lifestyle interventions, concerned with the prevention of certain choices and social risks, appear as the obvious method to address diabetes and to optimise self-management skills. Moreover, the notion of risk is not new but through the lifestyle dispositive risk is sought minimised or

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manipulated. This is a radical difference from earlier social insurance technologies in the 1960s and 1970s that sought to socialise and compensate for risk, i.e. things that had already happened (Villadsen, 2004). To clarify, this article does not suggest that the dispositive works in a deterministic fashion or cannot be resisted. The dispositive is characterized by a flexibility in which rationalities by themselves can produce effects event though actions are not necessarily being taken or are successful (Foucault, 2002; Raffnsøe et al., 2016). However, this article examines ways of problematising and rationalities of government and does not address the unfolding or the concrete practices of the lifestyle dispositive, i.e. the effect of such rationalities. Although this is a limitation, a detailed focus on the rationalities of government can offer a critical examination of the attempt to optimise self-management skills and lifestyle in diabetes care and illuminate the normative implications of the concept of lifestyle.

Methods

To understand the concept of lifestyle and the way it informs the preventive interventions in diabetes care, this article employs a document analysis of the government rationalities in diabetes care as they unfolded in policy documents before and after the structural reform of the Danish welfare system in 2007. Compared to other OECD countries, Denmark has a comprehensive public sector with a tax-funded, universal model in which all citizens have access to health services that are channelled through or controlled by public institutions (Kristensen et al., 2016). Following a major structural reform of 2007, parts of the administration and delivery of prevention and health promotion initiatives was relocated from the health sector working at the regional level to the social and health services at the level of local government (Andersen et al., 2017). The treatment of diabetes through preventive strategies in local government has been especially emphasised in the 2017 diabetes plan (The Ministry of Health, 2017). Danish municipalities were already responsible for a large part of public services, with total available resources accounting for almost a third of the public spending. Community health centres were established in all municipalities in which health professions, such as

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Paper one nurses, physiotherapists, dieticians, etc., were to create frameworks for healthy lifestyles and provide educations programs for people with chronic illnesses. The health governmental context of Denmark is thus particularly useful to study the expansion of preventive strategies in diabetes care. This article uses documents (health policy papers) as empirical material. Drawing on Mik-Meyer (2005) and Prior (2003), documents are seen to form part of a process in which they both reflect their institutional context of production and contribute to performing organisational activities in that very same context. Thus, documents are employed in the present article to examine rationalities of government. As indicated earlier, it should be mentioned that a document analysis cannot address the full scope of the lifestyle dispositive. To identify relevant governmental health publications, a manual search was conducted on the web pages of the Danish Health Authority and the Ministry of Health. All key health documents about diabetes care and more generally about chronic illness were selected, a total of 43 documents. Of those twelve policy documents — covering the years from 1981-2016 — were selected to form the main basis of the dispositive analysis (for a full list of the documents, please see Table 1). These documents were deemed particularly significant to illustrate governing rationales of diabetes care, as they were emphasised by other health documents and a leading Danish medical journal1. As described earlier, the analytical strategy of this article is inspired by Foucault’s analytics of the dispositive. This entails a nominalist approach in the sense of taking the actors’ arguments and mode of reasoning at face value, rather than searching for hidden agendas and motives (Raffnsøe et al., 2016). Consequently, rationalities underpinning diabetes care can be illuminated by mapping and contextualizing the explicit arguments given by the public authorities in these documents. Thus, as a first step, the analysis of documents focused on the rationales employed by documents when describing prevention in diabetes care. Two rationales seemed to be emphasised, namely the self-care of patients and the need to be more attentive to risk factors in order to detect people with undiagnosed diabetes or people at-risk of developing diabetes. These rationales also

1Ugeskrift for Læger

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aligned well with findings highlighted by critical studies of prevention in social science literature. Obviously, when focusing explicitly on elements derived from the body of literature of this study, the analysis can be criticized as simply confirming the existence of what we are searching for. Therefore, in the next step of analysis, I coded the documents in a chronological order using Nvivo software. First, the documents were open-coded based on a semi-structured approach to allow other descriptions and rationales of diabetes and chronic care to emerge from the data. Second, the analytical framework of the dispositive was used to refine the codes focusing on descriptions of problematisations, forms of knowledge, government techniques and interventions. Accordingly, the document analysis identified other central rationales of diabetes care. For instance, the economic costs of diabetes were often used as an explicit argument for improving the self-care of patients as well as for relocating health promotion and prevention to municipalities to save resources in hospitals. Furthermore, the documents’ descriptions of preventive strategies were interwoven with descriptions of curative strategies, such as pharmacological treatment, emphasising their mutual interdependence. Thus, economic rationales and curative strategies could also be analysed as central elements of diabetes care. However, the rationale of improving the self-care of patients as well as preventing complications of diabetes by focusing on the management of risk factors seemed to be emphasised as key elements of diabetes care. For instance, several studies have demonstrated that gastric bypass procedures can improve glycaemic control in type 2 diabetes and, in some cases, cure diabetes (Klein et al., 2013; Saeidi et al., 2013). Thus, such a curative procedure could in principle solve both the problem of economic resources and patients’ lack of self-care. Yet, even with the availability of a cost-effective curative procedure, the optimisation of patients’ self-management abilities as well as medical treatment are prioritised in the analysed documents. Based on the analysis of documents, two elements central to the lifestyle dispositive of diabetes care were identified: problematisations of self-care and risk as a government tool. The analysis is structured according to these two elements. The structural reform of 2007 is employed as a juncture in which the lifestyle dispositive

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Paper one intensified in the attempts to systematically intervene into the social surroundings to shape lifestyle choice — not only of diabetes patients but citizens in general. The structural reform is not the object of analysis per se, but functions as a reconfiguration of the lifestyle dispositive. The first two parts of the analysis examine the years between 1981–2005. The last two parts, which represent the dominant part of the analysis, examine the years between 2005–2016. To clarify, the first period ends in 2005 even though the structural reform was implemented in 2007, because the reform was finalized in 2004 (Vrangbæk, 2010). Thus, rationales for the organisational measures to be taken already figured in health policy documents beginning in 2005.

Table 1. Policy documents included in the study.

Year of publication and title Main focus 1. Danish Health Authority (1981). Diabetes: The document describes a proposal for the future organisation of examination and treatment. organisation of the diabetes area. The document Copenhagen. addresses the medical treatment of diabetes with a limited focus on self-care. It focuses on all known forms of diabetes. 2. Danish Health Authority (1994). Diabetes treatment The document describes the current status and the in Denmark: future organisation. Copenhagen. future ambitions and aims of the organisation of diabetes treatment. It focuses on all known forms of diabetes 3. Ministry of Health (1999). The Government’s public The document describes the health political health program 1999-2008: an action-oriented ambitions and strategies of the Government at the program for healthier frameworks in the everyday time. life. Copenhagen. 4. Ministry of the Interior and Health (2002). Healthy The document is a revision of the public health all life: the national aims and strategies for the program from 1999 made by the new Government. public health 2002-2010. Copenhagen. 5. Danish Health Authority (2003). Type 2 diabetes: The document describes four elements of diabetes health technology assessment of screening, treatment: technologies, the patient, the diagnostics and treatment. Medical Technology organisation and economy. The first program Assessment, 5(1). Copenhagen. included here that addresses type 2 diabetes distinctively. 6. Ministry of Health (2003). Action plan for diabetes. The document describes the comprehensive efforts Copenhagen. of diabetes care including both preventive and treatment efforts. 7. Danish Health Authority (2005). Health in the The document describes the new tasks and municipalities — new tasks and possibilities. responsibilities of municipalities in relation to the Copenhagen. structural reform. 8. Danish Health Authority (2006). Self-care — a The document describes how the concept of self- distinctive perspective on prevention and health care is employed in a Danish context and in relation promotion. Copenhagen. to prevention and health promotion. 9. Danish Health Authority (2007). Prevention and The document describes the obligations and health promotion in the municipality: a guide to the responsibilities of municipalities after the structural

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health act. Copenhagen. reform in relation to health promotion and prevention. 10. Ministry of Health (2013). More citizens, fewer The purpose of this document is to describe the patients: a strong, shared healthcare system. overall political rationalities of the Danish health Copenhagen. system with a specific focus on a shared system and the active citizen. 11. Danish Health Authority (2016). Recommendations This document describes the most recent aims of for prevention services for citizens with chronic Danish prevention strategies. The recommendations disease. Copenhagen. of this document are based on other publications and are to form the basis for Disease Management Programs. 12. Danish Health Authority (2016). Recommendations This document describes the recent for Cross-sectorial Pathways for People with Type 2 recommendations of an overall approach to diabetes Diabetes. Copenhagen. in the Danish health system. The recommendations of this document are to form the basis for Disease Management Programs.

Lifestylisation of individual choice (1981–2005) This section examines the period between 1981 and 2005 and focuses on a few exemplary elements of the lifestyle dispositive before the reform: first, how problematisations of self-care targeted the conduct of diabetic patients; and second, how risk as a government tool was concerned with ensuring diabetic patients a normal life. In brief, this section illustrates how preventive interventions in the social surroundings and in the life of diabetes patients were legitimized to encourage the choice of a healthier lifestyle.

Part I: Problematisations of conduct In 1981 the first comprehensive policy paper on diabetes was published. The document addressed self-care in diabetes treatment as it has been shown to reduce hospitalisation. In this document, self-care is also termed ‘self-treatment’ and “(…) denotes that the patient themselves – on the basis of knowledge and skills, motivation and appropriate tools – on a rational basis makes clinical decisions about his or her treatment” (Danish Health Authority, 1981, p. 32). The excerpt illustrated that the responsibility of diabetes patients was related to clinical tasks. Self-care was not a permeating term in this document as very little space was used to describe this. In the second major diabetes plan from 1994, more space was used to stress the need to

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Paper one strengthen the focus on self-care, however the focus was still predominantly on clinical tasks:

The future diabetes treatment centers around the diabetic in the sense that the diabetic must require knowledge of their own illness and must participate in the treatment with a view to achieve an appropriate blood sugar control. (Danish Health Authority, 1994, p. 14)

Some years later, two major governmental health programs, not specifically on diabetes, brought attention to the individual’s responsibility in relation to not only clinical tasks but to a more general notion of health. More specifically, individuals were expected to take charge of their own health status and life (The Ministry of Health, 1999; Ministry of the Interior and Health, 2002). Following Larsen (2005, p. 175), these programmes seem to illustrate how the efforts to foster healthy lifestyles became more comprehensive and sophisticated in the beginning of the twenty first century. In the same vein, several documents in this period promoted the self-measurement of blood glucose as a key tool to encourage the patient to take more responsibility in diabetes treatment (Danish Health Authority, 1994, 2003). For instance, a Health Technology Assessment in 2003 emphasised self-measurement not only for its biomedical advantages but to enhance the self-care of patients:

Even though the home measurement of blood glucose does not have an effect on HbA1c [the average plasma glucose concentration], it is still a useful tool in relation to self-care. For example, it illustrates for the patient, how diabetes reacts to changes in diet and exercise. (Danish Health Authority, 2003, p. 34)

Despite of its lack of biomedical effect, the tool was still emphasised by health authorities as a pedagogical tool to improve patients’ self-care. The rationale promoted by the documents was that when patients could observe and become knowledgeable of the effects of their lifestyle on diabetes, they were more motivated to take responsibility and make the necessary lifestyle changes (Danish Health Authority, 1994, 2003). Thus, this example indicates that diabetes was problematised with regard to behaviour, such as diet and exercise, but also with regard to the conduct of patients, i.e. patients’ mind and considerations. The example of promoting the self-measurement is a part of a wider

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strategy to encourage diabetes patients to choose a healthier lifestyle as well as a strategy to enhance self-management as an aim in itself. Moreover, it is an example of the kind of patient these documents attempt to bring to life. Following Armstrong et al. (2007), the documents seemed to promote a patient with the will-power and good sense to change their choice of lifestyle once they were made aware of their unhealthy habits.

Part II: Government of the normal life In the diabetes plan of 1994, the patient’s ability to lead a normal life seemed to be a central concern. For instance, factors were addressed that were considered to pose a risk for the patient to live a normal life for the diabetic. The document stressed that new research had documented that a good regulation of diabetes, understood as medical regulation and lifestyle changes, could not only prevent the risk of late stage complications but also ensure patients a better quality of life as well as a normal life (Danish Health Authority, 1994, p. 25). Consequently, the Ministry of Health published a new diabetes plan in 2003. In this plan, the observed rise in the occurrence of diabetes was emphasised as an urgent concern with great implications, both socio-economically and for the quality of life of patients (The Ministry of Health, 2003). In general, many of the preventive health strategies espoused in the public health programs in this period take their point of departure in a concern for the relatively inferior health status of the population (The Ministry of Health, 1999; Ministry of the Interior and Health, 2002). To optimise the health status, the prevention of risk factors was emphasized:

The increase in the new occurrences [of diabetes] is to be arrested by reducing the risk factors for diabetes in the population by health promoting and primary preventive interventions that is directed at the healthy population as a whole or at distinct target groups of healthy people with an increased risk, i.e. genetically dispositioned, physically inactive or obese etc. (The Ministry of Health, 2003, p. 7)

The quote illustrates rationales of an expansion of preventive interventions based on the potential and future risk of developing diabetes. The focus on future risks and a normal life moves the emphasis from manifested bodily symptoms to an emphasis on the

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Paper one potential health risks in everyday life, not only in the lives of diabetic patients but also in the healthy population. Based on the risk of future incidences of diabetes, the health authorities would suggest so-called primary prevention, a form of prevention that was directed at the entire population, both ill and healthy people. Similarly, it was not only individuals but society that was expected to take charge of the health status in the population. For instance, the public health programs in this period articulated an approach in which healthy settings and communities were to be created in the everyday life of citizens. Besides the health sector, schools, workplaces, and local communities were to take part in the efforts to make healthy choices easier for the entire population and especially for marginalised groups (The Ministry of Health, 1999; Ministry of the Interior and Health, 2002). Thus, the health authorities advance preventive interventions based on the possible occurrence of an undesirable event and not concrete dangers — everything was potentially a risk factor for something else. Well-being (which appears to be a normal life) became a relative state (not a binary: healthy vs. sick). Accordingly, you could always be healthier, you could always reduce your risk, and you could always legitimise interventions in the name of improving the life quality of citizens. As the understanding of what caused diabetes expanded, so did the repertoire of dealing with it. Moreover, diabetes and public health programs seemed to push a double message (Larsen, 2005, p. 183). They promoted the shaping of surroundings that could encourage individuals to choose healthier lifestyles, because they expect individuals to take responsibility for their health. However, if individuals for some reason did not act according to this message, the programs proposed earlier interventions. In brief, in the period from 1981 to 2005, the focus of Danish diabetes care, termed lifestylisation of individual choice. The political emphasis on self-care and risk management illustrates that the lifestyle dispositive not only addressed the behaviour of patients, including diet, exercise and blood glucose measurements, but also their conduct in the sense om making patients aware of and morally responsible for practicing a kind of self-care that would lead to a healthier lifestyle. Moreover, the documents recommended health promoting and preventive interventions not only in the lives of diabetic patients

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but also in the lives of at-risk citizens, indicating a broader target group when dealing with diabetes. Thus, the responsibility for health was not only placed with the health sector but with citizens and society at large.

Lifestylisation of the social (2005–2016) The period during and following the reform of 2007 transformed the rationales underpinning Danish diabetes care by relocating a substantial part of disease prevention from the health sector to local government. This transformation did not abandon all the old problematisations and government rationalities but reconfigured these. This section examines, first, how problematisations of self-care in preventive lifestyle interventions in municipalities targeted non-health-related problems such as the social surroundings of patients; and second, how the territory of government was not only the normal life of patients but the whole life as more aspects of the patients’ self-government was included — understood as medical, psychological and social aspects.

Part III: Problematisations of social surroundings A range of documents on the self-management and self-care of patients were published in connection with and in the period after the structural reform. One such document was Self-care — a distinctive perspective on prevention and health promotion, which was published in 2006. This document addressed self-care in two forms of prevention: patient-directed prevention, which is directed at patients with an illness to prevent illness profession and complications, and citizen directed prevention which is directed at the healthy population to prevent the development of illness. Although, the document stressed that the approach to self-care thus differed at this time for healthy citizens and ill patients, the rationales and recommendations for improving self-care did not seem to be significantly different. In this document, the authorities stressed that the concept of self-care in a Danish context was to be understood as a shared responsibility between the patient and the health system: “It is in the partnership between the individual and health system that the best possibilities for the exercise of self-care is created”. (Danish Health Authority, 2006,

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Paper one pp. 17–18). Similar to earlier documents, self-care was thus understood as a practice that not only consisted of the responsible and self-caring patients but also health professionals, who had the responsibility of creating the possibilities for lifestyle change. Furthermore, it was highlighted that psychologically and socially disadvantaged patients could find it difficult to live up to the expectation of being active in their own treatment (Danish Health Authority, 2006, p. 8). Accordingly, the practice of self-care as a partnership between health professionals and patients was promoted by health authorities as the necessary response to address certain patients’ inabilities to manage themselves:

By working with self-care, it becomes obvious, that in health and illness other things than the medical elements are at stake. Self-care work focuses on the psychological and social elements in the life of the individual. One might say that the concept of self-care makes it possible to think all the way around the patient – and thereby include both the medical aspects, living conditions, psychological and social elements. (Danish Health Authority, 2006, p. 16)

As the examples illustrated, one way to address the inequalities was to expand the gaze on the patient and “think all the way around the patient”. In this way, self-care was understood as medical-related behaviour but also as the conduct of patients and citizens in terms of living conditions to psychological and social aspects of the patient. These problematisations of self-care seemed to align well with the rationales underlying the structural reform. With the reform in 2007 local government was expected to constitute an important role in the prevention of illness by addressing the lifestyles of citizen. For example, the document, Health in municipalities — new tasks and possibilities (2005), emphasised that the established health centres were to play a central role and function as an arena for disease prevention and health promotion:

(…) local government will be responsible for creating a framework for a healthy lifestyle. This makes sense because local government forms the framework for a large part of the daily lives of citizens. (…) It is precisely here — in daily life — that prevention and health promotion can make a difference. Therefore, the efforts of local government are crucial when it comes to creating a framework for a healthy life for citizens in municipalities. (Danish Health Authority, 2005, p. 5)

Thus, at this time municipalities were to be in charge of citizen-directed prevention whereas hospitals and general practitioners were responsible for patient-

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directed prevention (Danish Health Authority, 2005, p. 4). However, in the government’s health initiative from 2013, entitled More Citizens, Fewer Patients: A Strong, Shared Healthcare System, the tasks of local government seemed to be expanded. The aim was now to strengthen the municipal patient-directed prevention — especially for the chronically ill (Ministry of Health and Prevention, 2013, p. 39). In this way, according to these documents, local government increasingly became in charge for more preventive interventions. Similarly, the terminology of which kind of person these policies took as their target changed:

The citizen is to be treated and cared for as close to their homes as possible and to avoid being hospitalised. The Government wishes that the individual to the extent possible remains a citizen and as little as possible becomes a patient. (Ministry of Health and Prevention, 2013, p. 7)

Citizen, a much broader term, further illustrated a focus on psycho-social elements rather than bio-medical. The patient role was problematised as inhibiting the individual from becoming an active and self-caring citizen. The rationale for reconfiguring the health system closer to the citizens’ social environment was to base the approach on the needs and preconditions of the individual citizen and not the needs and traditions of the health system (Ministry of Health and Prevention, 2013). The shift from patient to citizen as well as the increase of local government’s responsibilities in preventive interventions indicated a more extensive approach to the prevention of illness. To summarise, the problematisation of self-care in this period not only targeted the individual’s ability to lead a healthy life but also considered the individual choices to be determined by social structures and social risks. The established health centres in local government seemed to expand the governing ambitions of the health system. It became less about transferring the responsibility to patients and more about reconfiguring and institutionalising the social environment of patients. Moreover, the healthy framework for citizens was not a new strategy. However, it can be suggested that when the preventive strategies from the late 1990s and early 2000 described above did not prove successful, i.e. did not prevent a rise of incidences in chronic illnesses, the ambitions were expanded. This expansion sits well with the earlier description of the double message from

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Paper one politicians and health authorities in which patients were expected to be responsible, but when they failed to adopt healthier lifestyles, interventions became more extensive. Thus, the lifestyle dispositive was intensified through a lifestylisation of the social in which the rationalities of government into the social surroundings of diabetes patients and citizens in general were expanded: not beyond but through the state apparatus.

Part IV: Government of the whole life This section will show how the structural reform entailed a hitherto unseen intensification and expansion of the ambitions to govern the conduct of patients as well as citizens to prevent diabetes and promote health. The notion of risk was a key element in this expansion as the attention to risk suggests that all citizens – albeit highly varying – risk of being affected by diabetes. In 2007, the Danish Health Authority described the task for local government: “It is important that prevention practices [in municipalities] take as their starting point the health problems of the different target groups and their life situation as it evolves throughout life” (Danish Health Authority, 2007, p. 17). The health authorities specifically point out:

Municipalities have the possibility to take an overall consideration of the prevention task and think the health effort together with other efforts in other [municipal] sectors, e.g. social, environment, working environment, traffic, employment and education. (Danish Health Authority, 2007, p. 9)

Thus, to be able to take this lifelong approach to the citizens, it was necessary to mobilise the whole apparatus, i.e. a range of administrative areas, of local government to practice prevention. Similarly, more recent documents described diabetes as a disease in which treatment and the focus on a healthy lifestyle were a lifelong task (Danish Health Authority, 2016b, 2016a). Local government was considered to be particularly relevant for this task as “[m]unicipalities have access to significant groups in the population in terms of prevention and health promotion” (Danish Health Authority, 2007, p. 9). As such, placing the responsibility for prevention in local government expanded the reach of preventive strategies to include more of the population and more of the life of citizens in

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the government rationales. Health was considered not only as the absence of disease but also as the absence of a range of risk factors, including social problems as well as health- related risk factors. Thus, local government must relate to the whole life of the citizen — understood as both the medical, psychological and social elements of the life of the patient — as the object for intervention. Thus, the believe that the lifestyle of individuals can be continuously modified as well as the believe that some people need help to govern themselves according to the prevailing norms of a healthy life seemed to intensify with the introduction of local government. An illustrative example of this can be illustrated through a type 2 diabetes detection tool recommended to local government by the health authorities in the document Recommendations for Cross-Sectorial Pathways for People with Type 2 Diabetes (2016). The aim of this tool was to improve and systematise the detection of at-risk citizens outside of the practice sector (e.g. primary care and hospitals). Included in the tool was a standardised questionnaire consisting of questions regarding genetics, weight and type of lifestyle and estimates of risk based on a score system (Danish Health Authority 2016b). The basis of this recommendation was a problematisation of the existing approach employed by municipalities:

Until now, many municipalities have detected citizens at risk of having or developing type 2 diabetes by means of blood glucose measurement, for example in connection with citizen directed events, such as open houses in health centres. However, there is insufficient knowledge about the effect of this unsystematic investigation, including whether it is the relevant citizens who participate and if citizens who are suspected of having diabetes are referred to the GP afterwards. (Danish Health Authority, 2016b, p. 13)

The use of blood glucose measurements (HbA1c) is the recommended diagnostic method in hospitals and primary care (Danish Health Authority, 2016b). However, as the excerpt show, detection in local government must not only rely on these measurements as it will not enable the health centres to detect at-risk groups. With the detection procedure, local government seemed to emerge as a novel detection and sorting mechanism for categories of people based on their perceived risk for getting diabetes. Furthermore, the life of citizens seemed to be governmentalised through the risk tool in three ways. First, the gaze expanded in terms of which groups to target, second in terms of which elements

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Paper one of life to target, and third, in terms of when, that is how early, to start targeting citizens with preventive initiatives. Thus, the introduction of municipalities in diabetes care seemed, on one hand, to blur the distinction between healthy and ill as everyone in principle was in risk of developing diabetes, and on the other to expand the government rationales in terms of who and which parts of the life of citizens to include in preventive strategies In short, the inclusion of local government in prevention practice enabled an expansion of preventive strategies, as local government was expected to have access to groups and citizens as they go through life, which the traditional health sector did not. In this way, the entire lives of citizens were potential risk factors for diabetes, and the new tasks in local government seemed to expand the governing ambitions of the general Danish health policy towards diabetes. This also accords with earlier observations in the literature of preventive and health promoting strategies’ concerns with non-pathological aspects of illnesses. Peeters (2013b) has argued how prevention represents expansive rationales that transform the nature of political problems and push the state towards a more comprehensive approach to social risks and harm. The examples in this analysis indicated that the introduction of municipalities in the Danish context intensified theses rationales through problematisations of diabetes that seemed to have little do with illness in a strict sense.

Conclusion This article has examined the rationalities and ways of problematising in preventive diabetes care in Denmark. It has been argued, firstly, that the rationalities of diabetes treatment have undergone a transformation from an individual focus on lifestyle to a social approach, in which not only individual lifestyle choice is problematised but the social surroundings of the patient. Moreover, this approach governs not only through the behaviour of patients but through the conduct, i.e. patients’ minds, consideration and choices. Secondly, while both the conduct of patients and the social surroundings as a field of intervention figured in health strategies during the 1990s, the structural reform of the public sector in 2007 extended the rationalities of these interventions. Through local

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government, the rationalities of state-sponsored interventions systematically sought to address the social relations and surroundings of patients and citizens in general. The analytics of a lifestyle dispositive of unrelated elements demonstrate how a specific relation between the problematisations of self-care and government of risk came together and culminated in a social approach to lifestyle interventions in diabetes care intervention. However, we should be careful not to exaggerate the efficiency of such government rationales. This article has analysed these governing rationales; that is, the ambitions and the mode of reasoning underpinning the problematisation and government of diabetes care, not how and if these rationalities are put into actual operation. In the first section, this study demonstrates how health policies directed at diabetes and chronic disease in general focus on preventive and not curative strategies, emphasising health- related behaviours of the individual — as has been observed in other studies (Armstrong, 2009). The ability to self-care was problematized as an individual problem and a problem of will to be solved by forming responsible patients. In the second section, alongside the placement of prevention as a task for local government, self-care and the individual choice of lifestyle were conceived as determined by social structures and risks, illuminating attempts to manage other problems (ranging from living conditions to social problems) than strictly health-related behaviour. While these tools were mainly directed at patients who were regarded as not having the capabilities to manage themselves properly, problematisations of self-care and government of risk formed part of a continuous gaze that was applied to the general population. Conceptually, this article has suggested the existence of a lifestyle dispositive. Both Mayes (2016) and Lucivero and Prainsack (2015) have employed the concept of lifestyle in similar ways, suggesting that the concept of lifestyle in health care should take various social factors, such as people’s interest, hobbies, priorities and lifestyle, into account. Building on these insights, this article has applied the analytics of the dispositive and explored the rationalities of diabetes care to provide a nuanced picture of the role of state interventions in the realm of preventive health. The Danish structural reform adopted in 2007 clearly did not invent the lifestyle dispositive, but it served to extend and intensify it. The analytical concept of dispositive has enabled the article to redress some

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Paper one of the normative implications of the focus on lifestyle in preventive health care. In contrast to many critical sociological studies, which argue that public policies in OECD countries tend to neglect or ignore socially structured risks, this article will demonstrate that the Danish context seem to represent an expansion into the social surroundings to enhance self-management and make the choice of a healthy lifestyle easier. Not surprisingly, the Danish approach to diabetes includes a wide range of both curative and preventive strategies. However, the quest to improve the lifestyles of diabetes patients and citizens seems to be increasingly legitimated in the name of prevention. The Danish context can be said to promote a more socialised model in which preventive lifestyle interventions are not only about transferring responsibility to the individual but as much about the government, mobilisation and structuration of the citizens’ social relations and surroundings.

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The facilitating professional: government and self-government of Danish health professionals in diabetes care

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The facilitating professional: government and self-government of Danish health professionals in diabetes care

Sine Grønborg Knudsena a Department of Social Sciences and Business Studies, Roskilde University, Denmark

The paper will be submitted to Professions and Professionalism.

Abstract It is often argued that market reforms of public sectors have eroded professional autonomy and self-management. Using health programs and interviews with health professionals (HPs) in three Danish health sectors, this paper examines the government and self-government of HPs through two recent public health interventions in diabetes care: the empowerment of the individual diabetic patient to choose a healthier lifestyle and the creation of an institutional network surrounding the patients to make this choice easier. Employing Foucault’s analytics of governmentality and ethics, this paper argues that professionals involved with diabetes care are expected to conduct themselves as facilitative professionals — not with restricted but with new forms of autonomy. This professional subjectivity extends the self-government of HPs through two dimensions: a democratisation of expertise, and an ongoing reflection of expertise. The study demonstrates how HPs are urged to be more responsive and entrepreneurial than their standards-bound predecessors. While this role of the facilitating professional in various ways is both contested and accepted, HPs do not renounce attempts to govern their conduct but require more formalised structures to be able to facilitate patients’ ability to self-care.

Keywords: health professionals, diabetes care, Denmark, governmentality, ethics

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Introduction Over the course of the last few decades, studies have observed an erosion of the self-management of professionals in modern welfare states by government technologies emphasising market mechanisms and consumer culture in public service provision — often analysed under the notion of New Public Management (Hood, 1995; Freidson, 2001). More specifically, sociological studies of health professions have in the last 70 years discussed the changing roles of doctors and health professionals (HPs) as the former asymmetric relationship of doctors and patients has been under transformation. For instance, in the 1950s, the sociologist Talcott Parsons (1954) described the doctor-patient relationship as dependent on the medical knowledge and expertise of the HP as the essential organising principle for doctors was not who the patient was, but what was the matter with the patient. The doctor possessed the power and knowledge to identify and define the problems of the patient — a relationship that according to scholars was conceived as paternalistic (Johnson, 1995; May, 2005). Since then, studies have suggested that a de-professionalization of medical professionals — understood as a loss of privileged expert knowledge, work autonomy and authority over the client — has occurred (Haug, 1973; Owen, 1995). In more recent studies, three themes of this literature can be identified that all seem to point to a restriction of professional autonomy; first, state involvement in the medical professions — understood as external managerial and regulatory forces to ensure patient choice and satisfaction — increasingly controls clinical work processes and thereby to some extent restricts professional autonomy (Dent, 2006; Beedholm and Frederiksen, 2015); second, attempts to professionalise other health groups, e.g. nurses, midwifes, have led to loss of medical authority (Evetts, 2011; Schott et al., 2016); third, the increased interference of politics in the work of both doctors and nurses leads to decreased control over their work and an increased pressure on legitimating their actions in society (Leicht et al., 2009; Funck, 2012). By contrast, other scholars within the sociology of health professions observe that while the professional autonomy may be subject to change, HPs have not lost power, but their professional subjectivity has fundamentally changed according to new societal discourses of the empowered patient (Saks, 2016; Atzeni, 2017). For instance, scholars

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observe how health systems increasingly are dependent on non-health factors considering health to not just be a matter of biomedical factors but of psycho-social factors, such as the will and well-being of patients (Armstrong, 2007; Andersen and Knudsen, 2015; Atzeni and von Groddeck, 2015; Mik-Meyer, 2015; Harrits and Larsen, 2016; Gardner, 2017). Consequently, professionals are expected to interact with patients in more informal, concerned and caring ways (Brown et al., 2015; Flores and Brown, 2017). Thus, the legitimacy of the health profession relies on the patient’s recognition of professional knowledge and expertise (Funck, 2012) and less on the specialised knowledge it possesses in the capacity as a medical profession (Järvinen and Mik-Meyer, 2012; Larsen, 2014). It is often argued that these new societal discourses are linked to preventive rationales in public health strategies in advanced liberal societies (Rose, 2001; Larsen, 2010; Sharon, 2014; Mayes, 2016). This is particularly the case within current diabetes care, in which the lifestyle of patients is particularly problematised, reconfiguring the individual patient as an active agent and capable of self-regulation (Scambler et al., 2014; Seligman et al., 2015). Several scholars have demonstrated that a central element of preventive activities is the recasting of HPs as facilitators of this patient configuration (Dahlager, 2005; Armstrong, 2014; Pii, 2014). With this background, the present paper answers the following question: How — and with what implications — do problematisations of diabetes as a lifestyle disease inform the government and self-government of HPs? As such, this paper is not concerned with whether or not the autonomy of HPs is diminished by market reforms or patient empowerment. More specifically, the analysis does not explore the degree of professional autonomy but examines the relationship between problematisations of lifestyle in diabetes care and the concrete practice of HPs. I argue that the focus on unhealthy lifestyles in diabetes care enables an extension of the self-government of HPs. As I will demonstrate, the facilitating professional is expected to perform two tasks in particular to enhance the self-caring capabilities of the individual patient: the facilitation of an empowered patient who chooses a healthy lifestyle and the creation of an institutional network of various health professions surrounding the patient to make this choice easier. These tasks demand two dimensions of HPs’ self-government. First, HPs are expected to add a democratic dimension to their expertise, in which HPs

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Paper two must be responsive not only to the particular knowledge but to the agency of the individual patient. Second, HPs are expected to practice a network-oriented approach, in which they are urged to constantly reflect on themselves and their expertise as professionals while considering how to utilise a network of both professional and non- professional actors to mobilise the individual patient’s self-caring capabilities. The facilitating role of the professional relates to and is explored as part of a particular set of governmental practices informed by neoliberal rationalities seeking to enhance the self- government of human beings (Cruikshank, 1999; Dean, 1999; Rose, 1999). The facilitating role of HPs are suggested by other studies (Järvinen and Mik- Meyer, 2012; Pii, 2014; Scambler et al., 2014). Especially Rose (1996b) has pointed out how the professional gaze have become more superficial as professionals have become experts of conduct emphasising cognitive and moral aspects of clients instead of pathologies and diagnoses. However, this paper takes its point of departure in diabetes care (primarily type 2 diabetes) in Denmark. Although professionals in diabetes care are still to approach diabetes as a biomedical problems, this case is particularly relevant to study the facilitating professional as an extension of HPs’ self-government. First, the Danish welfare state — even among Nordic welfare states — has one of the most fully developed Beveridge-type modern welfare states, with a long tradition of universal health coverage and state regulation. As it stands, Denmark is often emphasised as a country with well-functioning and comprehensive state institutions (Bengtsson et al., 2015). The democratic dimension of self-government entails an individualising approach, in which the agency of the individual patient is mobilised. This dimension can be observed in many countries and is maybe most pronounced in the UK (Morden et al., 2012; Armstrong, 2014). The second dimension of creating and mobilising an institutional network around the patients is, however, particularly present in the Danish welfare state (Triantafillou and Vucina, 2018). To exemplify, the Danish health system is divided between three sectors, hospital care, primary care (general practitioners (GP)) and municipal care services. The provision of preventative initiatives is a shared responsibility between the traditional health system (hospitals and GPs) and local health centres in municipalities which have expanded the scope of preventive activities (Møller, 2016). Second, diabetes is a condition

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without a known cure and is — more than other diseases — associated with poor life choices (Ljungdalh, 2011). This has contributed to a shift in the focus of diabetes care from a curative strategy to an emphasis on enhancing the life-long self-care of patients (Mol, 2008; Scambler et al., 2014; Seligman et al., 2015; Whyte, 2016). Moreover, according to Danish authorities, diabetes requires a constant attention of both patients and the health system and lifelong, conscious choices about diet and exercise in everyday life (The Ministry of Health, 2017, p. 4). Thus, diabetes appears to require HPs to engage more comprehensively in the behaviour and conduct of patients. Investigating the ways in which Danish HPs practice diabetes care may highlight and nuance how HPs are not expected to govern less but improve the way they govern themselves to improve the patients’ self-caring capabilities. Drawing on document analysis of a central health policy document, a disease management program for type 2 diabetes, and interviews with HPs in three health sectors, the aim of this paper is to analyse the concrete practices of HPs’ in relation to government rationales seeking to govern them. The aim is not to analyse whether the governing rationales of health authorities are good or bad, but how they attempt to govern the norms and conditions of diabetes care. In the following, I first present the analytical framework and methodology, after which the analysis of government and self- government of HPs in preventive activities in diabetes care is presented in four sections. This is followed by a concluding section.

Government and self-government The focus of this paper is how the problematisation of diabetes as a lifestyle disease informs the relation between the self-government of HPs and the governing practices seeking to shape this self-government. The question is how to examine this relationship without succumbing to an analysis in which individual self-government is reduced to a form of government emphasising the suppressed autonomy of individuals by a dominating form of (state) power (Rose, 1996a). For this purpose, the analytical frame of this paper is inspired by Foucault’s analytics of governmentality, government, and ethics. This analytical framework enables the analysis to examine the self-government of

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HPs as a practice of freedom that is not determined by but always somehow linked to power, i.e. others seeking to structure the possible field of action of others (Foucault, 1982). Governmentality has only to a limited extent been employed to study problematics of professionals (see for example Fournier (1999), Johnson (1995), Larsen (2014), Picard (2010)). In the following I will first present a general model of government, then a general model of self-government and a specific problematisation of government, shaping the aforementioned figure of the facilitating professional, and lastly, some conceptual clarifications. In advancing the notion of governmentality Foucault (2002, 2007) tried to grasp the state — not in terms of an actor or a set of institutions but in terms of the rationalities and technologies, which inform the exercise of power through and beyond the state apparatus. Within the field of governmentality, then, government is to be understood in the broadest sense, as the thoughts about and the practices engaged in the exercise of power over a state, territory, and its population (Foucault, 1982). The notion of government is taken by Foucault to signify relations of power — i.e. the practice of commanding the conduct of others or of oneself — in which participants are free to adopt strategies to modify these relations of power. When the relations are frozen or blocked there is a state of domination, in which practices of freedom do not exist or are limited (Foucault, 1982, 1994b). As such, government is to be understood as relations of power that aim to structure the possible field of actions of others rather than to control, dominate, or force them. Being free, thus, means having the power to act in several ways and the possibility to resist (Foucault, 1982). Foucault explored practices of freedom through a history of ethics, which he regarded as “the considered form that freedom takes when it is informed by reflection” (Foucault, 1994b, p. 284). Ethics then denotes the ways in which human beings are urged to conduct themselves in reference to a moral code, i.e. a prescriptive ensemble of values and rules of conduct recommended by various prescriptive agencies (Foucault, 1985; Dean, 1996). To be clear, ‘prescriptive’ in this context does not mean the prescription of guidelines for specific actions but a structure of existence (Foucault, 1994a). Foucault proposes four analytical aspects to grasp how individuals constitute themselves and bring

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themselves to obey (or disobey) a set of prescriptions recommended to them (Foucault, 1985; O’Leary, 2002) — or as Rose (Rose, 1996a, p. 30) points out, four dimensions of “how one should concern oneself with oneself”. Foucault proposes, first, that the self be taken up as an ethical substance, which denotes the ontology that one’s behaviour must refer to — in other words the aspect of the self that is morally problematic. Second, the rationale of problematizing that aspect has to do with a mode of subjectivation, which is the way one brings oneself to follow a code. Third, the means for constituting oneself as an ethical subject have to do with the ethical work that one performs on oneself. Lastly, the fourth element is the telos of the ethical subject, which is the aim or the goal of the ethical practices (Foucault, 1985). Following O’Leary (2002), the analytical questions to pose the subject of ethics then become: what part of oneself should be subject to a work on the self, why should one engage in such a task, what tools or techniques are at one’s disposal in this work, and what mode of being or way of life constitutes the goal of this work? As mentioned, some scholars assert that public sectors in modern welfare states increasingly are dominated by politics of self-governance (Rose and Miller, 1992; Cruikshank, 1999; Dean, 1999; Rose, 1999; Sørensen and Triantafillou, 2009) and not, as argued by others, by an erosion of the self-management of professionals. In this view self- governance has become a prevalent or normative ideal that society has to live up to (Bramming et al., 2011). Moreover, the push towards self-government in these countries is linked to a specific critical problematisation of government, which is concerned not with the adherence, duties, and obligations of individuals and society but with how to govern through rights and freedom, perhaps best captured in the oft-quoted phrase by Rose and Miller (1992): “governing at a distance”. Drawing on Triantafillou (2017, p. 48), this problematisation of government can be termed constructivist neoliberalism, which denotes a neoliberal rationality that “seems more optimistic about the potential of state intervention” and promotes the self-government of individuals as the chosen government form. In this paper, I explore how this neoliberal problematisation of government in health care has promoted the facilitative professional figure. This figure is urged not with more or less autonomy than his or her predecessors but with new forms of autonomy in

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Paper two which the professional is urged to constantly reflect on his or her expertise to enhance the self-caring capabilities of patients. To clarify, Foucault is not explicitly concerned with autonomy per se but, as mentioned, concerned with an analysis of liberty and freedom and how these are required for power to function and resistance to exist. With the words of Rose (1996a, p. 100), liberal democratic governments “seek to govern through constructing a kind of regulated autonomy for social actors” in which individuals are “obliged to be free”. As such, within the governmentality literature, it is argued that autonomy is unfeasible as the possibility to resist only can be reactive as self-managing subjects operate within the relationships defined by the relationships of power (Thompson, 2003; Paulsson, 2011). Echoing this, autonomy, in this paper, is not understood as the absence of control or power (Rose, 1999) but as a form of power-freedom relation. Thus, individuals (in this study, HPs) are not free to do nothing or everything, but free to do something. Moreover, they are free to refuse the individuality that is imposed on them (Foucault, 1982, p. 785). Before turning to the methodology of the paper, some conceptual clarifications are in order. The facilitating professional is understood as a professional that is not guided by expert biomedical knowledge but of patient empowerment. Following Järvinen and Mik- Meyer (2012) a facilitator is understood as a HP invested with the task of creating a framework for the development of patients’ capacity to care for themselves and chose a healthier lifestyle. This study further suggests that to create this framework especially two dimensions of professional self-government is advanced. First, a democratic dimension that is, following Gudmand-Høyer (2015), understood as ‘disseminated agency’ in which the capacity to act rests not only with the HP as an expert but with the patient. This dimension entails that HPs are dependent on the actions of patients to practice diabetes care compared to ‘knowing what is best based on their medical expertise’. Second, a dimension of ongoing reflection of expertise, understood as a continuous self-reflection and self-evaluation of professionals in which they must not govern less, but improve the way they govern themselves to create healthy frameworks for citizens. This dimension is related to democratization processes as it implies that professionals and mechanisms of government themselves have become subject of management, problematization and

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scrutiny (Rose, 1996b; Dean, 1999). In this study, this is exemplified in the democratization of HPs’ expertise as they are urged to practice diabetes care through the creation of an institutional network in which HPs constantly must reflect on when to mobilize this network based on the individual citizens self-steering capacities. Finally, as Binkley (2009) points out, governmentality studies have often given emphasis to the institutional logics and technologies through which governmental rationalities seek to shape the population without giving emphasis to the practical work of individuals. This paper will draw loosely on the analytics of government and ethics to tease out how HPs are addressed within the various practices that seek to govern them and within which they come to govern themselves.

Methods Based on two sources of data material, this analysis examines the relationship between government and self-government in three specific health care sectors: primary care, hospital ambulatories, and municipalities. Document analysis will roughly reflect the rationalities of government of HPs, and interviews with HPs in the three sectors will reflect the self-government of HPs. Investigating all three sectors can illustrate how Danish diabetes care is practiced as a network of HPs from both the traditional health system, and local health centres in municipalities. Moreover, this form of organization highlights how non-medical expertise is considered relevant in the treatment of diabetes as municipalities conduct a range of health-related activities that do not require a diagnostic focus or a biomedical understanding of illness (Møller, 2016). The data collection was carried out in 2015-2016 in the Region of Zealand (in Danish: Region Sjælland) in Denmark. This region was chosen because it provides a relevant example of governing practices that aim to expand the reach of the health system and HPs. The document under study is the current Disease Management Program (DMP) in the region of Zealand in 2016 that is based on a national DMP by the Danish Health Authority (Danish Health Authority, 2012). The DMP is chosen as it, by its own standards, describes the comprehensive, interdisciplinary, cross-sectoral, and coordinated efforts towards citizens with diabetes with a specific focus on preventive and health

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Paper two promoting activities. Moreover, the DMP encompasses the administrative and political rationalities of both the national and regional health authorities (Region Sjælland, 2016). As such, the DMP reflects the most recent rationalities of the governing practices seeking to manage diabetes care and HPs. I carried out semi-structured interviews with 15 HPs: four GPs and one nurse in primary care, two doctors and four nurses in two diabetes hospital ambulatories, and four HPs, i.e. nurses, in health centres in two municipalities — all based in the Region of Zealand. As such, the chosen interview respondents inform the research question and argument of this study in two ways. First, the HPs form part of the treatment provision in the institutional network surrounding the patient and represent insights from all three relevant health sectors in diabetes care. Second, the main aim was to gain a deeper insight into the complexity of how HPs in three sectors describe their approach to patients and self-government in relation to governing practices — in this paper represented by the health authorities in the DMP. The strategy used to analyse the empirical material is inspired by Foucault’s nominalist approach that can be termed as a diagnosis of the present (Raffnsøe et al., 2016). In Foucault’ work, knowledge is seen as historically contingent and Foucault analysed power through ”problematisations through which being offers itself to be, necessarily, thought—and the practices on the basis of which these problematisations are formed” (Foucault, 1985, p. 11). Thus, the present as we experience it is the effect of discourses, knowledge and subjects that are historically situated. Following this perspective, it has been argued that research interviews may not be an appropriate method in Foucauldian inspired research (Fadyl and Nicholls, 2013). For instance, by asking participants to relate to problematisations established by the researcher, the researcher actively participates in the subjectification of the interviewee. In this way, interviews as a method of data collection contributes to power relations and with a normative element. However, the object of inquiry is not the authentic or knowing subject that is often emphasised in qualitative research (Roulston, 2010). Rather, the Foucauldian perspective does not take the individual as the unit of analysis but makes visible the perspectives on the basis of which knowledge and meanings are produced in a

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particular historical moment and the practical implications of different ways of approaching a particular social phenomenon (Fadyl and Nicholls, 2013). The DMP and the interviews were coded by using a two-step coding strategy. First, the initial coding process consisted of an open coding of the two sources identifying themes and patterns relating to the two aforementioned tasks: patient empowerment and the institutional network. Second, the following process consisted of a (deductive) conceptual coding focusing on the articulations by the DMP and HPs of the following categories: i) the professional subject, ii) the patient subject, iii) and, forms of knowledge in diabetes care. The coding was focused on capturing the various expectations of HPs as articulated by the DMP and by the HPs themselves. Quotes from the DMP and interviews are presented in the analysis and are chosen because they each illustrate one on hand, how government practice seeks to promote a particular self-conduct for the HPs, and on the other, how HPs conduct themselves in relation to the prescribed conduct. In the analysis, the HPs are referred to in different ways. When I make a general claim of the conduct of the professionals, they are referred to as HPs. Some of the analytical sections describe the conduct of specific medical professions, in which case they are referred to as doctors, nurses, or GPs, however professionals in municipalities are referred to as HPs throughout the analyses. The analysis of the government and self-government of HPs are presented in the next four sections: two sections will account for the government of HPs — i.e. the government practices — followed by two sections of the self-government of HPs — i.e. the ethical practice of HPs. The focus is on the aforementioned two dimensions of HP self-government — the democratisation and continuous improvement of expertise that make up the facilitating professional.

Government: facilitating the empowered patient This section explores the government practice’s prescriptions of the conduct of HPs in diabetes care in relation to the task of facilitating an empowered patient. I demonstrate how HPs as facilitating professionals urged to democratise their health expertise by acting not according to pre-defined standards but to the particular situation

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Paper two of the patient. As such, they are urged to actively engage the individual patient in the care to enable the self-caring capacities of the patient. Preventive activities in diabetes care are to a great extent promoted to prevent the progression of late stage complications and other illnesses. These activities predominantly revolve around encouraging the patient to lifestyle changes in their everyday life (Region Sjælland, 2016). As such, the DMP stresses that HPs are expected to relate to a new action competent patient by basing diabetes care on “the patient’s needs, wishes, risk factors, comorbidity, and motivation for treatment” (Region Sjælland, 2016, p. 10). The persona is illustrated in the Regional Health Agreement (2015) between regions and municipalities on which the DMP is based:

We meet the citizen as an equal partner. The individual citizen is the expert of his or her own life and holds resources and valuable knowledge of his or her situation which have to be brought into play more effectively — in the individual course of disease as well as in the development of the health system (Region Sjælland, 2015, p. 7)1.

The quote illustrates that the relevant HP is one who more effectively can mobilise the knowledge and experience of the patient. A transformative element of the expertise expected of HPs when they encounter patients is emphasised. Thus, the HPs must treat a more multifaceted patient and not only consider diabetes as a biomedical problem, but as a psychological, sociological and anthropological problem in which the life, resources, and knowledge of the patient, as well as the patient’s capability to actively engage in self-care, must be considered. Consequently, the DMP stresses that it only guides the actions of HPs:

The individual citizen and the overall life situation of the citizen will always be the basis and the governing factor in the choices the responsible health professional makes in the concrete situation (Region Sjælland, 2016, p. 4).

This means that the DMP does not prescribe specific actions for HPs but encourages them to promote more favourable behaviours to enhance patients’ self-caring capabilities.

1 Author’s translation for this and all forthcoming quotes

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Thus, these examples seem to problematize diabetes as a condition whose solution seems to be only available to the patients in their everyday lives. It seems that the expertise expected of the HP counter-poses or perhaps extends the aforementioned doctor-patient relation described by Parsons, as the HPs are expected to pay much more attention to who the patients are instead of what is the matter with them. This extension of the professional expertise entails a whole new range of considerations from the HPs that may be termed a democratisation of expertise. Now the HPs are expected not only to inform and involve the patient in the treatment but to equate the experiences and knowledge of the patient with the HP’s professional expertise. As such, the government practice prescribes the capacity to act to both HPs and patients, urging HPs to recognise that they no longer hold the one true knowledge as experts but must be responsive and facilitate the potential resources of the individual patient. In other words, the telos of preventive activities resides outside of the HPs’ profession and within the self- government of the individual patient. As such, the democratic dimension represents an individualising governing approach that expects HPs to constantly reflect on themselves in each encounter with the patient. In other words, the facilitating professional enables more self-government of HPs to facilitate the empowerment of patients in what seems to be a less formal structure compared to what may be conceived as the more traditional biomedical approach, informed by professional biomedical knowledge. To summarise, government practice in diabetes care — reflected in the figure of the facilitating professional — urges HPs to add a democratic dimension to their approach to patients. They are expected to actively engage with not only the knowledge but the agency of individual patients to facilitate empowerment and self-care. Preventive activities, thus, promotes HPs who govern themselves in a less formalised structure.

Government: creating an institutional network This section examines how the government practice urges HPs to create an institutional network around the diabetic patient to be able to take the multi-faceted patient into account. I suggest that in addition to the aforementioned democratic dimension, the governing practice adds a dimension to the conduct of HPs in which they

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Paper two must think of themselves as self-governing subjects who take an entrepreneurial approach to patients. More specifically, HPs are obliged to constantly reflect on the mobilisation of this institutional network to enhance the self-caring capabilities of patients. Diabetes care is described in the DMP as generally divided between the three aforementioned sectors (Region Sjælland, 2016). First, in primary care GPs are expected to take on the role as coordinators of the patient’s course of treatment (Region Sjælland, 2016). The Danish health system is organised in such a way that GPs are gatekeepers to specialised care in hospital ambulatories. GPs and nurses in primary care are to be attentive to patients showing diabetes risk factors relating to biomedical symptoms. Yet they must also assess the knowledge, resources, and motivation of patients, and if necessary, try to motivate the patient to make better lifestyle choices. Second, nurses and doctors in hospital ambulatories are expected to practice specialist diabetic care, such as the provision of short and intensive courses of treatment. In complex courses with patients suffering from comorbidity or poorly regulated diabetes with complications, ambulatories are expected to act as coordinator. Third, municipal health centres have the main responsibility for prevention activities directed at diabetic patients and are managed by HPs, such as nurses, dietitians and physiotherapists. Overall, the tasks of health centres are to provide a healthy framework for both healthy and ill citizens to make patients recognise themselves as autonomous and capable of acting on their own to promote their health. Thus, diabetes care in municipalities is defined as a range of health-related activities that do not require a diagnostic focus or a biomedical understanding of illness. The DMP encourages the collaboration of all three sectors to establish an adequate, coherent course of treatment in which HPs have the opportunity to have a flexible dialogue and reach a mutual understanding for the individual patient (Region Sjælland, 2016). As the DMP states: “the professional work surrounding a T2DM [type 2 diabetes mellitus] patient is interdisciplinary” (Region Sjælland, 2016, p. 10). Thus, the care of diabetes patients is characterised by multiple transitions for the HPs to consider. Similarly, the DMP portrays the management of diabetes as too complex for one health profession to handle. The prescribed conduct is therefore to collaborate in an institutional network with other professions — as well as patients, relatives, civil society, etc. — to be

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able to offer a flexible, cohesive, and responsive diabetes care (Region Sjælland, 2016). The DMP aims to provide a clear distinction between the tasks and responsibility of each of the described sectors. Yet the DMP offers no formal guidelines for the institutional network but describes: “we adapt our efforts and the degree of our collaboration according to the needs of the citizen/patient” (Region Sjælland, 2016, p. 4). Moreover, as the needs of the patient can change as diabetes progresses, the degree of collaboration must be flexible and dynamic to always offer the most appropriate treatment (Region Sjælland, 2016). The description of the three sectors indicates that, in addition to biomedical factors (such as co-morbidities, blood glucose levels etc.), the relevant factors to address in diabetes care are made up of a range of non-clinical components. More specifically, as many of the factors emphasised in diabetes care seem to be of a social and psychological constitution, biomedical knowledge no longer seems as conclusive and definite in the treatment of diabetes. It seems necessary to respond to the challenge of diabetes in a different way from the curative strategy of classical medical institutions. Several scholars have described how the emphasis on a range of patient attributes as signifiers of (chronic) disease extends the remit of medicine or the clinical gaze (Rose, 1999; Armstrong, 2014; Weisz, 2014; Karlsen and Villadsen, 2016; Gardner, 2017). However, the institutional network appears to add an extra dimension to the expertise of HPs in this study. They are not only obliged to be more responsive and entrepreneurial in their concrete meetings with the patient. They must also always seek to mobilise the institutional network of professionals and non-professional actors around the patient to be able to consider the various components that are problematized as both the cause and cure of an unhealthy lifestyle. As analysed in the former section, the facilitating professional imagined in the DMP is to pay much more attention to the needs of individual citizens than regulatory guidelines for treatment. Similarly, the institutional network is not comprised of formal and predetermined rules of when to collaborate. Instead, it appears to be individually assessed for each patient. Thus, the patient’s capacity to self-care, and in turn the HPs ability to foster these capabilities in patients, seems to determine when a network approach to the patient is needed. The institutional network

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Paper two thus enables HPs to constantly reflect on themselves as self-governing subjects who take an entrepreneurial approach to patients to constantly be able to stimulate and mobilise the self-caring capacity of patients. Obviously, there is nothing novel in the suggestion that HPs are expected to constantly improve approaches to care. However, while the traditional curative strategy ends with the cure or the death of the patient, preventive activities and optimisation of patient self-care seem to have no inherent terminal point, as people can always be healthier, happier, and less risky. To sum up, the institutional network urged by the government practice adds an additional dimension to the self-government of the facilitating professional. In addition to the democratic dimension, in which governing strategies are directed at the individual patient, this second dimension seeks to mobilise both professional and non-professional actors in a network around the patient to capture and govern the multi-faceted patient and make the choice of a healthy lifestyle easier. As such, multiple transitions emerge in diabetic care, which are premised on HPs continuous reflection on how to improve and facilitate the self-care of patients.

Self-government: democratisation of expertise The following two sections analyse the self-government or the ethical self- practices of HPs. The sections examine the accounts of HPs in primary care, ambulatories, and municipal health centres, specifically with respect to their self-conduct in relation to the government practices accounted in the two former sections. In this section, I explore how HPs subject themselves to the figure of the facilitating professional and the first dimension of the democratisation of expertise.

GPs: what is our aim? When GPs in primary care describe the key aspects and most challenging elements of diabetes care, they all foreground the patients’ motivation for lifestyle change, because medical treatment alone is inadequate to achieve well-regulated diabetes. One GP negotiates the course of care with the patient: “What is our aim for this year? Where can you come in? Can you quit smoking — is that what we should work on? Or should we

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work on fixing your cholesterol levels? Or should you exercise more?” (GP 1). Thus, according to the GPs own accounts, their medical expertise must be equalised with the agency of patients. Additionally, not only the agency of the individual patient is relevant in diabetes care but that of other people with diabetes. Another GP explains:

It is about getting out there and meeting others and listening to how other people go about it. To be able to identify with other patients is a really significant part — something that will never happen in their relationship to me or to my nurse (GP 4).

These quotes indicate that GPs emphasise the patients’ individual responsibility and ability to self-care in diabetic care. Similarly, GPs often articulate diabetes care as a shared task with the patient in which they, as HPs, must refrain from being judgemental and acknowledge the struggle of each and every patient. In the GPs’ accounts the capacity to act thus seem to rest as much with the patients as with them, because the key to prevention resides in lifestyle and self-care and therefore in the motivation and resources of the patients themselves to take responsibility for their illness. As one doctor explains: “You cannot treat a diabetes patient without educating that person” (GP 1). Here it becomes a question of educating the patient in self- caring practices, indicating that the problem of diabetes is more individual, pedagogical, and psychological than biomedical. In other words, GPs seem to be more concerned with who the patient is than what is the matter with them and may be said to conduct themselves with responsiveness rather than a standardised biomedical approach. They constitute themselves not as experts but as facilitators of the agency, i.e. empowerment, of patients. More specifically, it seems that the dimension of democratic expertise informs the self-conduct of GPs in primary care. As such they relate to a telos, an aim for the treatment, that seems to reside in the agency of patients and not in their functions as HPs — usefully illustrated by the GP that asks the patient what our aim is. In brief, GPs appear to thrive in an approach in which there are no predetermined actions, but the condition and capability of the individual patient guides the action to be taken. Thus, to an extent, they seem to subject themselves to the facilitating professional acting responsively, flexibly, and inclusively towards the patient.

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Ambulatories: it is their illness When HPs (doctors and nurses) in ambulatories articulate the most essential element of diabetes care, they all — somewhat similar to GPs — mention the autonomous patient that is able to self-care in everyday life. One doctor explains:

If [the patient] don’t play along, then it will not help, and we won’t get anywhere. To me it is very important to place the responsibility on the patient. They must understand that it is their illness, and they are the ones who must do something about it (doctor 1).

This excerpt is characteristic for HPs in the ambulatories. They emphasise the patient’s ability to self-care and to “take matters into one’s own hands” (doctor 2) as essential for the treatment. One nurse contrasts this emphasis on the agency of the patient with an earlier approach when HPs prescriptions would be considered “the law”, and HPs would “wag the finger” if patients did not comply with the treatment (nurse 2). Doctors and nurses alike describe that now their concern is to identify the resources and motivation of the patient before delivering their guidance and recommendations. In their own accounts the conduct of HPs in ambulatories to some extent resonates with the democratic dimension of the facilitating professional. Similar to GPs, HPs constitute themselves not as the bearers of the true knowledge of the approach to diabetes but as facilitators of the knowledge and agency of patients. This is illustrated by a nurse:

If he can change this thing [in his lifestyle], then he might have changed a massive thing for himself. Then next time we can consider moving on to another thing. It gives my words meaning, when he experiences that it helps (nurse 2).

The excerpt indicates that the nurse strives towards a telos that is located in the agency and knowledge of the patient and not in her expertise as a nurse. In other words, successful care is to be judged by the effect it has on the self-government of patients. However, it seems that HPs in ambulatories do not in the same way consider it their job to facilitate the empowered patient. As such, HPs in ambulatories focus prevention more narrowly on biomedical factors (i.e. stabilising blood glucose levels, pharmaceuticals etc.). For instance, if they cannot accomplish a well-regulated patient due to the lack of self-

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care from the patient, then they do not see it as their job to facilitate the self-care but instead believe it is the job of the other sectors (nurse 2). Even though this in some instances is followed by economic arguments about the best way to use the resources of the health system, it nevertheless has the effect that hospital ambulatories to some extent resist the conduct of the facilitating professional. In brief, HPs in ambulatories emphasises the importance of patients’ self-care and active agency in diabetes care. However, they seem to a certain extent to resist the role of the facilitating professional and guide their own conduct according to biomedical rationalities.

Municipalities: medical expertise is not necessary Most of the HPs in the municipal local health centres emphasise that their approach to citizens goes beyond a narrow biomedical approach (here patients are termed citizens, as it is the vocabulary of HPs in municipalities). One HP explains how this approach allows her to relate to citizens in a health promoting way:

It is a delicate balance. I try to be humble in the interaction. We do not wag the finger. We don’t. If any of us do that, we got something wrong. It is about being visible [in the public space] and have a conversation about symptoms and so on. (HP 2).

The nurse further states: “We are not the experts, but we facilitate this knowledge sharing, motivation and driving force” (HP 2). The emphasis on facilitating a conversation with patients instead of focusing on biomedical factors is further underscored by another nurse. The nurse contrasts this approach to the one in primary care and hospitals describing how, in conversations with her, citizens do not have to explain themselves, for example, if their blood glucose levels are too high. Furthermore, non-biomedical approaches are foregrounded as crucial for diabetes care. As a nurse illustrates:

Medical expertise is not necessary to prevent chronic illness, including type 2 diabetes. There are so many places we encounter citizens, where we have the opportunity to work in a health promoting way (HP 1).

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Accordingly, the gaze of HPs in local government is not upon ill citizens but upon insufficiently healthy citizens. They conduct themselves not according to strict guidelines but emphasise how they facilitate a conversation with citizens and try to be visible in public space. To empower the citizens to make healthy choices, the HPs recognise that the key resides with each individual citizen and not with them as professionals. This approach is illustrated in this quote:

As a professional you have to decentre yourself (…), but we still have to be close so that they feel safe and can understand the consequences of doing a lot, doing minimum and doing medium [to change their lifestyle] (HP 2).

These examples thus show that HPs in local government constitute themselves as being capable of delivering the relevant knowledge to patients in a non-moralising way. They conduct themselves according to the figure of the facilitating professional prescribed for them by the DMP. The relationship between their self-conduct and the democratic dimension becomes clear when they emphasise how their approach is less moralising and more about just having a conversation with citizens. Particularly, this underpins their self-conduct as ethical subjects, emphasising how the capacity to act is divided between the professional and the citizen. For them, the telos of their self-conduct is to facilitate a self-governing citizen who is able to choose a healthy lifestyle. To sum up the accounts of all three sectors, the conduct of the facilitating professional prescribed by the government practice has caught on in the municipalities more comprehensively than in ambulatories and primary care. This is perhaps not surprising as the intention with the establishment of municipal health centres in 2007 was to take a more facilitating approach to diabetes. However, HPs in primary care and ambulatories agree that they as well must democratise their expertise to make room for the knowledge and experience of the patient. Overall, HPs acknowledge that diabetes care demands a new form of expertise, illustrated by the facilitating professional, in which the solution to diabetes is seemingly only available to patients in their everyday lives. In brief, these accounts suggest that by democratising their expertise and mobilising the knowledge and agency of patients, HPs in this study expand their reach beyond the traditional medical profession and institutions to facilitate the empowered patient.

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Self-government: continuous improvement of expertise This section examines the second dimension of the self-government of HPs: the continuous improvement of expertise. This dimension relates to the creation of the institutional network around the patient promoted by the government practice. The key point in this section is that while HPs do not appear to resist the government practice altogether, some HPs seem to call for a more formally structured institutional network. As such, HPs in general do not resist the idea of the network approach but require more structured boundaries for manoeuvre.

GPs: I can never get her down to that level Most GPs explain that when patients do not respond to or comply with the treatment, and they as professionals have reached the maximum of their capabilities, they consider referring the patients to other sectors. The rationale is that the hospital can take over for a period of time to establish better glycaemic control for the patient. Likewise, if the patient lacks motivation or self-caring capabilities GPs consider referring them to municipal health centres. Thus, GPs make use of the institutional network when the condition of the individual patient requires it. This practice is illustrated in this example: “[I]f we know that a patient’s [glycaemic] levels are too high, we face the challenge, and if we encounter resistance or problems, then we can use the available services” (GP 4). However, according to GPs, they often encounter patients for whom the continuous attempts to improve self-caring capabilities, motivation, or glycaemic control are not meaningful — for instance patients with co-existing illnesses or social or psychological problems. For these patients, the GPs are reluctant to make use of the institutional network, as they do not consider the network approach appropriate for the continuous improvement of the condition of the patient. One GP explains, with reference to an incompliant patient who refuses diabetic medicine, how the registration of patients’ treatment progress in an ICT system keeps track of the glycaemic control of her patients:

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She has to be at that level, but she’s not. She is twice as high, and I can never get her down to that level, and then it looks like I’m not a good doctor (GP 3).

As the quote illustrates, the GP fears that it will reflect badly if patients are allowed to have poor glycaemic control. As such, GPs seem to only reluctantly take part in the creation of an institutional network in which HPs constantly must consider how to improve the patient’s situation. Nevertheless, GPs often articulate that it is difficult not to follow the guidelines of the DMP, as it can reflect badly on them if they do not utilise the possibilities in the institutional network — for instance, referring a patient with poor glycaemic control to specialised treatment in ambulatories. Furthermore, the self-conduct of GPs in relation to the institutional network appears somewhat conflictual. Especially two issues stand out in the accounts of the GPs. On one hand, the GPs express that the DMP portrays diabetes care too rigidly, impeding them from approaching diabetes patients individually (GP 2; GP 3; GP 4). On the other hand, GPs call for a more formal collaborative approach as the institutional network at this point does not have an established structure for collaboration but is mostly based on the individual HP’s professional network (GP nurse 1; GP 1; GP 2). In brief, GPs seem to somewhat contest the obligation to constantly try to improve all patients’ situations through the institutional network. However, as GPs reflect on how to constitute themselves as a competent HP, they tend utilise the institutional network around the patient. In this way, HPs in primary care do not resist the government practice that seeks to shape them as facilitating professionals who are responsive and constantly utilises the options available to support patients’ self-care. Rather they problematize, on one hand, the rigid structure of the DMP, and on the other, the lack of formalised structures of the DMP. Thus, it seems that some HPs call for more formalised guidelines — not to determine specific action guidelines but to set out fundamental structures for the institutional network.

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Ambulatories: we must accept that sometimes we cannot get any further Most HPs in ambulatories describe patients’ motivation for self-care and taking responsibility as a central element of a successful treatment process. For instance, one doctor describes:

If they are not interested in lifestyle changes, and you have started the treatment for the most essential things, such as blood pressure, etc., then you might have to accept that you cannot get any further. It is about how willing the patient is to contribute. If they, for example, are not at all interested in [self-]measuring blood glucose or receiving insulin treatment, then you sometimes have to compromise on that (doctor 2).

Another doctor terminates courses with certain patients with poor glycaemic control, because the doctor considers it inappropriate to pursue tighter control — even though the patients have been referred to the ambulatory by their GP. The doctor further describes how this is in contrast with the recommendations of the DMP: “That’s not what the DMP describes. The DMP describes that then you [the patient with poor glycaemic control] belong to the hospital until eternity” (doctor 1). As such, HPs in ambulatories, like GPs, seem to resist the obligation to constantly try to improve the patients’ health or attitude towards lifestyle change through the institutional network. Similarly to the democratic dimension, this self-conduct is often rationalised with economic arguments, e.g. hospital treatment is more expensive than primary care. Nevertheless, ambulatory HPs, for the most part, still consider diabetes as more of a biomedical problem than a pedagogical problem. However, the nurses in the ambulatory see it is as one of their most important tasks to guide the patients through all the different services available to them in the institutional network after termination from the ambulatory but find this guidance difficult because of the lack of a formally established network. In the current network approach nurses cannot refer patients to other sectors but only guide the patients through the system (nurse 1, nurse 2, nurse 3, nurse 4). However, doctors problematize the lack of formal structures in the institutional network as well, which makes the patient’s pathways between the sectors dependent on the HPs’ individual professional network and individual knowledge of services (doctor 1, doctor 2). As such, HPs in ambulatories (especially doctors) thus call for more formal

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Paper two structures in the institutional network for them to conduct themselves as facilitating professionals within the institutional network. Summing up, HPs in ambulatories conduct themselves according to the role of the facilitating professional to a certain extent. Based on biomedical rationalities they try to delimit the expectation to constantly mobilise and utilise the institutional network to improve the patient’s self-caring capabilities. However, to make use of the institutional network, HPs in ambulatories seem to call for more government in order for them to self-govern as the facilitating professional.

Municipalities: we are here until eternity Most of the participating HPs in local government describe their role as locating themselves as close to the citizens as possible to be available and visible for the citizens. This is in part because municipal HPs consider the current health system to be unsuccessful in reaching the citizens who need health interventions the most. Consequently, most of the municipal HPs express a wish to expand their approach to be able to detect potentially undiagnosed diabetes in the population or to supplement diabetes rehabilitation with psycho-social and employment services. An example of this, is one HP who expresses the need for establishing more decentralised health centres than the existing ones:

We want to be as close to the citizens as possible. That is an advantage local government have compared to the other sectors. [W]e want to come out where patients live and be more outreaching by opening health and care centres in the local environment and make sure that it is an open house where people can just come in from the street and have a conversation about health (HP1).

The excerpt must be seen in relation to how HPs in municipal health centres conduct themselves in relation to the democratic dimension (analysed in the first section of self-government). The HPs constitute themselves as a much-needed alternative to, what they term, a narrow biomedical approach from GPs and doctors at ambulatories to facilitate the empowerment of patients. As HPs in local government they can collaborate with other sectors to establish continuity in the life of diabetic citizens. Thus, in the

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accounts of HPs in local government the institutional network is essential to provide an appropriate care. HPs in local government thus seem to comply with the code of the facilitating professional prescribed by the DMP. More than the other sectors, they conduct themselves according to the telos of a continuously improvement of the patients' self- government. As one nurse explains referring to a citizen declining to participate in the lifestyle intervention: ‘I told him: “We are here until eternity for you. You are welcome”.’ (HP2). In this excerpt, the conduct of the facilitating professional is foregrounded. Municipal HPs constitute themselves as being able to constantly adapt to a particular situation that a citizen presents them with, providing constant improvement of their expertise and the patient’s situation. They do this by attempting to make themselves available as much as possible and by placing themselves as a necessary supplemental part to the medical expertise of the institutional network. In brief, according to the accounts of all HPs across the three sectors, HPs in municipal health centres seem to endorse the dimension of continuous improvement of and adaption to the (specific) patient situation to a larger extent than those in ambulatories and primary care. Ambulatories and primary care do not always constitute themselves as being continuously adaptive towards the specific situation of the patient. Their self-conduct strives towards making judgements about the treatment of patients based on their biomedical knowledge. Nevertheless, as I have tried to show, the conduct of the facilitating professional, who is responsive and entrepreneurial towards the individual patient and within the institutional network, comes to figure as a strong structure of existence, as all HPs in various ways feel obliged to facilitate the patients self- caring capabilities. Additionally, ambulatory and primary care HPs especially call for more formally structured institutional network to conduct themselves as facilitating professionals.

Conclusion This paper has explored the research question: How — and with what implications — do problematisations of diabetes as a lifestyle disease inform the

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Paper two government and self-government of HPs? To answer this question, it is argued that contemporary preventive strategies in diabetes care enables an extension of the self- government of HPs. The present analysis demonstrates this extension through a facilitating professional obliged to self-conduct not with less autonomy but with a new form of autonomy. Inspired by Foucault’s analytics of government and ethics and using document analysis and interviews with HPs, the analysis highlights the attempts of the government practice to govern the conduct of HPs and the ways in which HPs govern themselves by themselves. It is argued that the government of HPs’ self-government is characterised by two new dimensions. First, HPs are expected to democratise their professional expertise to engage not only the knowledge and experiences of patients but the agency of patients. This is related to the task of facilitating the empowered patient in which government strategies are directed at the individual. Second, HPs are expected to continuously reflect upon the ways in which they can improve the self-caring capabilities of patients. This is related to the task of creating an institutional network around the patient to continuously encourage the patient to choose a healthy lifestyle. It is not only the clinical illness that is of interest but the life, resources, and knowledge of the patient. Thus, the patient’s capability to actively engage in self-care seems to be the main problem that HPs must relate to. Through the analysis of the HPs’ ethical practices the democratic dimension of HPs self-government appears to inform the accounts of HPs the most. HPs in all three health sectors conceive diabetes as a lifestyle disease that demands the agency of the individual patient. To some extent, the second dimension of an ongoing improvement has informed the accounts of HPs as well. HPs acknowledge the need to create an institutional network around patients to make the choice of a healthier lifestyle easier, as biomedical knowledge no longer seems enough to respond to the challenge of diabetes, locating the key element of care in the everyday life of patients. However, the figure of the facilitating professional seems to inform the conduct of HPs in municipal health centres in a more comprehensive way than those in ambulatories and primary care. This is perhaps not surprising, as a major Danish welfare reform in 2007 had the purpose of

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creating health promoting and disease preventive efforts in the local environment of citizens. HPs in hospital ambulatories and primary care seem to still orient themselves towards biomedical forms of knowledge in their approach to patients and are more reluctant to practice the network approach. Particularly, they call for a more structured and formal network setting: not a network that determines when or how to collaborate but one providing more formalised pathways between HPs in each sector within the network to make communication within the network easier. Overall, the analysis suggests that HPs appear to accept the first dimension, the democratisation of expertise, in which diabetes is to be treated individually by focusing on the empowerment of the patient, whereas particularly ambulatories and primary care are more reluctant to practice the second dimension, a network approach, in which they are obliged to always improve the patient’s situation. A limitation of this study is that it is based on a local and specific empirical background, i.e. diabetes care in a region in Denmark. Thus, I do not claim that the facilitating professional dominates the whole spectrum of diabetes care as diabetes still is predominantly conceived as a biomedical problem. However, public health strategies in many OECD seem to be increasingly concerned with the prevention of so-called lifestyle diseases and diabetes in particular. Notwithstanding this limitation, this research may extend our knowledge of the government of conditions labelled as lifestyle diseases and the various attempts to tackle these conditions. I have tried to show how HPs are to act as facilitating professionals, which may be conceived as part of an enabling form of power that works through the self-government of individuals. The facilitating professional is linked to a constructive form of neoliberalism that seems more optimistic about state interventions seeking to responsibilize citizens. As noted earlier, the literature tends to suggest that soft NPM forms such as patient empowerment in health care have diminished the autonomy of HPs. However, considering the findings of this study, it might be suggested that the modern government of HPs does not seek to restrict HPs agency but seeks to make HPs practice more self-government to enable them to continuously responsibilize and empower patients and citizen in general.

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Ethical considerations The data collected is approved of the project from the Danish Data Protection Agency. As this project did not involve clinical interventions, it has not been required to seek formal ethical clearance. I ensured that all participants gave their consent to participate in this study, all interviews have been treated confidentially, and participants are anonymised.

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Self-government of diabetes patients: opting for freedom-based power versus direct power

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Self-government of diabetes patients: opting for freedom- based power versus direct power

Sine Grønborg Knudsena a Department of Social Sciences and Business Studies, Roskilde University, Denmark

The paper is being revised for a resubmission to Social Theory & Health.

Abstract Lifestyle is often regarded as both the cause of and cure to a range of challenges facing public health today. Consequently, public health strategies aim at empowering citizens to self-manage their health issues through patient education. Specifically, a new approach is emerging in which the potential resistance of patients is anticipated in the quest for a well-balanced subject. From a Foucauldian power-freedom perspective, this paper explores the self-government of diabetes patients participating in patient education that focus on optimising the self-care and self-management of patients. Employing Foucault’s analytics of ethical practices, the paper explores two distinctive modes of self- government: those who opt for freedom-based power and those who call for more direct forms of intervention. While all patients tend to problematize their own behaviour and lifestyle, the different patterns of self-government are linked to different self- understandings by the patients. The former group of patients constitute themselves as individuals with a number of social problems, and the latter constitute themselves as pathological individuals. Overall, the paper suggests somewhat paradoxically that to be able to govern themselves and practice self-care according to the norms set out by public health strategies, diabetes patients request more direct intervention.

Keywords: diabetes, self-care, ethics, Foucault, public health

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Introduction In contemporary liberal societies, individual lifestyles are increasingly being offered as the cause of the challenges facing public health today (Triantafillou, 2012). These challenges include the rise in a number of different chronic illnesses (Ljungdalh and Møller, 2012). Scholars have observed that in most contemporary liberal societies, there is strong political support to empower individuals to make responsible choices and adopt healthy behaviours (Danholt, 2012; Mayes, 2016; Vassilev et al., 2016). Thus, scholars have observed how patients are construed as active, entrepreneurial and autonomous individuals (Rose, 1996b; Mol, 2008; Ayo, 2011) with the — often not fully realised — potential to manage their health (Sharon, 2014). As such, public health strategies often consider a healthy lifestyle as a deliberate and rational choice of free individuals (Devisch and Vanheule, 2015). In 1999 the American Chronic Disease Self-Management Programme (CDSMP) was developed by researchers at Stanford University to empower people with chronic illnesses to take control of their health (Lorig et al., 1999). The programme has subsequently travelled and been adopted by governments and health providers in the USA (Kaiser Permanente), Australia (Sharing Health Care Initiative), Canada (Diabetes Self-Management Programme), and the UK (Expert Patient Programme) (Wilson, Kendall and Brooks, 2007; Rijken et al., 2014). Health programmes inspired by the CDSMP are widely considered to be health promoting programmes that also produce empowerment — often practiced through patient schools — developed to give patients the knowledge and skills to self-care in their everyday life and as a movement away from a paternalistic approach of compliance. In the sociology of health literature, a number of scholars have explored public health policies and programmes through the lenses of biopolitics and governmentality and observed the attempt to shape and facilitate the responsible and autonomous self-conduct of patients, especially within conditions defined as lifestyle diseases (Fullagar, 2002; Larsen and Stone, 2015; Peeters and Schuilenburg, 2017). Moreover, studies point out that a new type of rationality has come to the fore in these recent health programmes, which not only presupposes the potential resistance and disobedience of citizens but

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utilizes such resistances to improve patient health. These programmes envisage a patient subject that maintains health by working on his or her lifestyle while at the same time acting as an autonomous human being (Gudmand-Høyer, 2015; Karlsen and Villadsen, 2016; Mayes, 2016; Kirkland and Raphael, 2018). For instance, Karlsen and Villadsen (2016, p. 22) argue:

The well-balanced subject that today’s health promotion seeks to produce is someone who certainly may – indeed is enjoined to – enjoy, but within reasonable limits, that is, in a controlled manner, so as not to damage her own or others’ well-being too much.

Thus, according to these scholars, these health programmes are informed by a biopolitical rationality of optimising patients self-caring capabilities and a neoliberal governmentality wherein individuals are urged and expected to continuously govern and reflect on themselves according to norms of healthy living. Lifestyle interventions are regarded as particularly important in diabetes care as an attempt to promote healthy behaviour and choices among individuals with diabetes (specifically Type 2 diabetes) (Mol, 2008; Ljungdalh, 2013). This paper draws attention to a number of oft-cited medical anthropological studies that represent a much wider body of research that demonstrates the various micro-level health understandings, practices and behaviour of people with diabetes. In particular these studies highlight how noncompliance or poor self-caring capabilities in diabetes care often are perceived by health systems as lack of self-control or as a deliberate choice (Kleinman, 1988; Garro, 1995; Ferreira and Lang, 2006; Ferzacca, 2012). Alternatively, this literature advances how noncompliance should be understood as an attempt to reclaim autonomy vis-à-vis health professionals giving them lifestyle advice and instructions (Broom and Whittaker, 2004), or the diabetics’ different cultural understandings of what constitutes well-being (Borovoy and Hine, 2008), or as a result of the complex nature of diabetes and the diabetic body (Mol, 2009), or finally, as a question of social class influencing how diabetics engage in and appropriate the normative practices imposed on them by health promotion and illness prevention interventions (Merrild et al., 2016). According to the outlined literature, the approach to diabetes care in a range of countries and populations seems to have a strong emphasis on the ideal of autonomy on

248 Governing lifestyle the one hand and on the deficient self-caring abilities of these individuals on the other. Studies — inspired by the Foucauldian notion of governmentality — have demonstrated how a form of freedom-based power imposing norms of good health and wellbeing is present in practices of empowerment (Cruikshank, 1999; Rose, 1999). These studies have illuminated and nuanced the way we conceive of power in contemporary liberal societies and evoked critical reflections on health policies. However, some governmentality studies tend to reduce governmentality to an imposing apparatus and emphasize institutional logics through which rationalities of neoliberal governmentality produce subjectivities and thereby reduce self-government of individuals to a question of government, i.e. how one group — such as public authorities — governs others — such as patients (Binkley, 2009). Very little attention has been given to the various self-practices of people subject to self- management programmes within the field of lifestyle intervention (Pedersen, 2017). This study employs Foucault’s notions of ethical self-formation to open up a space for studying and thinking about issues of freedom and resistance (O’Leary, 2002; Clarke and Hennig, 2013). Based on interviews with diabetic patients and observation in patient schools in the Danish welfare state, the following research question is explored: How are diabetes patients practicing their freedom (and shaping their lifestyle) in the context of interventions that seek to optimise their self-caring capabilities? I argue that the norms and practices imposed by such self-management programmes are appropriated differently by diabetic1 patients. Broadly speaking, their appropriation can be divided into two distinctive modes of self-government by patients: those who opt for freedom-based power and those who opt for more direct forms of power. The latter mode of self-government may seem paradoxical, as it seems to be practiced by patients who have no trouble conforming to the self-care regime supported by the public health program. Rather than resist or reject intervention in their lives, they call for more direct intervention to govern themselves. Overall, the different modes of self-government in diabetes adds nuance to how the imperative to self-care is practiced in everyday life by patients.

1 In the medical sciences diabetes has commonly two types: type 1 (juvenile-onset diabetes) and type 2 (adult-onset diabetes) (Ferzacca, 2012). This study deals solely with type 2 diabetes.

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The following two sections will account for the analytics of self- government and the methods of this paper. In the third section, I present the analysis of patients’ self-practices in three parts followed by a concluding section.

Analytics of self-government This section accounts for the critical analytics applied in analysing the practices of empowerment and self-care in diabetes care. Attempts to promote empowerment and self-care of patients with chronic diseases and citizens in general have not passed without critique. Often these attempts are criticized for not prioritising the participation or recognising the resources of the patient, resulting in unsuccessful empowerment (van Dam et al., 2003; Dybbroe and Kappel, 2012; Ewert, 2017). Others write off the attempts to empower patients as the result of budgetary concerns (O’Cathain et al., 2005). The main limitation of these various critiques is that they all assume that there is a true and morally good way of empowering individuals. Seeking to overcome this limitation and to avoid reducing the self-governing practices of individuals to a question of government, I draw on Foucault’s analytics of ethics, the government of the self by the self, to analyse how individuals are both subject to power and active subjects within power relations. To clarify, this study addresses the form of power Foucault termed government, that is: “To govern, in this sense, is to structure the possible field of action of others” (Foucault, 1982, p. 790). Following Karlsen and Villadsen (2016, p. 4), the kind of health interventions promoted in the patient schools “takes its starting point not only in the personal freedom of the individual, but in its conflicting desires”. This approach anticipates the potential resistance of the subject by using a non-paternalistic approach. It can be linked to the salutogenic2 (i.e. origins of health) approach promoted by Antonovsky (1996), which opposes a pathogenic focus on diagnostic categories, making the disease the sole focus of attention and neglecting to attend to the complex human being. Instead, the salutogenic approach emphasises the person over the patient and is not

2 The salutogenic approach is based on three assumptions: First, seeing individuals in binary well/diseased or health/illness categorisations are inappropriate, because the human system is inherently flawed. Second, instead the salutogenic approach sees each of us at any point in time along a health/disease continuum and thereby encompass all human beings. As such, and third, health interventions must attend to salutary factors (i.e. factors that promote health) and not only risk factors. (Antonovsky, 1996).

250 Governing lifestyle as concerned with the cure of an illness (pathogenic) as with the promotion of the general health condition and well-being of human beings (Antonovsky, 1996). Following Rose (2016), the orientation towards encompassing the complex person and not the patient might be suggested to be part of a rapid movement of things that began as a radical critique — such as the empowerment of patients as a critique of the power of authority — but turned into practices of regulation by the health system. I term this a balanced approach that works through what may be termed a freedom-based conception of power. This is a form of neoliberal power that is not only concerned with the freedom of individuals but intervenes by way of optimising the self-governing capabilities of individuals and enjoining patients to act autonomously and do what they believe to be in their own best interests. In contrast, sovereign, disciplinary or other more direct forms of power may seek to govern through strict guidelines and to some extent involve health professionals to act paternalistically towards patients. This form of power may be seen as an authoritarian strategy of government using disciplining technologies to govern individuals (Rose, 1996a). Foucault suggests in his later writings (1985, 1994) that freedom cannot be reduced to the struggle against a dominating or supressing form of power. He distinguishes between liberty understood as liberation processes from total domination, such as colonisation, and freedom practices that should be analysed as “the relationship of the self to itself and the relationship to others” (Foucault, 1994, p. 300). Thus, it is about analysing:

not behaviors or ideas, nor societies and their ‘ideologies’, but the problematizations through which being offers itself to be, necessarily, thought—and the practices on the basis of which these problematisation are formed” (Foucault, 1985, pp. 6–11).

Foucault proposes to analyse these practices of the self as ethical practices to make visible how certain attitudes towards the self can facilitate continuous critical self- transformation and which may manifest in diverse practices (O’Leary, 2002). Such an ethics “is not a field of rules, principles or precepts — it is a field of our self-constitution as subjects” (O’Leary, 2002, p. 11).

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In the analysis of the ethical practices, Foucault delineates a four-dimensional model or four principle aspects of our self-constitution (Foucault, 1985, pp. 26–27; O’Leary, 2002, p. 12). First, the ethical substance denotes the essence of the self’s conduct, or in other words the object of ethical concern: for example, the different ways diabetes patients practice self-care in terms of problematising their own lifestyle and health behaviours. Second, the mode of subjection concerns the reasons given for following a code and recognising her/himself as obliged to put it into practice: for example, diabetes patients can engage in lifestyle interventions and either comply with or resist the health precepts that are imposed, because they see themselves as part of a group that accepts it. Third, the ethical work is the practice and techniques the self engages in and performs on itself when bringing its conduct into compliance with rules: for example, diabetes patients can examine their daily thoughts and actions in terms of changing their lifestyle. Fourth, the telos of the ethical subject is the aim of the self’s ethical work, which is not isolated but contributes along with other practices to a mode of being characteristic of the ethical subject. For example, the telos for diabetes patients can be using lifestyle interventions to strive towards a certain state of well-being or health. In the analysis, I regard Foucault’s four aspects of ethical practice as heuristic tools, not as essential principles that must be schematically followed.

Methods To analyse patient self-government along the lines of Foucault’s four-dimensional analytics, the paper draws on data from an empirical study conducted in 2015-2016 in two patient schools in different municipal3 health centres in the Danish welfare state. In Denmark lifestyle interventions are promoted as a crucial element of diabetes treatment. Increasingly, these interventions are being managed by municipalities, through patient schools in which patients are termed citizens, and not the traditional health system, i.e. hospitals and general practitioners (The Ministry of Health, 2017). A key common objective of both schools is to make patients aware of and reflect on their lifestyle and

3 In Denmark, municipalities (local government) have been given the task of providing citizens with services of rehabilitation, health promotion and disease prevention.

252 Governing lifestyle how it influences their health condition. Consequently, the two schools are explored as examples of the same phenomenon and may capture the diversity of health interventions and the diversity of the self-government of patients. The main methods applied were semi-structured interviews and observation. In all, the study consists of 13 observational studies covering 26 hours of observation at patient schools and 15 interviews with patients (sometimes with family members present) with diabetes (see table 1). 11 of the patients participated in the patient school and four declined participation. While these four patients cannot speak directly of how the patient school urged them to reflect on their lifestyle, these patients received an individual intervention at their home by one of the nurses from the patient school in which they were given advice on how to measure blood glucose as well as urged to reflect on how to improve self-care in their daily life. Thus, all interviewed patients have been included in a government practice seeking to optimise their self-care and choice of lifestyle. I carried out the observations as an ‘observer-as-participant’ (Jackson, 1983), as I did not participate directly in the work of diabetes schools per se but interacted with both health professionals and patients through informal chatting. The observations were documented through notes and quotes written down during the day, which I wrote up and elaborated on from memory at the end of each day. I recorded and later transcribed the interviews. Observations was conducted with the purpose of studying the dynamics of the interaction between patients and health care professionals in a health educating setting and observing the way the participants respond (govern themselves) to the self-caring practices imposed on them by the patient school. The purpose of the interviews was to examine how — by their own accounts — patients practice self-care, including how they problematise their own conduct and bring their various practices and considerations into play and in which way this conduct reflects the message from government practices: the balanced approach. The combination of interviews and observation allows the analysis to examine patients’ own accounts of self-care practices as well as their own attempts to work on themselves to become healthy/adopt a healthy lifestyle. The coding process of the empirical data is loosely inspired by Nanna Mik-Meyer’s (2016) interpretation of the grounded theory approach and Clarke’s (2009) combination

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of grounded theory and situational analysis. Following this, the coding process was guided by the conceptual frame and the research question but at the same time attempted to avoid conducting a deterministic analysis by keeping an eye on contradictions and things that cannot readily be explained or interpreted by the dissertation’s conceptual frame. I first conducted an open coding followed by a systematic, focused coding across all interviews. In doing this, I aimed to allow for issues and themes to emerge from the data that I did not expect as well as gaining an in-depth understanding of the data. During this open coding, I grouped the issues the respondents talked about in themes. Next, a focused coding was used in which I focused on these themes in relation to the practices of the self along the lines of Foucault’s four-dimensional ethical model. Thus, the second stage of coding entailed focusing on the problematisations made by patients, reasons given, and techniques employed for engaging in changing their lifestyle, as well as the overall aim of engaging in lifestyle interventions. Through this systematic reading of the empirical data, two forms of self- government emerged that roughly divide the patients into two groups. The observations and quotes presented in the analysis here have been selected for their illustrative power, as examples of both broad tendencies and significant variation in these forms of patients’ self-government. While the analysis focuses mainly on the distinctive feature of the two forms of self-government to illustrate how different forms of power are called upon in the ethical practices of patients, it will also focus on the common traits. To clarify, I begin to investigate the self-government of patients by analysing the first ethical aspect, the ethical substance. Next, the three additional aspects, in which the mode of subjection and the ethical work especially bring forward the two different modes of self-government identified in the analysis, are investigated in the two latter parts of the analysis. The interview respondents have all voluntarily agreed to receive some form of guidance. As such, it may be assumed that patients in this study all wish to engage in lifestyle changes on some level. This fact represents a limitation to the study, as it the empirical material collected for this study does not allow the exploration of diabetic patients who completely opt out of any form of intervention into their lifestyle, i.e. what could be called a third mode of self-government.

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The analysis of these self-practices of diabetic patients is presented in the next three sections, which focus on the problematisations made by the patients; on the considerations and practices of patients opting for a freedom-based power; and finally, on the considerations and practices of patients opting for a direct form of power.

Table 1. Overview of interview respondents’ age and gender.

Pseudonym Age Gender Lars 65 Male Poul 72 Male Kirsten 75 Female Michelle 49 Female Anders 63 Male Eva 59 Female Anna 53 Female Mads 45 Male Karen 72 Female Marianne 85 Female Kasper 41 Male Carl 72 Male Anita 68 Female Charlotte 73 Female Elisabeth 82 Female

Part I: Problematisations of behaviour and lifestyle This section explores how patients problematise their behaviour and lifestyle. By and large all the patients in this study have subjected themselves to understanding diabetes as an individual psychological problem caused by their own ignorance and sedentary lifestyle and their inability to change their lifestyle. Almost all of the patients interviewed express some sort of self-blame or emotional distress relating to diabetes and their lifestyle in general. Many patients describe their own lifestyle as lazy (Carl, Kirsten, Anita, Kasper, Michelle). In general, the interviewed patients describe diabetes as specifically caused by their unhealthy lifestyle, but many patients also express other concerns, such as obesity, alcoholism or financial issues. These wider concerns are linked to their personal behaviour, which they describe

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with guilt and shame. These utterances from patients suggest that diabetes makes them question their whole life prior to their diabetes diagnosis. For example, Anna, a woman in her early 50s, explains her reaction when she was diagnosed with diabetes a few years ago:

I thought about why I was the one to contract it, when people who are a lot plumper than me don’t. I have friends who are considerably larger than I am, but don’t have it. And then you think: Do I really sit down that much more than them? But I must do” (Anna: 41)4.

In this quote, Anna problematises her lifestyle as being more inactive than non- diabetic people’s indicating that she blames herself for her diabetes. Moreover, many patients describe how their self-blame often continues post diagnosis if they do not live up to their own expectations of how they should live or manage their diabetes. Anders, a man in his early 60s, describes his daily struggles:

It is a battle every day. And I’m dissatisfied with myself every day, because often something will happen during the day, and I get to eat something I was not supposed to (Anders: 127).

The self-blame illustrated by Anders is linked to the daily management of diabetes. Diabetes patients are urged to self-manage their diabetes at home, and the shame and guilt patients experience are often directly linked to their blood glucose levels, which many, but not all, self-monitor at home. Eva, a woman in her late 50s, illustrates one of her recurring struggles that has to do with her sugar dependency:

The other day I could feel the urge. Usually it is an urge for sugar I feel, and then I run around like a zombie, and it is only when I swallow [the candy] that I stop and think: ‘Oh, this is not good’ (Eva: 145).

Afterwards she feels awful and afraid to check her blood glucose level: “I am worried that it is too high, you know, it is completely self-denial: If I don’t check it, then maybe it is not too high” (Eva: 229). In this way, unregulated blood glucose numbers

4The numbers used in direct quotes refer to the transcribed material and each response given by respondents to the interviewer’s (the author) questions in the interview setting. Each response have been numbered and translated from Danish by the author.

256 Governing lifestyle then come to figure as an indicator of one’s ability to self-care. These problematisations of lifestyle indicate that diabetes is not just experienced as an illness but also as a personal failure. The shame of diabetes patients is something that health professionals in the diabetes school are aware of. For instance, in the diabetes school Charlotte, a woman in her 70s, talks about her difficulties with eating healthy:

Charlotte: The food is a huge challenge. To constantly think about that I have to lose weight. The professional: Do you feel guilty? Charlotte: Yes, all the time. To plod up and down that scale. I’m so inpatient. The professional: It is all the little things you can do. Walk to the telly, park your car in a distance from the super market and so on. Charlotte: The grandkids. It is terrible. I have to spoil them, and then I eat it too. The professional: There has to be a balance. You also have to enjoy life. Charlotte: But the food and the exercise. It gives me such a guilty conscience.

This interaction illustrates the balanced approach and how the professional seeks to confront Charlotte’s negative feelings of guilt to prevent them from becoming unproductive. Almost all interviewed patients experience shame and self-blame in relation to having diabetes. Moreover, many describe diabetes as a disease they constantly have to defend or explain, as their family, friends and co-workers do not understand the effect diabetes has on their lifestyle (Anna: 117; Michelle: 154-56). The patients describe how people around them often will give them lifestyle advice and have opinions on what they are allowed to eat or drink. Yet, the patients’ reaction to this self-blame differs significantly, which can be illustrated in the way diabetes patients relate to their social surroundings. Mads, a man in his early 40s, explains how he often feels it is necessary to raise his voice to get his friends to listen:

(…) it is a little silly that you have to go there [raise his voice] to defend your disease (…) I’m considering wearing a sign saying, ‘I’m an alcoholic’, the next time I’m out drinking with my mates, because then they’ll have a better understanding [of his non- drinking] and no longer say: ‘You’re fine – you can drink’ (Mads: 60).

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Some patients react like Mads, drawing attention to the fact that they are ill. However, many patients find it tiresome to constantly feel obliged to explain lifestyle choices not least because they are often met with the response that diabetes is not really a serious disease. Others feel less comfortable explaining a lot about diabetes. Michelle, a woman in her late 40s, says: “You don’t run around advertising that you have diabetes” (Michelle: 202). Overall, most patients have accepted the notion that their lifestyle, and in particular their motivation, will and self-discipline, is the key to improve. They problematise their own behaviour and to some extent recognise that they themselves must do something to manage their lifestyle, i.e. the ethical substance for these patients is to use these lifestyle interventions to transform particular aspects of themselves. However, which aspects of their lifestyle and how this transformation is practiced, is interpreted quite differently among the patients. The following two parts of the analysis will focus on two different forms of self-government that can be identified in the self- caring practices of diabetic patients.

Part II: Opting for freedom-based power This section examines the first mode of self-government, in which patients in many ways opt for the freedom-based power/balanced approach practiced in the patient school. Patients have various considerations for governing themselves in accordance with the freedom-based power, but I try to show that one essential aspect is that they consider other (social) problems as more important and urgent to deal with than their diabetes. During a session in one of the diabetes schools, one of the health professionals, Sarah, explains that if a person has a well-regulated diabetes, he or she can drink the same amount of alcohol as everyone else, i.e. the amount recommended to the general population by the health authorities. Kirsten, a woman in her 70s who has expressed struggles with an unstable blood glucose level, says: “Well, I don’t stick to that. I drink two glasses of wine everyday”. Kirsten’s statement prompts no immediate response from the professionals, but a few moments later another health professional, Tina, states: “There is nothing that one mustn’t do – just not too much at a time. It is a good idea to

258 Governing lifestyle drink with food”. In general, the expression “it is okay to sin, just remember to enjoy it” is often repeated at the diabetes schools (field notes). In an interview conducted at her home, Kirsten explains:

I can easily live with it [the lifestyle changes], because nothing is totally forbidden. The ones who blow it out of proportion, they look on the dark side. Most people won’t check out [meaning: die], just because you live a bit improperly (Kirsten: 161).

Kirsten, then, is adamant about maintaining elements of her favoured lifestyle, for instance drinking two glasses of wine with her husband every night, even if she is aware that by doing so, she exceeds the recommended amount of weekly alcohol consumption. It seems as if the approach nothing is forbidden suits Kirsten, which she explains has to do with the fact that she is not young anymore and she does not want her life to be too boring. Kirsten attends an exercise class for retirees where she — by her own account — is in much worse shape than the other participants. Yet the professionals at that class tell her just to do what she can manage, which she likes. Kirsten is not the only one who has adopted this approach. Others express the same satisfaction with the mantra of the balanced approach. For example, Karen, a woman in her early 70s, explains that her doctor has suggested that she should quit smoking, but she does not intend to quit as she has so few pleasures left. She contrasts the doctor’s approach with the approach from municipalities:

She [the municipal home nurse] is not lecturing. She doesn’t say what you can and cannot do. She actually doesn’t do that, because she just makes other suggestions such as: ‘You could do this instead…’ And I think that is really nice (Karen: 166).

Although the described practices expressed by patients align with the balanced approach, it seems they bring in other logics and considerations than the ones proposed by health professionals. These logics and considerations are linked to the ethical substance of these patients’ ethical practices. Patients opting for the freedom-based mode of self-government acknowledge that they have diabetes but do not consider it to be their main problem. Kirsten, presented earlier, explains that she has reduced lung function and

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has been hospitalised due to a blood clot in addition to diabetes. She describes her thoughts about diabetes when she was first diagnosed:

I was very preoccupied with other things [other illnesses], so it didn’t really make a big impression on me [to get diabetes]. I probably just thought: ‘Yet, another thing’. (…) I didn’t feel like it was a death sentence (Kirsten: 129).

Kirsten’s statement displays a very common trend among these patients: that they do not think that much about diabetes in their everyday life (Michelle, Anita), but talk of diabetes as a side-effect of their otherwise unhealthy lifestyle. Both in interviews and in the diabetes schools, many, but not all, express that they cannot feel their diabetes and therefore do not make serious alterations to their lifestyle, i.e. practice self-care (Carl). However, in the interviews, the patients do talk of other problems in their everyday life. Many patients have multiple illnesses or disabilities. Moreover, many also struggle with social or family problems, financial issues, alcoholism, and obesity. Kasper, a man in his early 40s, struggles with alcoholism, for which he takes medicine. In an interview conducted at his home he explains that he is not too concerned with diabetes at the moment:

If I were to take [diabetes] more seriously, then I would also have more inconveniences in life, right? Then I have to be more considerate (…). I just push it away until I’m told I can’t push it any longer. Then I can eat and enjoy as I want to now. I think that is easier than to take it all at once (Kasper: 82).

Similar to Kasper, many patients do not consider diabetes to be in need of serious attention compared to their other problems. In the patients’ narratives these problems often serve as causes for developing diabetes or causes for their lack of self-care and adherence to the recommended lifestyle advice. One example is Anita, a woman in her 60s, who explains why she struggles with a healthy diet:

I knew before [the diabetes school] that I had to eat more vegetables, but I’ve had some bad experiences. Two years ago, my daughter-in-law took very ill and passed away. I helped [her son and family] a lot with cooking and other things, and in that time, I just couldn’t manage to eat all those vegetables, and after that it has been difficult to get that going (Anita: 50).

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These practices illustrate the ethical substance of the patients. They use lifestyle interventions to transform certain aspects of themselves. These aspects, however, are not exclusively linked to diabetes, but the reasons to engage in lifestyle interventions are often more motivated by a wish to deal with a variety of complex (social) problems. Thus, they do not subjectify themselves as diabetic patients. A central practice, the ethical work, that patients engage in when attempting to transform their lifestyle, is to establish a balance in their lives by maintaining elements of their lifestyle that bring them joy while also relieving some of the self-blame and stigmatising elements that come with diabetes. The patients seem to refuse to be pathologised as well as being blamed for their illness. This form of ethical work is to some extent encouraged by the professionals at the diabetes schools. To be clear, the professionals constantly recommend against consuming alcohol above the recommended amount and smoking, but they continuously try to level out the advice with balancing statements such as remember to live a good life and you must remember to enjoy it when you sin. They conduct themselves as autonomous individuals and bring in other considerations and logics than the ones proposed to them by the health professionals in terms of how they engage in self-caring activities. Although, these patients have a number of diverse strategies of engaging in lifestyle interventions, their telos seems to revolve around establishing well-being in their lives. Overall, the patients that seem to opt for the freedom-based power thrive with the governing approach where professionals tell them that to do a little to change their lifestyle is better than nothing. Moreover, according to this preferable governing approach it is acceptable to sin once in a while if they remember to enjoy it, and that they have to live a good life even though they have diabetes. The patients seem to be aware of and tacitly accept that this balanced approach has a limited capacity of changing their self- caring capabilities and improving their blood sugar levels. In general, they do not speak too much of their diabetes when interviewed about it. A lot of other problems are more urgent and present in their minds. Furthermore, many of them seem to like the balanced approach, as it allows them to carry on with their lives without thinking that they must change their lives completely because of diabetes.

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Part III: Opting for direct power This section examines the second form of self-government, in which patients tend to opt for direct power (and instructions) from health professionals — both in the diabetes schools and from the health system in general. These patients consider diabetes to be their main problem, and I show how they subjectify themselves as pathologised individuals by using the self-blame as a source of motivation to change their lifestyle. Some patients call for more direct guidelines and instructions to be able to practice self-care with diabetes, while others call for health professionals to be authoritative figures. Mads, presented earlier, in particular problematises the balanced approach in which patients are constantly told that they may indulge but in a limited way:

You have to be aware of these things [healthy and unhealthy food]. Instead of saying: ‘It will be all right’. No, because ‘it will be all right’ is exactly what got me here (Mads: 210).

Mads is referring to a particular session focusing on diet at the patient school. Many of the participants have very specific and detailed questions about diet at the session. The health professional, Sarah, having difficulties answering the questions, emphasised the general message exemplified by the balanced approach outlined earlier: that they should not complicate things but basically have the same diet as people who do not have diabetes and do what they enjoy (field notes). In an interview at his home, Anders, presented earlier, opposes this balanced approach as well:

You have to be careful that the attitude doesn’t become too weak. That is, sometimes it seemed like they just skimmed over it all. They could have said: ‘Listen, if you want to get something out of this, then you have to do this and this. That is the aim. You don’t have to get there in one day, but that is the aim, that you have to reach’. ‘It is better to go for a walk than not to go for a walk’ [referring to something the health professionals said at the session]. Yes, I can bloody well tell them [the other patients] that. It is just too weak (Anders: 247).

Both Mads and Anders have recently been diagnosed with diabetes and describe in the interviews how they have rearranged their lives to make up for their prior unhealthy lives. They request more clear-cut guidance so that they can manage diabetes themselves. Some patients diagnosed with diabetes years ago who still struggle with self-care request

262 Governing lifestyle more clear-cut guidance as well, but they to some extent transfer some of the responsibility for their self-care on to the health system by requesting more scrutiny from professionals (Eva, Anna, Poul). Anna — presented earlier, who by her own account could manage better and take diabetes more seriously — in particular calls for more in- depth knowledge of the consequences of diabetes – both from the school and from the health system in general. She feels neglected by the health system as she was diagnosed as pre-diabetic before her actual diabetes diagnose:

They could have looked at you more seriously and said: ’You have to lose weight, you have to stop eating candy’. That could have been nice. (…) [I]t is something about them being more concrete saying: ‘You have to lose weight! Come back every 14th day and be weighed. We will send you to a dietician and get control over your diet’ (Anna: 335; 339).

Anna’s frustration with the approach from the health system points to a mode of self-government that requests authoritative health professionals to provide more direct guidance and intervention. Thus, in this form of self-government, patients expect to get more direct guidance and interventions from the professionals and do not feel that these expectations have been met in the diabetes school and the health system in general. In contrast with the patients opting for freedom-based power (the balanced approach explored in the former section), the patients opting for a more direct approach often articulate diabetes or diabetes-related issues as having a significant place in their lives. Anders explains:

You think about it all the time. Not a day goes by where I don’t think about it. It is not a fatal disease, but it lingers in your head all the time (Anders: 125).

Others describe diabetes as a wake-up call that made them realise that they have been living beyond their means. The realisation that they have a chronic disease has made them change their life and adopt a healthier lifestyle. Poul, a man in his early 70s, describes how exercise takes up all his time:

That is [my] life at the moment (…) My blood glucose levels and my weight have dropped [after he started exercising], and my doctor told me, that if everyone was like me, then [all doctors] would be unemployed (Poul: 21).

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It seems, then, that patients opting for the direct mode of government to some degree constitute themselves as autonomous, proactive and entrepreneurial subjects capable and willing to change their unhealthy lifestyle. In this way, they thrive in the freedom-based power in the sense that they have fully accepted that they themselves are the ones to do something about this illness. However, they insist that diabetes is a serious chronic disease that also requires strict guidance from medical professionals. In this form of self-government, lifestyle interventions are used to transform their former unhealthy lifestyle. Patients recognise that they have contracted diabetes due to their unhealthy lifestyle. In this sense, the mode of subjection is about pathologising themselves (and diabetes) and thereby questioning the balanced approach. As such, they use the self-blame as a technique to change their lifestyle as they refuse to be “wrapped in cotton wool”, as Anders (284) puts it. Understanding themselves as pathologised individuals, they call for more government and direct intervention to be able to practice self-care and accomplish their telos of well-being.

Conclusions In diabetes care the optimisation of the self-caring capabilities of patients are often framed as a key element. Accordingly, patients are urged to take responsibility for their illness and employ strategies to avoid risks to their health and well-being. A range of self- care management programmes are used in diabetes care and in chronic disease care in general. In Denmark, these programmes are specifically managed by municipalities through patient schools. According to the sociology of health literature, these schools employ a freedom-based form of government, in this study termed a balanced approach (informed by a neoliberal rationality), in which the patients concomitantly are construed as responsible and autonomous and as individuals who lack self-caring capabilities. Medical anthropological studies argue that diabetic patients practice self-care in various that cannot be interpreted as strictly non-compliance with lifestyle interventions. This study has investigated the self-practices of patients with diabetes in the context of lifestyle interventions seeking to optimise their self-care through Foucault’s governmental and ethical approach.

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In this study, the self-government of patients with diabetes is linked to a problematisation of their own lifestyle as the cause of their diabetes. They all blame themselves for their diabetes, which is linked to feelings of shame and guilt of having diabetes but also an acknowledgement of their own role in choosing a healthier lifestyle. As such, the ethical substance of these patients is to transform certain aspects of themselves by to some extent taking responsibility for improving their health and changing their lifestyle. However, the patients engage in lifestyle changes in quite different ways. Here I have pointed out two general modes of self-government employed by patients in terms of self-care. In the first form of self-government, patients’ reasons for transforming their lifestyle are not solely linked to diabetes but an understanding of themselves as individuals with a variety of complex problems. They practice a balanced form of lifestyle transformation in which they maintain pleasurable elements in their lives while relieving some of the self-blame they experience. In the second form of self- government, patients understand themselves as pathological individuals stressing that they are diabetics. They use the self-blame as a technique to motivate themselves to change their lifestyle. Through the request for more direct guidelines and instructions they opt for a more direct form of power or government practice. The telos for all patients’ in their self-government practice is to achieve some kind of well-being through lifestyle transformation, but the reasons given and the practices undertaken differ significantly. Patients opting for direct power seem to practice their freedom in a different way than patients opting for freedom-based power. The findings of this study suggest that the patients opting for the freedom-based power express more difficulties in self-managing their diabetes and changing their lifestyle than the patients opting for direct power. It may appear as a paradox, that patients who are having difficulties managing their diabetes do not want more direct government in form of clear instructions and guidelines, and the patients who by their own accounts have been successful in changing their lifestyle, request more direct government to be able to govern themselves. However, rather than being a paradox it is an illustrative example of how self-government is not practiced in isolation but always in the context of government seeking to give direction to the self- practices of individuals (Foucault, 1985). In other words, the form of self-government

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opting for more direct forms of power reveals the link between government and self- government. The self is neither a historical constant nor characterised by an attached autonomy, but it is always in an interdependent relation with others (Clarke and Hennig, 2013). However, the interdependence between government and ethical practices must not be mistaken for a field of rules or precepts of how one ought to conduct oneself (O’Leary, 2002). On the contrary, Foucault’s four-stage model of ethical work illustrates how different forms of self-government emerge and by focusing explicitly on self-government and not the practices of government, this study highlights how individuals possess the freedom to change what they are made into.

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