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Hist. cienc. saude-Manguinhos vol.19 no.1 Rio de Janeiro Jan./Mar. 2012
The weight of pathological: bio-politics and bare life
Cristiane Marques SeixasI; Joel BirmanII
doctoral candidate at the Graduate Program in Psychoanalytical Theory/Universidade
Federal do Rio de Janeiro (UFRJ). Rua Alfredo Chaves, 15 22260-160 - Botafogo
- RJ - Brazil email@example.com
IIPsychoanalyst; Associate Professor at the Institute of Psychology/UFRJ; Assistant Professor at the Institute of Social Medicine, Universidade do Estado do Rio de Janeiro; Directeur d'Etude en Sciences Humaines and Associate Researcher at Laboratoire sur Psychanalyse et Médicine/Université Paris VII. Rua Major Rubens Vaz, 426 22470-070 - Gávea - RJ - Brazil firstname.lastname@example.org
This article analyzes the historical formation of the idea of obesity as illness, starting from the differentiation between the normal and the pathological so as to show the replacement, in present times, of the ancient view of self care by a medicalization of life. In the light of a bio-political interpretation, there is an exposition of how obesity shows, in a paradigmatic way, the play of the various forces within contemporary power mechanisms which have a direct effect on the body, aiming for the control and management of life. From this perspective we develop a criticism of the treatment of obesity bearing in mind the increasing custodianship over life which can be observed in modern states, where the exception has become the rule.
Keywords: obesity; bio-politics; care of the self; medicalization.
From the care of the self to illness
Despite the vast body of medico-scientific literature on obesity, there are few works in which its historical formation as a clinical discipline can be clearly identified. This method of approach, however, goes back to the very early days of medicine, even to the beginnings of modern science. Initially associated with health concerns, excess weight was seen as a feature of each individual, involving a series of recommendations and warnings, not because obesity indicated an imminent threat to life, but because of the limited knowledge of the mechanisms leading to illness and death.
According to Mazzini (1998), a great deal was written in Antiquity with regard to nutrition and, among medical works, those dealing exclusively with nutrition were called dietary treatises. 'Dietetics', which together with surgery and pharmacology originally composed the basic foundations of ancient medicine, was definitively incorporated in the concept of health, despite being a discipline originally confined to the rich and well-off, who were in a position to concentrate on taking care of their health. In contrast to later developments, the received wisdom of the time maintained the view of the nature of the body: "In the first place, it is important for everyone to be aware of the nature of his own body. Some people are thin, others are fat; some are hot, others cold ... it is rare to meet anyone who does not have a weak point. The thin person needs to put on weight, the fat person needs to slim down; the hot person must cool down, the cold person must heat up ... there is always a need to bring help to an unhealthy part" (p.257).1
In contrast, the investigation of Foucault (1984) into the history of sexuality points out that Greek society developed a train of thought around the way in which citizens treated their bodies, introducing dietetics into the field of the 'care of the self.' Thus, during Greek and Roman times, dietetics came to occupy a strategic position along with 'erotica' in practices associated with self care. From this perspective, dietetics constituted a regime to be followed in order to reach equilibrium, which was the supreme good available only to men of virtue. However, the regime was not confined to nutritional guidance, it prescribed a set of rules for conduct, a code for the 'art of living' under which a person's moral firmness was tested, showing that, as well as caring for bodily health, the rules looked in just measure to a "useful and happy life within the limits laid down for it" (p.96): It was thus a code of ethics in harmony with the political and philosophical norms of those societies.
In his article entitled "Obesity: a medical history", Haslam (2007) shows that acceptance of obesity as a medical phenomenon was slow, because in most cases it was only the rich who became obese, owing to their privileged access to food. Hippocrates, the father of medicine in ancient Greece, was already writing about the connection between obesity, infertility and premature death, but he stressed the risks associated with a poor diet and the benefits produced by changes in diet. According to Haslam, one of the first cases of the clinical management of obesity was described by Galen, but the majority of works indicated dietary improvements and the practice of physical exercise as the recommended requirements for the maintenance of good health, which, in the view of Foucault (1984) obviously implied the care of the self.
It was only in 1765, with Morgagni (Haslam, 2007) and the development of pathological anatomy, that obesity was viewed primarily as an illness and the location of fat within total body tissue was considered crucial. This theoretical precedent, marked by an attempt to locate the source of the illness, had important results in the field of dietetics. If up until then the symptoms had been viewed in isolation, or even considered as personal characteristics of specific bodies, from then on a series of symptoms began to be associated with obesity. In this connection, emphasis should be given to type-2 diabetes - initially linked with excessive consumption of alcohol - which led to increased concern with an interest in studies of the mechanisms of obesity in action.
It is in this transition from a 'maintenance of health' perspective to a pathological point of view that certain questions arise with regard to the idea of illness which today defines obesity. First of all, it is necessary to think of the scientific context of this epistemological change within medicine in order to relocate, in the present, the new condition of obesity. Let us therefore make a short historical digression on the development of pathological anatomy, with the changes brought by the advent of modern science, in order to support a bio-political interpretation of obesity.
Norm and modern medicine
In classical times, medicine ran up against certain limitations, in terms of both diagnosis and techniques. Diagnosis was very often based on the descriptions by Hippocrates and Galen of the temperaments and humors in order to determine the treatment to be followed. According to Foucault (1994), that which showed itself to the 'medical gaze' consisted of experiments which were confined to a superficial level, where there was a certain corporeal opaqueness which did not then admit any more profound analysis. Under Christian influences, the building up of knowledge and clinical practice were based on inconsistent understandings forged as a result of a mystical view of the world and the body.
It was from the development of pathological anatomy and the resulting transfer of this knowledge to the clinical field (anatomoclinical medicine), that illness came to be seen as a change in the natural equilibrium which was equated with health. With the desanctifying of the body initiated during the Renaissance, it became accessible to knowledge, because the actual act of discovery became divorced from religious experience, from revelation, and entered the field of reason. The need to establish the 'seat' of diseases grew to the extent that physiological knowledge of the body deepened, establishing a correlation between physiology and pathology. However, the fundamental matter in question was the relationship between disease and medical perception:
New objects will come to the attention of medical knowledge, to the extent and at the same time as the enquiring subject reorganizes and modifies itself and arranges itself to function in a new way. It was not, however, primarily the conception of disease which changed, followed by the manner of recognizing it; nor was it the case that the system of signs was modified, followed by the theory; but everything together and, more profoundly, the relationship between disease and the perception to which it offers itself and which, at the same time, it forms part of (Foucault, 1994, p.101).
A new conception of disease was coming into being in that it was no longer a question of the introduction into the body of a naturally pathological species; it was the body which became ill (Foucault, 1994). This important change in the paradigm withdrew the 'symptom' from its passivity as a natural phenomenon, and it came to be seen as the signifier of the disease itself. Foucault points out that something in the nature of a symptom now indicated the pathological, through its opposition to a phenomenon of organic life.
Prior to Foucault, in The normal and the pathological2, Canguilhem (2002) analyzed the construction of medico-scientific concepts. His first questioning concerned the idea, derived from a positivist and rationalist viewpoint, that pathological phenomena were a quantitative variation on the normal state. In effect, every problem in pathology had developed from this fundamental idea, which had become a dogma of medicine, so wide was the theoretical reach of the positivism of Auguste Comte.
An analysis of the conception that illnesses are only symptoms is relevant because this reductionist view has directed scientific research in the quest to find the location of illnesses, and still has its effects in current medicine, which we shall consider below. Accepting the hypothesis that illnesses have a location has provided fertile ground for the development of the idea of the existence or prior establishment of what is normal. These two points of view are at the bottom of the positivist theory of Comte, who understood illness as disorder and disequilibrium. For him, in effect, the concept of a normal state was equivalent to the concept of a physiological state, being thus "reduced to a qualitative and polyvalent concept, aesthetic and moral even more than scientific" (Canguilhem, 2002, p.33).
For Canguilhem (2002), the imprecision of the concepts of Comte shows, above all, the impossibility of medical therapeutics becoming totally scientific. The author emphasizes that, because the normal cannot be defined objectively and any variation measured quantitatively, it is only in relation to a 'valid and desirable norm' that excess or insufficiency can be measured, the normal ceasing to be a fact itself and becoming a manifestation of a 'value' with reference to the perfect or the ideal. Canguilhem therefore declines any attempt to establish a science of the normal on the basis of the natural sciences and proposes the concept of vital normativity in order to grasp the differentiation between 'normal' and 'pathological', through his understanding that a judgment made from a fact is always made with reference to a value and, at the same time, subordinated to that which institutes it.
The conceptual rupture that Canguilhem (2002) improves is worthy of the legacy of vitalist philosophy, according to which life dispenses with anything which is extra-natural. In this view, the value which distinguishes human beings from inanimate beings is the immanence of life, which does not allow itself to be objectified and cannot be reduced to a physical-chemical proposition, which is the basis on which the natural sciences have developed. It is from the idea that life possesses in itself this capacity to perceive that which does or does not threaten the survival of the human being that Canguilhem deduces that a state is considered normal by an individual when this state is implicated with the value of life, above all with its continuity in a specific environment: "for a living being, the fact that disease is the reaction to a wound, an infestation, a functional disorder leads to a fundamental fact: that life is not indifferent to the conditions in which it is possible, that life is a polarity and for this very reason, a position which is unconscious of value, in short that life is in fact a normative activity" (p.96; our italics).
With regard to the continuity of life, it is in opposition to a negative value (threatened loss of life) that normative activity occurs through preference and exclusion, in one movement on itself. Vital normativity is therefore the capacity of the living being to 'institute' norms for itself, at the same time as it indicates the course of the art of healing (vis medicatrix naturae).
As early as 1943, when he was preparing his thesis for his doctorate in medicine, Canguilhem (2002) realized that he faced a problem without an easy solution, namely the origin of the notion of the norm, in the normative sense of the word. This concept is discussed by him in the light of physiology, where the norm is equivalent to the average found from the parameters of a defined group. However, the inverse proposition advanced by Canguilhem is that the average expresses the norm, because it bears witness to the normative activity of a defined trait and not the contrary: "A human trait would not be normal because it is frequent; but it would be frequent through being normal, that is to say, normative within a defined genus of life" (Canguilhem, 2002, p.126).
The hope of finding an ultimate truth with regard to the body rests, since antiquity, in the theoretical investigations of medical science, the construction of concepts and the establishment of therapeutic principles. In furtherance of this hope, there have been evident advances in medical technology since the beginning of modern times in constructing functional parameters on the basis of the population average. Let us ask ourselves: would a normative reference point also emerge in this way, or rather, would medicine convert and validate traits which, in theory, would be more normative in a general norm?
As an approach to the problem, Canguilhem (2002) takes as an example the analysis of 'anomalies', comparing them to 'abnormalities' in order to establish that an anomaly, being something outside the norm, only becomes an object of scientific interest when it becomes pathological, that is to say, when it raises a question mark over the value of life and threatens its continuance. On the basis of this reasoning, he also points out that something that differs from the norm is not pathological, and adds that the abnormal is not equivalent to the pathological, but the pathological is always abnormal. It is worth stating that, from this viewpoint, the pathological is an indication of another possible mode of life:
No fact which is said to be normal, by virtue of having become normal, can usurp the prestige of the norm of which it is the expression, from the moment there was a change in the conditions within which it took the norm as a reference point. There is no fact which is normal or pathological per se. The anomaly and the mutation are not in themselves pathological. They express other possible life norms. ... Their normality will proceed from their normative nature. The pathological is not the absence of a biological norm, it is a different norm, but in comparison it is repulsed by life (p.113; our italics).
Mechanism of security
On the basis of the view of health advanced by Canguilhem, and bearing in mind that obesity started to become relevant in the general medical picture in the 1980s - when the number of cases of obesity started to have a substantial impact on health systems3 - , we are concerned here to define the social, political and normative context in which obesity registered as a relevant problem of public health.
Starting from a parallel with the considerations outlined by Alain Ehrenberg (1998) with regard to depression, we can consider how obesity appeared at the crossroads of a series of determining factors, and made explicit the imprecision that existed at the frontier between the normal and the pathological. In order to clarify the context in which depression appears as one of the main aspects of the unhappiness of modern man, Ehrenberg gives a historical analysis of how depression was elevated from the secondary role which it played in the 1940s to become a syndrome described in the diagnostic manuals, which provoked important nosographic debates. The author points out that the increase in depression is directly related to a change in the normative context and, therefore, to changes in individuality itself at the end of the twentieth century, as well as to the growing medicalization of life.
At the end of the nineteenth century, the subject was doubly regulated by disciplinary power: on the one hand, prohibition, at the same time prior to and exterior to him; and on the other hand, the discipline of the body, which regulated his conduct from outside.4 For Ehrenberg (1998), depression makes its appearance in contemporary times with the weakening of a disciplinary system for the management of conduct whose rules of authority and conformity to prohibitions supplied the social classes with their destiny and identity. In this new normative context individual sovereignty became the rule, and it was the task of the individual to prescribe his own rules, where only his abilities and aptitudes were valid to individualize him. In the context of discipline, psychological suffering was the result of the conflict in relation to the prohibitions imposed from without; in the new normative situation, the gap between the requirement to create one's own rules and to achieve a state of well-being appears as a nodal point. This imposed individualism became the general rule, and the 'personal' is no longer more than a normative device, showing that the new norm was also impersonal in character.
When considering this normative context, it will be observed that in contemporary times there is a movement from the suffering based on the anguish arising from psychological conflict to the suffering centered in depression and the feeling of inadequacy, that is to say, a mode of suffering which embodies the tension involved in individualizing the self and the difficulty of being so. Ehrenberg (1998) points to the way in which, in the face of the emptiness which challenges the identity of each person, it becomes a matter of re-enlisting the subject in the conflict, removing him from this individual sovereignty.
It has also been in this same historical and social scene that we have seen a growth in the number of cases of obesity, which reveals that this normative change has also made itself heard in the realm of the body and nutrition. Bearing in mind the permanent demand to conform to an aesthetic ideal which, in the final analysis, banishes us from the biological criteria which define how it is possible to live, we would identify the distancing from a Canguilhemian view of health. What is now central is the social image of the body as a decisive rule for the appearance of the individual.
Dietary practices have been disseminated more and more widely in the day-to-day life of the world's population, and slimming methods built into our daily life disguise the permanent control which has been registered in the recent picture of the 'reconfiguration' of the body, which has become an asset to be preserved and a possession to be valued. The growing lipophobia associated with this distancing results in a failure to differentiate between abnormality and pathology, thereby harnessing obesity to the sphere of pathology and granting exclusively to medical expertise the guidelines to be followed in the treatment given to obese individuals. In this way the body has been constituted as the locus for the consolidation of an discourse which deals in control and normalization, in such a way that it walks hand in hand with the elimination of that plurality which biology imposes on the order of life. Thus, where the dietetics of antiquity looked to the preservation of health through a quest for bodily equilibrium, in the social and ethical field of self care this objective gradually gave way to a pathological view of excess weight, in harmony with the birth of clinical anatomy.
Such a key to interpretation allows us to put the following question: if from a physiological point of view slimming is favorable to better health and from a subjective point of view leads to an increase in suffering, linked to a feeling of inadequacy, does the permanent search for an ideal of perfect health make it impossible to 'subjectivize' the register of the body, bearing in mind the limits and possibilities for each individual? It can thus be affirmed that the critical exercise necessarily passes through an examination of the sets of forces dispersed among contemporary positions of power which have a direct effect on the body, looking to the control and management of life.
In order to think of the body as the locus for the consolidation of power, we can consider, in a Foucauldian interpretation (Foucault, 2000, 2008b), a line of continuity between the sovereign power, the disciplinary power and the bio-power. Throughout the eighteenth century one observes the rise of a new modality of power, the disciplinary, which, more than the exercise of the power of life and death, sought to regulate life by conditioning bodies so as to extract useful and productive strength from them. The creation of docile bodies, undertaken by the disciplinary institutions, sought to optimize human performance by means of the control and organization of time and conduct.
Side by side with this, at the turn of the eighteenth and nineteenth centuries the focus of action moves from power over the individual body to the population in general. Bio-power, which expands in the nineteenth century to complement the techniques of disciplinary power, is then directed totally and without restrictions towards the human species. It scrutinizes every phenomenon which detracts from its power, not only through disciplinary devices intended to normalize, by means of techniques of individuation, individual behavior and conduct, but also through a bio-politics disseminated throughout the institutional web which exerts itself to analyze population data, so as to construct statistics and parameters for the control of social processes (Foucault, 2008a). From this perspective, emerge epidemiological and demographic studies which look to extract knowledge from their field of operation, which is the population itself. It is in search of ways to plan the life of the population as a whole that bio-politics disseminate themselves, "ensuring that life and its mechanisms enter into the domain of explicit calculation" (Foucault, 1988, p.134) and provoking important changes in power relationships. Knowledge power becomes the agent for the transformation of life itself, not because it is totally dominated and managed, but precisely by continually escaping from this.
However, if during the nineteenth century it was through sex and reproduction that life and population phenomena were controlled, we can affirm that now it is also in the domination of the body - slim and healthy - that this regulation takes place. The legacy of Foucault's work and his genius lies in his perception that it was there, where the ideal in relation to humanity was outlining itself as preventive concern, that an important mutation in the incidence of power was taking place in counterpart, but submerged in the guise of necessary, perhaps obligatory, care.
A consideration of the biological register in politics has consequences in the make-up of power, because it is based not only in itself, but arises from relationships themselves, be they relationships of production, families or hierarchies. This characteristic of power ensures that it is permanently produced and reproduced, and this demands a careful analysis of its mechanisms at the present time. The role of such an analysis is to show the effects knowledge produces on society (Foucault, 2008a). Thus, starting from the model of disciplinary societies, Foucault presents a new modality for social control and regulation, which he calls a 'safety mechanism.' This regulates events from its introduction into an average, which will determine the limits of the acceptable and that should not be exceeded. These mechanisms are not a substitute for disciplinary devices; they are articulated to disciplinary techniques as much as legal mechanisms. It is therefore a question of analyzing the 'risks' to which a defined population is subject, and, on the basis of such data, constructing forms of prevention, so as to normalize the population:
In the same way, the disciplinary corpus is also fully activated and fertilized by the establishment of these security mechanisms. Because, in the end, in order to actually ensure this security it is necessary to have recourse to, for example, and it is only an example, a whole series of techniques for keeping watch on individuals, for diagnosing what they are, for classifying their mental structure, their actual pathology, etc., a whole disciplinary complex which thrives on the security mechanisms so as to make them function (p.11).
Bare life, qualified life and the state of exception
Despite the fact that a reading of Foucault does not encourage a juridico-institutional approach to the processes of medicalization, there are various studies of mechanisms and techniques which help us to understand how power penetrates bodies and produces subjectivities. In this context, with the contributions which Giorgio Agamben (2002, 2004) incorporated into Foucauldian thought, by means of a lengthy analysis of different contemporary political events, we can assess to what extent bio-politics is directly involved in the creation of new forms of suffering. His reflections are based on Foucault's concept of bio-politics, but include important contributions from the thought of Hannah Arendt with regard to the advent of totalitarian regimes as a result of processes which place life and work at the core of political power. This analysis, in its presentation of the concept of bio-politics, has developed into one of the principal strands of thought of Agamben.
In Homo Sacer: sovereign power and bare life5, Agamben (2002) undertakes a long journey starting in antiquity, where he stresses the notion of sacred life6, looking at sovereign power from the classical age until the middle ages, and rescuing the historical roots of modern bio-politics. Continuing the genealogy of Foucault, he shows how much modernity is essentially marked by a link between sovereignty and bio-politics, and lingers over a question left open by Foucault, namely, the existence, in power, of a zone of indifferentiation where there is a convergence of techniques of subjective individualization, which relate to discipline, and procedures of objective totalizing, which are characteristic of bio-politics, constituting a genuine political double bind. In parallel, Agamben emphasizes a process whereby what was earlier the exception gradually becomes the general rule in the present.
Agamben (2002) rescues the Greek distinction between zoé - the simple fact of living, common to all human beings; 'natural life' - and bios - a way of living applicable to the individual or group; 'qualified life' - so as to reveal the erasure, in modern times, of the boundaries which clearly defined the natural and political spheres of life in antiquity. In this sense, he repeats the Foucauldian maxim that "modern man is an animal whose politics places his existence as a living being in question" (Foucault, 1988, p.134).
In order to further the propositions of Foucault with regard to bio-politics, Agamben makes use of a figure from ancient Roman law, the homo sacer - in which the character of sacredness is linked primarily with human life as such - in order to show the complex relationship between politicized life, sovereign power and bare life. From the viewpoint of sacratio, the homo sacer is placed in a position where he is excluded from both the sacred and the human spheres, thus constituting a double exception: the homo sacer is someone who, paradoxically, anyone may kill without being guilty of murder, but who, because he is sacred, may not be sacrificed in a ritual ceremony. This is evidence of the indeterminate zone into which the bare life of the homo sacer reverts - a sacred life at the crossroads between liability to be killed and impossibility to be sacrificed - which is present in modern times in the form of totalitarian governments and above all in the form of a bio-politics which encroaches on territories which were previously unthinkable and unattainable. For Agamben (2004, p.91), "sovereign is the sphere where one can kill without committing murder and without celebrating a sacrifice, and sacred the life which has been captured in this sphere".
Through the prism of sovereign exception, considering the progressive adoption of the exception as the rule, the author claims the essential function of bare life in the new bio-political body, citing the concentration camp as the new political paradigm of modernity, because these political spaces come into being when the state of exception7 becomes the rule. In reproducing to the limit the advance of sovereign power in contemporary life, modern bio-politics are transformed into the 'thanatopolitics.' That is to say: it is no longer a question purely and simply of 'making die and letting live', the prerogative of the sovereign over his subjects, but of 'making die and making survive', with everything that survival suffers from the emptying of life and the power over the body.
In analyzing a series of fundamental political events and restoring them to their bio-political context, Agamben shows, from the paradigm of the concentration camp, that in our time the citizens appear to be virtually homines sacri, 'killable' but 'unsacrificable', just as under the sovereign power structure:
This is the force and the inherent contradiction in modern democracy: it does not abolish the sacred life but shatters it into pieces and disseminates it in each individual body, making a wager of it in the political conflict. Here is the root of its secret bio-political vocation: that which will show itself as the bearer of rights and ... as the new sovereign subject ... may constitute itself as such only by repeating the sovereign exception and isolating within itself the corpus, the bare life (Agamben, 2002, p.130).
According to Agamben (2002), there can be observed a displacement and an enlargement of the decision over the bare life which is the prerogative of sovereignty, which points to an increasingly intimate symbiosis between the sovereign figures. The theoretical advance proposed by the author concerns the political value which life assumes and which sets in counterpoint its lack of value. If in modern bio-politics the biological data is immediately bio-political, the decision over life and death passes from the figure of the sovereign to that of the doctor, and the rule becomes imperceptible of exception. The radicalization of the custodianship of the life of the population which emerged in modern absolutist states, of which Nazism is the most outstanding example, indicates a transformation in the significance and attributes of medicine, which becomes the repository of a political economy of human richness. By way of example, we quote what Agamben (2002, p.149) writes with regard to the validation of euthanasia in the Nazi state:
If it is within the sovereign's power, to the extent that he decides on the state of exception, at any time to decide which life can be taken without murder being committed, in the age of bio-politics this power tends to free itself from the state of exception, becoming a power to decide at what point a life ceases to be politically relevant. ... In modern bio-politics, the sovereign is he who decides on the value or lack of value of the life as such.
This discussion on the movement of sovereign power to the figure of the doctor, which is related to a shattering of bare life within individual bodies, is favorable to the construction of a new point of view, on the basis of which one can raise questions with regard to the problem of obesity. If, in modern bio-politics, bare life and political space converge in a zone of irreducible indistinction, we may believe that the decision that slimming is a desirable course of conduct answers a political strategy that looks, in the ultimate analysis, to encroach on the last frontiers of modern individuality. This side of life, and beyond death, the survival which characterizes the zone of indistinction of bare life shows itself in various ways in the interval between qualified life and life without value. Obesity, because of its negative value from the point of view of health and aesthetics, is one of the figures of bare life to be normalized by medicine.
Obesity under discussion
Within this social and ethical picture, which is harsh and uncertain, we can return to certain questions so as to think of new ways to understand obesity. In an amusing passage, paraphrasing Freud with regard to the relationship between the ego and the id ("Wo Es war, soll Ich werden")8, Agamben (2002) affirms that the political task in modern times is to create a people where bare life exists. In search of the guarantee for a healthy economy of human richness, that which in antiquity consisted in the search for health involved in the perception of the body becomes a demand for slimming. Even though it is not possible to disassociate the concept of body from the bio-political body tied to a device, it is necessary to have as threshold the distinction between zoé and bios:
There is no way back from the concentration camps to classical politics; in them, the city and the home became indistinguishable, and the possibility of differentiating between our biological body and our political body, between what is incommunicable and dumb and what is communicable and capable of being said, was paralyzed for us for all time. And we are not only, in the words of Foucault, animals whose politics calls their existence as living beings into question, but also, inversely, citizens whose very politics is at issue in their natural body (Agamben, 2002, p.193).
Considering therefore the intimate relationship between politics and the register of the body, it is not possible to ignore the maneuverings with regard to the directions on slimming which repeat the medicalizing discourse, which in its turn links freedom and happiness to something which, paradoxically, reveals itself as bare life. It is while bearing in mind that life continually escapes the techniques for domination and management of knowledge-power that we must read the attempts, still embryonic in the field of medicine, at resisting the dominant view which looks at obesity a priori as an disease to be cured.
The Australian researchers Michael Gard and Jan Wright have devoted themselves to identifying the obscure points in the theories on obesity, for which purpose other knowledge is invoked to reach an opinion and to radically question the dead ends of the medico-scientific model. The obesity epidemic (Gard, Wright, 2005) proposes that scientific writings on obesity and popular opinion are a complex mixture of scientific uncertainties and familiar moral and ideological conceptions. The authors seek to show that, more than a global health crisis or an objective scientific fact, the much touted current obesity epidemic can be seen as a complex pot-pourri of scientific, moral and ideological hypotheses with regard to people and their lives, with questionable ethical results.
The authors argue that scientific knowledge of obesity and excess weight is incomplete and full of errors, making it difficult to identify progress in the academic studies. They point out that these errors become more evident when scientists turn to the causes of the development of obesity. Here the simple data - statistics of prevalence, measurements from the Body Mass Index and classification into overweight or obesity, for example - are insufficient to explain what is happening, and they are forced to make excursions into other fields of knowledge with which they are less familiar and give little consideration to the social and cultural aspects of the human being. To demonstrate how speculations are taken as certainties, the authors cite the following passage from an article by Claude Bouchard and Steven Blair:
The tools available to reverse this unhealthy trend are remarkably simple in appearance as they center on the promotion of eating regular and healthy meals, avoiding high calorie density snacks, drinking water instead of energy-containing beverages, keeping dietary fat at about 30% of calories, cutting down on TV viewing time, walking more, participating more in sports and other energy-consuming activities. However, it will be a daunting task to change the course of nations that have progressively become quite comfortable with an effortless lifestyle in which individual consumption is almost unlimited. (Bouchard, Blair, 1999, quoted in Gard, Wright, 2005, p.6; our italics).
In this example, Gard e Wright (2005) observe that the presumption that people do not want to change their life style has become a certainty, and despite being a "remarkably simple" solution, it would be a daunting task for the majority. Whether or not it is true that people want to maintain their comfortable life style, the authors draw attention to the air of exactness and certainty attributed to the hypothesis that such changes cannot be realized. Associated with the notion that obese people are lazy, this idea that assumes the form of certainty is one of the elements in constructing the epidemic of obesity, being a direct consequence of the western life style.
Gard and Wright (2005) list the ingredients which make the so called obesity epidemic a history of sloth and gluttony. Firstly, certainty before uncertainties, because even though there are various ways to interpret excess weight and obesity, only one version is mentioned; the empty spaces where empirical knowledge has no answers are filled by assumptions and generalizations. Secondly, there is the fact that these assumptions find support in deeply rooted popular beliefs. Thirdly, the obesity epidemic rests on a particular form of morality, that which sees obesity as the product of weakness and individual failings. The authors argue the need for a critical view of obesity and excess weight for two reasons. One is the risk of the word epidemic exaggerating the actual situation, as well as per se conveying the idea of imminent disaster and associating obesity with infectious disease, which is capable of 'catching' anyone. The other reason consists in the fact that, in explaining the obesity epidemic by reference to individuals and to society, we run the risk of diverting attention from what is happening in fact: the construction of scientific knowledge on the basis of contingent explanations.
The radical approach of Gard and Wright repositions the argument about the scientific limits of medicine, and about its submission to bio-political devices employed by modern states, with regard to the control of obesity. At the threshold of biological modernity, the pulverization of the power over bodies transforms the obese person into one of the most shocking figures of the bare life and sets up the scenario where control strategies come into play. If in the concentration camps individuals were deprived of the right of decision with regard to their life and pushed into pure survival, at the present time the obese body represents a true zone of indistinction, over which hang an infinite number of technico-scientific constructions which seek to establish a regime which amounts, in fact, to an exclusion. Medical knowledge, as one of the figures of modern sovereignty, lays down the manner in which we should live and with its statistical data excludes the obese from the field of lives which it is possible to live.
In this scenario, what is valued as a rule is no longer the 'art of living' which aims at the proper measure of a qualified life, still less that 'vital normativity' in the singularity of each person with his way of life, but the general rule which prizes the perfect health of a people. The obese body as bare life exposes the precarious nature of a field which is open to new interventions, a body without value, liable to be killed by anyone who might desire to intervene, but not permitted to be sacrificed, even though a tributary to human weakness. There is thus a repetition of the suffering centered in the feeling of inadequacy which propels the individual into an unceasing search for new formulas and techniques which might help him become tolerable to himself, thereby greatly augmenting this zone of indifferentiation and impersonalization.
The path described here represents merely an attempt to encourage an opening up of the treatment guidelines to subjective aspects inherent in the organic condition of obesity, so as to pass beyond the apportioning of blame with regard to the obese for their lack of discipline and will power.
Sacred and profane
We intend to go part of the way in the direction of what we might call the profanation of the treatment of obesity, in an allusion to what Giorgio Agamben (2007) proposed in his "In Praise of Profanation".9 Just as a religion, through sacratio, withdraws things, places or persons from common use and transfers them to another sphere, medical practice removes the body and nutrition to the sphere of the sacred, and there withdraws the use that can be made of them. This separation, imposed by the sacrifice of diet, with its own rituals, can only be bridged by its profanation, opening up the possibility of a special form of negligence and making a particular use of separation. In this bridging, which is not the abolition of separation, still less a new edition of the norm, it is necessary to make the subject happen, a subject that put 'hands on' his diet, who 'plays' with his body and his nutrition. In this sense, the unceasing search to become slimmer shows us the paradox of the spectacle under discussion: the demonstration of an impossibility of using the body and living in it. In the words of Agamben, the important thing is to wrest from the devices the possibility of use which they capture, 'to profane the unprofanable' - this is the task of the generation which will be forged in the future, in a historical perspective.
1 In this and other citations of texts from non-English languages, a free translation has been provided.
2 Georges Canguilhem, The normal and the pathological, New York, Zone Books, 1989. The authors used the portuguese version (Canguilhem, 2002).
3 It is estimated, on the basis of the National Health Accounts (NHA) of 2003-2004, that in the United States alone, where obesity affects more than 32.2% of the population (approximately 60 million people), expenditure on such illnesses in 1998 was around 78.5 billion dollars (Finkelstein, Fiebelkorn, Wang, 14 May 2003), the equivalent of 9.1% of annual medical expenditure - a high percentage when compared with investment in prevention and the direct costs of other illnesses such as cancer or Alzheimer's disease.
4 This view is in line with Foucauldian thought on the mechanisms of power (Foucault, 2000) and will be developed further below.
5 Giorgio Agamben, Homo sacer: sovereign power and bare life, Stanford, Stanford University Press, 1998. The authors used the portuguese version (Agamben, 2002).
6 The concept of sacred life is fundamental for understanding the links proposed by Agamben between antiquity and modern bio-politics. The sacred life marks the passage of the human world subject to death and to sacrificial rites to the sacred sphere (sacratio), in which two fundamental aspects are conjoined: the impunity for killing and the exclusion from sacrifice (Agamben, 2004), aspects which are taken up again by the author in the bare life of homo sacer.
7 In defining the state of exception, Agamben (2004) has recourse to Carl Schmitt, a German intellectual who subscribed to Nazism and produced a theory of the continuity between sovereignty and the state of exception. In this theory, Schmitt describes a 'form of government' in which the sovereign decides on the suspension of the rule of law and which, according to Agamben, has become a paradigm for contemporary democratic states. The state of exception is positioned on the border between politics and law, and its fundamental paradox lies in the fact that the state of necessity, on which the exception is based, cannot be included within the legal system.
8 "Where id was, there shall ego be".
9 Giorgio Agamben, Profanations, New York, Zone Books, 2007. The authors used the portuguese version (Agamben, 2007).
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for publication in December 2010. Translated
by Derrick Guy Phillips.
Approved for publication in November 2011.
for publication in December 2010.
Translated by Derrick Guy Phillips.