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Interface - Comunicação, Saúde, Educação

Print version ISSN 1414-3283On-line version ISSN 1807-5762

Interface (Botucatu) vol.23  Botucatu  2019  Epub Sep 02, 2019

https://doi.org/10.1590/interface.190208 

Dossier: Biopolitics and governmentality in Health

The government of conduct and the risks of risk in health

Sergio Resende Carvalho(a) 
http://orcid.org/0000-0002-4260-2507

Henrique Sater de Andrade(b) 
http://orcid.org/0000-0001-9847-3663

Cathana Freitas de Oliveira(c) 
http://orcid.org/0000-0003-0723-9519

(a, b, c)Departamento de Saúde Coletiva, Faculdade de Ciências Médicas, Universidade Estadual de Campinas. Rua Tessália Vieira de Camargo, 126, Cidade Universitária Zeferino Vaz. Campinas, SP, Brasil. 13083-887. sergiorc@unicamp.br hsatera@gmail.com cathanadeoliveira@gmail.com


ABSTRACT

Through a governmental perspective, we seek to reflect on the ways that the concept of risk operates in health field and dialogue with discursive practices such as New Public Health and Surveillance Medicine. We understand that risk does not exist itself but represents a moral and political technology that produces ways of looking and calculating reality, governing conduct, normalizing the social and making up subjectivities. By stimulating a healthy life, its effects can contribute to a “neoliberal governmentality”, inducing us to active self-vigilance, building an “economic citizenship” and an ideal of “self-entrepreneurs” and creating networks of surveillance and normalization that reinforce submissive and powerless ways of living. Despite these “risks of risk”, these technologies are continually confronted with resistance practices and counter-discoveries that invent others that are possible for health and life.

Key words: Risk; Governmentality; Public health; Medicine

RESUMO

Buscamos, a partir de uma perspectiva governamental, refletir sobre os modos que o conceito de risco vem operando na saúde e dialogar com práticas discursivas, como a Nova Saúde Pública e a Medicina da Vigilância. Entendemos que o risco não existe em si, mas constitui-se como uma tecnologia moral e política que fabrica modos de olhar e de calcular a realidade, governar condutas, normalizar o social e produzir subjetividades. Ao estimular uma vida saudável, seus efeitos podem contribuir para uma “governamentalidade neoliberal”, induzindo-nos a uma autovigilância ativa, construindo uma “cidadania econômica” e um ideal de “empresários de si mesmos” e criando redes de vigilância e normalização que reforcem modos submissos e pouco potentes de viver. Apesar desses “riscos do risco”, essas tecnologias defrontam-se continuamente com práticas de resistência e contracondutas que inventam outros possíveis para a saúde e a vida.

Palavras-Chave: Risco; Governamentalidade; Saúde pública; Medicina

RESUMEN

A partir de una perspectiva gubernamental, buscamos reflexionar sobre los modos en que el concepto de riesgo opera en la salud y dialogar con prácticas discursivas tales como la Nueva Salud Pública y la Medicina de la Vigilancia. Entendemos que el riesgo no existe en sí, pero se constituye como una tecnología moral y política que fabrica modos de mirar y de calcular la realidad, gobernar conductas, normalizar lo social y producir subjetividades. Al incentivar una vida saludable, sus efectos pueden contribuir para una “capacidad de gobernabilidad neoliberal”, induciéndonos a una auto-vigilancia activa, construyendo una “ciudadanía económica” y un ideal de “empresarios de sí mismos” y creando redes de vigilancia y normalización que refuercen modos sumisos y poco potentes de vivir. A pesar de esos “riesgos del riesgo” esas tecnologías se enfrentan continuamente con prácticas de resistencia y contra-conductas que inventan otros posibles para la salud y la vida.

Palabras-clave: Riesgo; Gobernabilidad; Salud pública; Medicina

Introduction

If the task of critique — after the work of Michel Foucault — is to investigate the historical conditions of true knowledge, then the critique of risk will investigate the different modes of calculation of risk and the moral and political technologies within which such calculations are to be found. Most importantly, it will investigate (...) the “regimes of government” in which risk is imbricated and the political programrnes and social imaginaries that deploy risk and its techniques and draw their inspiration from it.1 (p. 131).

Despite the undeniable contributions of medicine and Public Health for contemporary society, we have observed especially since the middle of last century a growing disillusionment with the results of many of its practices. This dissatisfaction has led to the emergence of other propositions that will be here described and analyzed, based on critical dialogues about the concept of health risk derived from the Foucauldian approach to governmentality1 , 2 .

We were particularly interested in reflecting on contemporary discursive practices that prioritize collectives, in this case the “New Public Health” (NPH)3 and individuals, in this case “Surveillance Medicine” (SM)4 . Numerous components of these propositions are present in elaborations of Brazilian National Health System, who have sought incorporate the notion of risk into their conceptual and practical frameworks.

We sustain our research with the understanding that every language has a performative character and the analysis of these speeches can help us to elucidate thought systems through which health authorities and specialists place and specify the problems of government and seek to implement actions in order to achieve certain goals2 , 5 .

In what follows, after some considerations on “Foucauldian” elaborations on governmentality, we describe and reflect on the ways in which the concept of risk has been operating in the field of health in the present day, in order to dialogue with the discursive practices of NPH and SM. We seek to understand the implications of the notion of risk on how we think about others, ourselves, our organizations, institutions and government issues. In this process, we will correlate discourses, technologies and practices around the phenomenon of risk to the government of “neoliberal” conduct.

Governmentality

For Foucault, power is a concept that encompasses a network of strategic relations and a set of mechanisms and procedures which seeks to exercise power and maintain a correlation that is favorable to those who is part of this network. Its practices are carried out through a multitude of alliances between various authorities who, with their projects, try to govern many facets of social life and act upon the actions of individuals and groups.

Differently from hegemonic thought, these individuals do not carry identities that are fixed and culturally and historically defined. They are not the origin, but the transient and mobile effect of government, resistance and counter-conduct practices. Therefore, individuals are considered here as an effect of productive power6 , 7 that sustains itself and is accepted less by what is affirmed as negative and by the order of repression, and more by the fact that it does not weigh on us as a force that says “no”. Power goes through and produces things, manufactures pleasure, ways of knowing and discourses that together produce modes of living.

From the mid-70s, Foucault will connect the analytical power to the theme of biopower and governmentality. The central element of this passage is the emergence in the 18thcentury of the population phenomenon - a social body that will require State intervention in order to manage and protect health, well-being and increase the productivity of all. A biopower that makes increasingly mention to the survival of bodies and race and to the government of men as living creatures: a biopolitics which axis and principle of actions is “to make you live and to let die”7 .

This power is a bipolar technology that invests life in its entirety and in its details7 - 9 . At one of the poles, the disciplinary power: a political anatomy which has as object the human body, seeking to guard it, maximize its strengths and integrate it into efficient systems underpinned by certain rules. Thus a “normation” of life in society10 . On the other hand, a biopolitics technology which seeks to normalize conduct through regulatory controls, having as object the population and the “species body “ in its dimension of being alive and in its biological dynamics in which it is present birth, death, reproduction, sexuality, subjectivity and the vital processes in general7 . If in disciplinary society the exercise of power was given over individual bodies submitted to orthopedic or corrective moldings, relations of power will affect in the present the very process of life.

The body of individuals and the population becomes a support of multiple variables that include not only the healthy and the sick, but also the strong and the weak, the rich and the poor, the more or less usable, the more or less prone to a profitable investment, those more or less likely to illness or death and those that are more or less able to be trained effectively11 .

This biopower will require new ways of operating power relations sustaining what Foucault called “governmentality”: rationality and government strategy that seeks to make the regulation and social control through the conduct of government. This direction of conduct refers to the conduct of the other, but also to “the way in which one conducts oneself, lets oneself be conducted, is conducted, and finally, in which one behaves as an effect of a form of conduct as the action of conducting or of conduction”10 (p. 255). A conduct that involves men, but men in their relationships, bonds and imbrications with things such as their health, livelihoods, territory, habits, ways of acting and thinking, accidents and misfortunes like hunger, epidemic, diseases, etc.

This government of men is accomplished by associating traditionally named entities as “political” (the State, for example) and countless other power centers with projects, plans and authorities practices (economic, cool, spiritual, medical, technical, etc.) that seek to manage the lives of others in the light of conceptions about what is good, healthy, normal, virtuous, efficient and profitable. In this context, the government will affirm less as a constituted authority or a sovereign State and increasingly by the way it seeks to

direct the conduct of individuals and groups [covering] not only the legitimately constituted forms of political or economic subjection but also modes of action, more or less considered or calculated, which were destined to act upon the possibilities of action of other people. To govern, in this sense, is to structure the possible field of action of others12 . (p. 244)

This rationality is present in Western societies after the 18thcentury, assuming in the 1970s a new modus operandi that some characterize and/or denominate as “neoliberalism”, “neoliberal governmentality”13 or “advanced liberal societies”14 . It refers to a new ethos that permeates the lives of all and each one and has, among other elements, the affirmation of freedom and of individual rights as opposed to excessive State intervention.

Another essential component of this new society order is given away by the reconfiguration of the role of experts in the processes of normalization of individuals and the population5 . Physicians, sanitarians, psychologists15 , statisticians, sociologists, social scientists, economists, anthropologists, etc., have a central role of coordinating and carrying out social and populational surveys and producing curves of normality that will subsidize interventions on the social body. Curves and means that support in this process what is called “risk” and “risk factor”2 .

Governmentality and risk: relations

“Nothing is a risk in itself; there is no risk in reality. But on the other hand, anything can be a risk; it all depends on how one analyzes the danger, considers the event.”16 . (p. 199)

There are different ways to understand and study the risk in the social and scientific literature. According to Lupton2 , the most common approach is the “realist”, which was developed and expressed by technical and scientific perspectives that define physical risk as a product/result of the possibility of adverse events; as a naturally pre-existing factor and that can be identified by calculating and scientific measurements. From this concept arises the related term “risk factor” that can be defined as an attribute of a group that has the highest incidence of a given disorder in comparison with other population groups or lower dosage of such feature17 , 18 .

These notions, central to modern epidemiology, tend to objectify the existence of the risk phenomenon, understanding that it can be measured independently of social and cultural processes, but that these processes are responsible for the interpretation - often distorted and skewed - of scientific findings. It derives from this understanding of issues that the scholars linked to this approach prioritize in their investigations, which are: What are the risks? How should we manage them? How do people respond cognitively to them? “Counter-hegemonic” epistemological positions, such as the “social constructionist” approachd , question elements that are central to the “Realist” approach. They consider, for example, as one of the central weaknesses of the latter the naturalization of what is asserted as risk, when they consider that the concept, like any other phenomenon, represents disputed values, not being something static and objective, but constantly produced and negotiated as part of a network of social interactions and the construction of meanings16 .

Within the “social constructionist” approaches, we find the “governmental” perspective that values, as well as the perspectives of “Risk Society” and “Cultural/Symbolic”, sociocultural aspects of risk. It is distinguished, however, from the latter by the negation of an a priori existence of the risk phenomenon.

For the “governmental” perspective, nothing constitutes a risk in itself, since what we understand as a risk (a threat, a danger) is a contingent product of “ways of looking”2 . “Ways of looking” which are present in discourses that, rather than representing an objective reality, make up the notion of what is claimed as risk. Such a perspective prioritizes investigations that focus not on the risks themselves, but on the ways in which they are fabricated by discourses and practices. And, not least, they seek to understand how the phenomena of risk operate the construction of subjectivity and social life.

The “governmental” theorists understand that the concept of risk, when seeking to order reality and make it calculable, plays a fundamental role in shaping government strategies, technologies and practices. More than an event, it considers that risk and its strategies are important components of a “rationality of calculation” that are now a fundamental element in the governance of conduct2 . Risk refers, rather than to the notion of danger, to chance, threat, probability, eventuality on the one hand, and loss or damage on the other.

Besides being a phenomenon subject to permanent manufacture, risk translates and gives concreteness to moral and political technologies that dispute and give meaning to life in society. Discourses on risk and their prevention regulate the lives of individuals indicating how they should move in and out of the bodies and how they should relate to others and things. They also mention time management and seek to induce, in us, a disciplinarization and regulation of a future that awaits us18 .

When we define risk as a present form of describing the future, life and its possibilities are limited. Under the assumption that one can decide which future is desirable, the contradictions of the present and the present are equated, and point to a single path of risk and the becoming: a rationality guided by the utilitarian logic of profit and loss19 .

On the other hand, it is important to point out that increasingly risk has been an important vector of the set of practices and technologies of the self, in the production of our identity and subjectivity. In the name of a healthy “normality”, we are increasingly compelled, and we also induce ourselves to have an active attitude and self-regulate with the intention of minimizing and preventing risks. Thus, behavior that seeks to avoid risk is seen as a moral duty that mentions self-control, self-knowledge, and self-improvement. It is a form of self-government that involves the acceptance and internalization of institutional and moral goals and which demands eternal vigilance over ourselves.

A process that, in coherence with what has already been said, leads us - “responsible and free citizens” - to assume our status as “self-entrepreneurs” seeking to maximize the human capital that constitutes us in the name of health and happiness1 , 11 , 13 . It is a transformation of the sense of citizenship that, each time, ceases to be social to become an economic citizenship, anchoring itself progressively in the capacity of individual production and which reinforces the idea that we are all entrepreneurs of ourselves1 , 11 . As Ewald13 and Dean1 argue, the increasing processes of privatization and risk individualization are today a central indicator of the shrinkage of management techniques associated with the welfare state and the emergence of new forms of neoliberal governance. An individualization that

the very notion of social rights and is linked to a form of governing that seeks to govern not through society but through the responsible and prudential choices and actions of individuals on behalf of themselves and those for whom they feel an emotional bond or affinity. Social citizenship makes way for an economic citizenship1 . (p. 133-4)

It is important, finally, to mention that the rationalities provided by the notion of risk have been proposed to identify social groups at risk or of “high risk”. These include those who stand at the edge of society3 , 20 , 21 , and are fabricated as the abnormal, the unreasonable, the undesirable, the “junkies”, the out-of-order, the marginal. A fabrication that is due to the fact that today those who do not have a behavior that prevents risk is considered socially as a failure, a person unable to take care of himself, an “abnormal of desire”22 .

Abnormal that are branded as such when imagined - and produced! - as “high risk” individuals, irrational people who deviate from norms and put at risk the healthy society. A kind of “stray sheep” that demands control and, where necessary, disciplinary and repressive actions that protect the society from the threats and violence of the government and its different experts/pastors (health professionals, sanitarians, pedagogues, managers, etc.) and from the anxiety caused by such groups10 .

In what follows, we will reflect on the presence of the concept and strategy of risk together with important discursive practices of health in the contemporary.

(New) Public Health, risk and the government of conduct

Throughout history, Public Health was constituted having as reference different formulations and strategies of intervention. The model of the quarantine that aims to isolate the sick, illnesses and risks in certain spaces. The model of Sanitary Science that seeks to monitor and give way to substances (air, water, feces, urine, etc.) across the boundaries between bodies and non-corporeal spaces. The Personal Hygiene Model in which hygiene, cleanliness and healthy behaviors of individuals are stimulated in relation to interaction with themselves and with other individuals23 . In recent decades, a (New) Public Health (NPH), without abandoning these previous models, has also prioritized the confrontation of situations of risk through the surveillance of individuals and groups under external and internal “threats”, seeking to intervene on the “lifestyle” of people and collectives13 .

In this NPH, there is a considerable expansion of interventions on individuals, collectives and the environment. In the name of absolute eradication of risks, the environment is scrutinized in its physical, psychic and social dimensions, multiplying the objects to be measured, monitored and regulated. In this framework, the medical, scientific, epidemiological and social knowledge is routinely employed as the “truth” to build “public health problems” and to find their solutions3 . NPH technicians are responsible for describing and mapping social life in the form of reports, statistics, graphs and other techniques, with the objective of circumscribing the real and facilitating the society management and government.

In this way, both the patient and the healthy individual are encompassed in a network of observation, in which experts play a central role in developing the quantitative and qualitative norms of classification and production of varied identities. Petersen3 draws attention to the occurrence in this process of some kind of dissolution of the boundaries between healthy and unhealthy, since all things become potential sources of risk and everything can be seen as “at risk.”

The “risk” here is that, through the elaboration of rules on healthy living, these knowledges and their experts can reinforce subtle forms of social surveillance and regulation through strategies based on abstract risk calculations, which aim to anticipate and prevent the emergence of deviant and abnormal behaviors described as diseases and health problems.

Surveillance Medicine, risks and the government of conduct

As in Public Health, medical practice has undergone important changes in which the concept and strategy of risk has been an influential vector of its transformations.

Authors such as Armstrong4 , 23 - 25 reflect on this process by describing a new discursive practice that he calls Surveillance Medicine (SM). Relating the transformations in the field of medicine that stress and reconfigure the hegemonic pathological medical model, the author observes and analyzes new discursive practices on medicine with specially after the middle of the 20thcentury.

Responding initially to the problem of how to manage new “social” diseases such as tuberculosis, sexually transmitted diseases and childhood infections, medicine will progressively take the population as its central object of intervention. It begins to pay more attention to interactions between people in the community, “this multifaceted population space encompasses the physical gap between bodies that needs constant monitoring to guard against transmission of contagious diseases”4 (p. 401). This new medicine will increasingly have as its focus the surveillance of the population and individuals, broaden its gaze to non-contagious diseases and perform a fundamental remapping of the disease spaces and problematizing of the question of normality.

In this process, there is a reconfiguration of the three-dimensional relationships between symptom, sign and lesion that characterize hospital scientific medicine through a conceptual twist, in which the disease is considered only “a nodal point in a continuous network of health status monitoring.”4 (p. 401). In the hegemonic medical model, the pathology was unveiled by physical lesion. In Surveillance Medicine and under the discursive logic of risk factors, the disease affirms itself as a “perpetual becoming”. For example, when

a person eats junk food; this increases the risk that their lipid profile will be altered; this increases the risk that they will develop angina; this increases the risk that they will have a myocardial infarction; this increases the risk that they will die; this increases the risk that their child might carry a cardiovascular gene; this increases the risk that the child, especially if they eat junk food, follow a similar trajectory24 . (p. 504-5)

In this context, new medical technologies, such as qualitative and quantitative inquiries, are invented to inspect the “normal” population, seeking to identify the “risk factors” that represents internal and external threatens to the human body. The disease ceases to be essentially a static phenomenon which can be found at a specific point in the human body. Everyone becomes potentially sick and no one is truly healthy.

In this world permeated by a multitude of risk factors manifested in the multiple dimensions of the life of each one of society and the environment in which we live, medicine as Public Health seeks to reinvent itself, expanding its surveillance role, seeking to encompass in their field of interest, diagnosis and intervention the “healthy” and “normal” individuals and populations. Here, it is no longer just the body that is examined, but the whole life of the patient who is constantly at risk of visible and invisible dangers.

A reinvention that manifests itself, among others, by the tracking of risk factors, which makes it possible to identify incipient diseases in people as yet undiagnosed; by offering to “normal” populations of health promotion actions and stimulating changes in lifestyles that lead to healthy behaviors; and by surveying risk profiles of patients when they access health services. Surveillance is broadening the field of intervention of medicine at a time when it seeks to identify the precursors of future diseases, directing their actions to extracorporeal spaces that are often represented by the notion of “lifestyle”25 , 26 .

In this process, it is interesting to note the occurrence of important changes in conduction of the conduct and production of subjectivity by SM. Contrary to what happens in the anatomo-pathological clinic, where the passivity of the “patient” is stimulated and produced by the disciplinary practices, SM is faced with the challenge of intervening on the multiplicity of risks that inhabit the social body and individuals. It seeks, more than an external intervention, to produce in the individuals an active posture in relation to the factors, internal and external, that threaten their health.

In the name of health and happiness, self-government, self-vigilance and constant self-control are encouraged to face the risks that exist in the “interior” of individuals, through practices and techniques such as safe sex, healthy eating, risk factors and abstinence or moderation in smoking and cigarettes, alcohol and other drugs3 .

And, as we have already argued in this work, this machinery of surveillance produces a “self at risk” that is reflected and is often reflected in a neoliberal and individualistic ethos and stimulates the formation of a legion of “entrepreneurs of themselves”11 .

Final considerations

We have sought in this work to describe and reflect on the ways that the concept of risk has been operating in the field of health in the contemporary from a sociocultural approach and from a governmental perspective and dialoguing with the discursive practices of New Public Health and Medicine of Surveillance. Based on the understanding that there is no risk in itself, we were interested in examining this phenomenon from a critical analysis of the discourses and practices that have been producing it.

We argue that the definition and prioritization of risks by “experts” are not neutral and objective as it is usually described in the technical-scientific literature, but rather constructed through implicit social and cultural processes with ethical, political and social consequences that demand our attention. Risk is not something that exists beforehand in reality but constitutes a set of different ways of ordering and transforming it into something calculable and of representing events in a way that they can be governed by means of techniques and specific objectives1 . It is nowadays a component of several forms of rationality of calculation that seek to govern the conduct of individuals, collectives and populations2 . Rationalities, discourses and strategies that, in last instance, give concreteness to the risk, that select certain phenomena as “risk” and that aims to intervene and govern on the social and the conducts.

Understanding that its importance does not lie in the risk itself, but in the things (and the people) to which the risk attaches, we have tried in this paper to discuss the links between risk and health with “neoliberal governmentality” and in this process, with its rationalities, technologies and practices1 , 13 , 14 .

In this sense, we find that different technologies on health risk often contribute to and are influenced by the implementation of neoliberal governance practices. They have played a very important role in the induction and formatting of what we think we are15 . This occurs, for example, when, in the name of a healthy life, we are guided by risk-prevention guidelines and strategies that increasingly demand our active vigilance over ourselves and others in an incessant search of the “human capital” that constitutes us. By similar paths, every facet of life is virtually affected by government policies that seek to facilitate healthy choices and make choices that presumably harm individual and collective health more difficult. In this way, technologies that seek to intervene on the phenomenon of risk can contribute to the regulation of the bio-social body and to the strengthening of a neoliberal hegemony20 . Under the influence of these strategies, consciously or unconsciously, we are increasingly assuming a neoliberal ethos that encourages us all to fully exercise our individual freedom and to become “entrepreneurs of ourselves”2 , 11 , 27 .

A modus operandi that undermines the sense of citizenship1 , 18 and has been reinforced by the increasing processes of “risk privatization” that reconfigures the way in which Social Welfare Societies used to do risk management through social and solidarity insurance and places the very notion of social rights. A risk management that has as its base of support no more social insurance and solidarity, but self-management of risks by individuals.

It is important to point out that this process of conducting conducts is faced with resistance, counter-conducts and care practices guided by an ethic of care of the self. A movement that perhaps can be described as a sort of revolt against those who want to govern us and normalize our lives, seeking to lead us in another way, composing and interacting with certain “conductors” and not others, with other purposes and forms and that seeks to be realized through procedures, methods and techniques that put the status quo in question10 . Foucault invites us in his writings regarding e next to power12 , there will always be the insubmission of freedom and Deleuze reminds us the possibility of inventing lines of escape to what is revealed as intolerable. These considerations seem to focus on the importance that we increasingly aim to broaden our research by trying to understand how people in situations of risk have, in different situations, answered to the technologies informed by this rationality of calculation. Therefore, we try to reflect on how the discourses and strategies of risk operate and are perceived and how those who are the target of their technologies and practices have been resisting.

We conclude our reflection affirming that although the rationalities and technologies around the risk can serve for societal projects and of health production that interdict the power of the living, they also have historically been together with arrangements and social inventions that have an important role in the defense and affirmation of the life in the maximum boundaries of possible.

As we seek to demonstrate in this article, these findings support the need for constant and meticulous critical work when confronted with discourses and practices around the so-called “risk” phenomenon. A critique in which we should exercise the right to question the truth about risk and its effects of power and to question power over its discourses of truth. To make of the critique, as Foucault invites us, an “art of voluntary inservitude”, of thoughtful indocility that unveils the moral and political technologies that the phenomenon of risk entails and produces a life that is in fact worthy to be lived.

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dLupton emphasizes among the main aspects of Constructionist approaches the following prospects: a) Risk Society, which has in Antony Giddens and Ulrich Beck its main exponents; b) Culture / Symbolism, which highlights the work of the anthropologist Mary Douglas and, for last; c) the governmental/post structuralist perspective influenced, among others, by the work of Michel Foucault.

Received: April 03, 2019; Accepted: May 16, 2019

Translator: Henrique Sater de Andrade

Authors’ contributions

All authors participated in all stages of preparation of the manuscript.

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