TABLA DE DESARROLLO

At the close of Chapter 4, I shared some reflections on the methodological approach employed in the thesis. Having now presented the analysis and the discussion, I wish

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to share some further reflections on the strengths and limitations of the research. Firstly, a strength of this study is the use of a robust theoretical framework which I feel has elevated the quality of the analysis, and the insights generated. It has also assisted in presenting these insights systematically and in a transparent way. This is in contrast to some of the literature, which, while alluding to employing a Foucauldian perspective, has tended to be light on detail about the analytic steps involved. Additionally, employing a Foucauldian perspective has allowed me to go beyond an overtly politicised view of the literature and participants’ accounts, to produce a more grounded description of the ways in which people use, and negotiate the upstream parable, something which I see as a strength of the research.

A second point to highlight is the iterative process involved in identifying academic texts for the analysis. To manage the scope of the study, I had to devise some inclusion and exclusion criteria. I settled on excluding texts that only employed the language of ‘upstream’ to describe determinants of health, without any explication of what it means to work ‘upstream’, or without detailing ‘upstream’ interventions. While this criteria allowed for a systematic approach to identifying and including texts in the analysis, there are of course texts that, while not meeting these criteria, could actually have contributed to the aims of the analysis. For example, the structural competency text by Metzl and Hansen (2014, p. 5) detailed in Section 8.2, refers only to “upstream decisions” such as decisions relating to “health care and food delivery systems, zoning laws, urban and rural infrastructures”. As such, this, and other related texts were not included in the analysis. It is my reflection that when working through some of these texts in the earlier stages of my study, I did not have the required lens or conceptual discernment to always recognise texts that could have made valuable contributions to the aims of the analysis. However, I would also suggest that due to the similarities between the proposals put forward by Metzl and Hansen (2014) (see Section 8.2), and the included texts (Table 5), much of the underlying principles were still captured in the final analysis. Additionally, due to the pragmatic limitations employed in identifying and selecting only academic texts for inclusion in the discourse analysis, it is important to acknowledge that there is a range of other sources (e.g. books, health inequalities reports) which could also have contributed to the analysis. Thus, the resulting account of the upstream counter- discourse as presented in Chapter 5 is just one account limited by the analysed texts, and would likely be further developed, improved, and refined through the inclusion of a wider range of materials in any future analysis.

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Finally, while I found a Foucauldian framework to be invaluable in giving shape to the thesis, Foucault’s ideas are not without their critics. So, prior to concluding the thesis, I wish to briefly summarise here some of the most compelling concerns raised by commentators, and the possible implications of these for future work. As described in Chapter 1, Foucault is not interested in going behind discourse in an attempt to access a “non-discursive ‘deeper’ reality” (Kendall & Wickham, 1999, p. 39). Rather Foucault’s analyses remain at the level of discourse and interpretation (with some consideration of the social function of these discourses), an approach which is suggested to pave the way for ‘radical relativism’ (Callewaert, 2006). Additionally, Foucault evades normative judgements about the effects of power and power-knowledge relations demonstrated through his analysis, and so is notorious for the consequential lack of solutions or actions proposed in his work. Indeed, Fraser (1989, p. 18) describes that it was perhaps only through this bracketing of traditional normative frameworks of the legitimacy and operation of power that Foucault was able to “look at the phenomenon of power in interesting and new ways, and thereby, to bring to light important new dimensions of modern societies”. However, despite the recognised value in Foucault’s ubiquitous and productive notion of power, it too has been criticised for its potential to be somewhat deterministic in nature, failing to fully account for the role of individual agency, and as a consequence being pessimistic about the potential for social change (Taylor, 1984). Thus, a Foucauldian framework could be said to paradoxically bring to light the pervasive ‘evils’ of existing regimes of truth, while ignoring the logical conclusions that something should be done about them.

In this study, I have resided in the realm of diagnosing and describing the nature of action advocated in the academic literature and by study participants. However, future efforts seeking to more actively bring about change in how we think and work to reduce health inequalities would likely demonstrate the less than stable platform that a Foucauldian perspective can provide for such work. In such instances, I would see a greater role for approaches underpinned by, for example, critical social theory and critical realism (Connelly, 2001; Scambler, 2018). These approaches go some way towards overcoming the limitations set out above. Most notably these theorists adopt the perspective that, without denying aspects of social constructionism, there does exist an independent albeit only partially knowable reality, and that close examination and illumination of the mechanisms sustaining reality can have emancipatory potential thus facilitating engaged action and activism for positive social change. Additionally, such perspectives allow for greater engagement with

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questions of morality, ethics, and politics, something which is in stark contrast to the rather disengaged stance espoused in a Foucauldian standpoint.