Healthiness creates a “governable space” (Rose.1999a, p.31) in which governmental objectives and the encultured desires of its citizens coalesce. These are locations in which citizen/patients are drawn to consult with experts and “authorities of all types exercise their powers over the conduct of others” (Rose, p.36). In this chapter, I consider weightfullness as a virtual governable space within the medicalisation-as- governmentality project. When a physical sign such as weightfullness becomes subject to clinical diagnosis, a particular structure is imposed unproblematically on a form of cultural deviance (Rosenberg, 2002). In the promotion of overweight as a disease, WLS may be promoted as a reasonable intervention. Within the medicalisation of weight as a governable space, particular “translation(s)” (Rose, p.48) occur between government funded bodies and a variety of local agencies that support the application of trade in medical technologies to the clinical management of weightfull citizen patients. Within this space, weightfull citizens are encouraged to consider that weight is a clinical sign of disease that medical science has the potential to cure.
In the aftermath of the Second World War, the purview of medical science expanded as the surveilling gaze of governments concentrated on their problem-based populations
(Wailoo, 2004). Scientific understandings have become foundational to a risk model of modern life. “(R)isk thinking brought the future into the present and made it calculable” (Rose, 1999a, p.247). With the emergence of surveillance medicine (Armstrong, 1995), the normal body became problematised as pre-diseased, always holding within itself the seeds of potential illness. With the gradual advent of “biopower” (Foucault, 1990a, p.139) the normal body became an object for problematisation, intervention and modification through treatment. Biopower is enacted on the basis of truth discourses about the essential nature of living human beings through the mediation of anointed professionals: These professionals promote interventions of supposed benefit to the wider society and individuals are encouraged to perform these tasks for themselves and for others (Rabinow & Rose, 2006). In the existence of weight/height tables, for example, research into deviations from average weight held promise in explaining disease; in manipulating the weight of populations, disease potential might then be ameliorated. The onus was placed on individual citizens to choose weight-for-health interventions.
Large corporations, governmental agencies, hospitals, clinics, unions, national (and international) politics (Klein, 2004) grasped the wealth of opportunities made available by the increasing individualisation of risk and its intensification through media presentations (Rose, 1999a,). This focus on citizen health has spawned a vast medical industry (Starr, 1982). As well, citizens have progressively internalised the statistical basis of intervention-for-prevention in modern medicine. This ensures that the rationality of modern medicine is less available for questioning (Stewart, 2001). From praying to God for eternal life in the hereafter, the modern citizen requests and awaits the promise of a longer, ‘natural’ ideal of life. This is a life potentially free of pain, disease and abnormality through the application of medical science and technology mediated by Spratling’s priest-physicians (Rosenbaum, 2003). Holding the answers to bodily and mental ills, the medical practitioner is positioned at the interface between the fragility of the patient-body and the promised sturdiness of pharmaceutical and technological interventions. Physicians have become the “[…] guardians and gatekeepers of a technological fountain whose elixir grants eternal health” according to one editorial in The Lancet (Anonymous, 1995, p.1126). Our personal problems have been opened to interpretation within the abstracted language of science (Starr, 1982) for which interpretation by an expert is required.
Western science, technology and medicine are culture (Casper & Koenig, 1996; Franklin, 1995) acting in, acting on and acting through the neo-liberal citizen/patient. The basic modus operandi of the conduct of health-conduct in Western democracies - or medicalisation as a specified operation of governmentalisation - signals a hegemonic neo-liberal positioning. Individual citizens as agents need, and are encouraged to want, to take care of themselves in relation to accessible projects of health and norms of health-related behaviours. The web of governmental control over the health of its citizens is increasingly at a distance but clearly directive. The devolution of responsibility for fulfilling governmental agendas in relation to health is evident in the purposeful development of a variety of agencies funded or contracted to provide health- related services.2 The proliferation of professionals and experts, and risk thinking as an individual and societal concern, are central in the bio-political era (Rose, 2001). With the ability to surveil-by-surveying, proportionate risks are assigned to groups of citizens (Czerniawski, 2007). The reasons for doing this have moved from the security of the nation to the domains of the economic in the “rising costs of health care,” and the moral such as inequalities in health care provision vis-à vis a nation’s relative reputational standing to other countries as in the WHO Report (2000). Still, these phenomena eventually track back onto individual citizens who are exhorted to care for themselves. Neither governmentality in regards to health nor risk thinking have abated through the bio-political era. Medicalisation, though, has become increasingly connected with new concerns.
The notable success of pathological medicine (Armstrong, 1995) brought with it an increasing demand for, and possibility of, new cures and preventative measures. Experimentation for innovation could be justified within largely utilitarian notions of ‘the greater good’ of the population as a whole. Medical research as treatment was increasingly tied to its social outcome,3 and the means, including the use of human subjects,4 justified by the ends.5 In its seeming inviolability, medicine remained
2For example, in New Zealand, District Health Boards are accountable to Government for meeting agreed health targets through the Sector Accountability and Funding Directorate (http://www.moh. govt.nz/dhbfp)
connected with science in a way that has allowed it to remain largely immune to critique (Casper & Koenig, 1996). The assumption is that, as an established Western, scientific practice, medical science is answerable only to rationality and knowledge. Medical professionalism came to be based on the association between “scientific values, morality and democracy” (Casper & Koenig, p.12). In this “ dream of reason” (Starr, 1982, p.3), power needed to be accounted for. While Starr was specifically – and some would say rather short sightedly (Wailoo, 2004; Warner, 2004) – referring to the power of medical practitioners, this insight lingers.
Medicine has maintained its authority by linking judiciously with big pharma, the large technology companies and governments, those forces determining the focus of medical research and development. In connecting with power bases in science and technology, modern medicine emerged, established itself and proliferated even as its commitments and practices changed to maintain these connections. While modernist medical science has continued to hold sway, a powerful postmodernist critique has emerged. Modern scientific medicine has a range of effects: It may be either “the knight in shining armour or a new body snatcher” (Porter, 1997, p.669).
From a concentration on the public infrastructure, state interventions in health activities were initially focussed on the elimination or control of epidemics, and the provision of public health programmes in Western nations.6 By the late 19th century and early 20th century, governmental interventions and concerns had shifted focus from the physical conditions in which citizens en masse lived their lives onto individual citizen-lives. In the next section, I trace the emergence of conducting the conduct of the body, enumerated and individualised, as it moved to embrace the freedom to choose health within the rules of a self disciplining, docile citizenship.
2.3 Weaving the threads of the Psy7 through medicine and trade: Surfacing