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A postmodern public health?

A postmodern public health? disagreement among theorists about whether the postmodern perspective is ultimately conservative, a ‘culture of eclecticism which celebrates the status quo’, a nihilistic rejection of ethical principles and truth claims, or whether there is also the space for an affirmative and critical postmodern position that still draws on ethical principle^.^ Rather than deciding that the postmodern is discretely one or another approach, it is perhaps more useful to accept that there is a continuum of postmodern perspectives, ranging from the highly relativist and politically nihilistic (the ‘strong’ program that tends to be identified with European scholars) to a postmodern approach that embraces principled positions and recognises some universal moral values and truth claims (the ‘weak’ program, identified with Anglocentric scholarship).5,6 This latter approach tends to incorporate progressivist or oppositional stances, particularly in the context of feminist critiques and other social movements seeking emancipation and social equality, such as the gay, black and civil rights movements. A postmodern position, therefore, is not necessarily one that avoids any adherence to values such as democracy, equality and social justice. However, those who adopt it will probably be always cautious and sceptical about accepting values on their face terms and want to look closely to see who might be using them to further their own interests. As Nicholson has put it: __. is no reason why a postmodernist could not appeal, for there example, to the very same values of equality or liberty that a modernist might appeal to in defending his or her political stance. The difference is that while the modernist would believe such values to be grounded outside of human history, in the human condition or society as such, the postmodernist has given up on that belief.7 How might such approaches be seen to have been incorporated into public health? The most relativist of postmodern perspectives would simply decry the use of any kind of universalising approach to public health, calling into the question the notion of ‘health’ itself and seeking to destabilise the assumption in all public health endeavours that ‘health’ should be privileged over other aspects of life. This more extreme end of the postmodern spectrum of thought, however, is rarely found in analyses of public health. The meanings that are ascribed to ‘good health’ as a universal social good and individual right are rarely challenged, even by the most trenchant critics of public health practices. The clear challenges to features of the practice of biomedicine, an archetypal modernist institution, evident in many of the discourses of contemporary public health, including ‘the new public health’, may be described as evidence of a postmodern critique towards the progressive claims of modernity. Rosenau, for example, labels such strategies as community participation, the consumer health movement, ‘holistic’ health promotion and the adoption of alternative therapies as postmodern.’ Kelly and Charlton also see health promotion as a particularly postmodern activity, singling out its rejection of medical science as the primary basis for action: its VOL. AUSTRALIAN AND NDN ZEALAND JOURNAL O PUBLIC HEALTH 1998 F 22 NO. 1 EDITORIALS emphasis on a social model of health; its broad conception of health which incorporates aspects other than the purely biomedical; and its focus on empowerment and community action for health improvements, as its principal postmodern characteristics.2 On the other hand, however, it may be argued that the vast network of expertise and bureaucratic organisation that has developed around the problem of public health over the past two centuries remains firmly wedded to, and indeed, inextricably embedded in, the principles of modernist approaches to public health.8.gDominant features of public health, such as epidemiology and the emphasis on personal responsibility for health evident in health promotion and community participation remain underpinned by traditional modernist ideals and practices. Medical, scientific, epidemiological and social scientific knowledges are routinely employed as unchallengeable ‘truths’ to construct public health ‘problems’ and find solutions for dealing with them. The current obsession for identifjmg ‘goals’and ‘targets’ for health ‘outcomes’ (that can be specifically enumerated, measured and evaluated) is a highly modernist approach to managing public health. Health economics, currently a reigning sub-field in public health because of the promises it offers in rationalising health spending, is a quintessentially modernist enterprise. While some practices of medicine and public health may be currently challenged by community advocacy groups, this is not in itself a particularly postmodern feature. In the nineteenth century, for example, there was vociferous community critique of, and opposition to, efforts on the part of western governments to vaccinate children against smallpox.’ Nor do the new social movements, so trenchant in their opposition to some aspects of science and medicine, reject altogether the knowledges offered by modernist institutions. The environmental movement, for example, relies for its own truth claims upon the expert knowledges of sciences such as toxicology, meteorology, ecology and biology, while feminist and gay health activist groups both critique biomedicine as well as continually call for greater access for their constituents to the benefits offered by biomedicine. Further, although the rhetoric of the new public health champions community involvement, in most public health endeavours professional expertise remains privileged over lay expertise. This is highly evident in health educational advice to populations on how they should regulate their lives to achieve good health. The current Commonwealth Department of Health mass media campaign exhorting smokers to give up their habit, for example, using revolting images of internal organs clogged with gunk and harshly-lit faces of smokers making them appear like living corpses, is highly coercive in its use of shock and fear tactics. Such campaigns go well beyond simply ‘giving people the facts’ so as to encourage them to voluntarily change their behaviour, retaining the paternalism that was a dominant feature of nineteenth-century public health. They single out a specific social group (‘smokers’) as the stigmatised ‘other’, requiring surveillance and discipline on the part of public health authorities. There is little recognition in such campaigns that individuals may possess rationales for continuing to smoke that they value over any health improvements that giving up the habit might allow them. ‘Good health’, as it is defined by experts, continues to be privileged over these other rationales. The ‘needs’ or ‘wants’ of this particular ‘community’ are here discounted as irrelevant and ignorant, as barriers to public health goals. The notion of the ‘ideal citizen’ as taking active steps to avoid ill-health for both personal and the public good is dominant in such campaigns (and virtually all other public health strategies) to the exclusion of other notions of citizenship. So too, ideas about ‘the community’ and the ‘healthy city’ in the new public health are often universalistic, tending not to acknowledge the differences between social groups within units that are defined as ‘communities’ or ‘ ~ i t i e s ’ . ~ . ~ If it is understood that selfhood and social identity are fragmented, dynamic and contextually-based,as is argued in much of the postmodern literature, it is difficult to continue to argue that individuals share fixed concerns related to membership of defined social groups. A social category is never homogeneous and itself is characterised by differences of experience and access to resources. However many times statistics may be used to show patterns, these always cover up difference. Social groups are not discrete or mutually exclusive entities but overlap with each other, involving multiple membership. There are competing interests and needs within as well as between social groups that cannot necessarily be reconciled. Challenges to the central ideals and tenets of public health are often met with scorn and hostility by those working within or researching the field. Postmodernist theory for some is regarded as impenetrable, irrelevant or useless, drawing attention away from the main issues and concerns in public health. Advocates of modernist principles may claim that to continue to scientifically measure health indicators, social disadvantage and access to health care; to rationally develop and use expert knowledge to advise populations about how best to prevent ill health; to calculate the most effective use of limited health care and preventive health resources, should all be regarded as important, if not the most important endeavours of public health. The trouble with such a position is that it ignores the important problems of such approaches identified by postmodern critics, some of which have been outlined above. Like it or not, public health at the end of the twentieth century is positioned inextricably within a context of uncertainty as is ‘the public’ with whom it concerns itself. In a social, economic and political context in which there has been a continuing undermining of modernist truths, a sense of growing disorder and an emerging distrust of social institutions and traditional authorities on the part of the public,’” an unexamined modernist approach to public health is no longer tenable. The ‘limits and limitations’ of public health need to be acknowledged. I VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 F NO. EDITORIALS am not championing a wholesale turn towards postmodern perspectives as the way forward for public health. Hrowever, some awareness of, and debate about, the postmodern critique as it relates to public health may go some way to formulating important questions (if not necessarily neat answers) about the future direction of the field. Deborah Lupton School o Social Sciences and Liberal Studies f Charles Sturt University, Bathurst http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

A postmodern public health?

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References (6)

Publisher
Wiley
Copyright
Copyright © 1998 Wiley Subscription Services, Inc., A Wiley Company
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1467-842X.1998.tb01134.x
Publisher site
See Article on Publisher Site

Abstract

disagreement among theorists about whether the postmodern perspective is ultimately conservative, a ‘culture of eclecticism which celebrates the status quo’, a nihilistic rejection of ethical principles and truth claims, or whether there is also the space for an affirmative and critical postmodern position that still draws on ethical principle^.^ Rather than deciding that the postmodern is discretely one or another approach, it is perhaps more useful to accept that there is a continuum of postmodern perspectives, ranging from the highly relativist and politically nihilistic (the ‘strong’ program that tends to be identified with European scholars) to a postmodern approach that embraces principled positions and recognises some universal moral values and truth claims (the ‘weak’ program, identified with Anglocentric scholarship).5,6 This latter approach tends to incorporate progressivist or oppositional stances, particularly in the context of feminist critiques and other social movements seeking emancipation and social equality, such as the gay, black and civil rights movements. A postmodern position, therefore, is not necessarily one that avoids any adherence to values such as democracy, equality and social justice. However, those who adopt it will probably be always cautious and sceptical about accepting values on their face terms and want to look closely to see who might be using them to further their own interests. As Nicholson has put it: __. is no reason why a postmodernist could not appeal, for there example, to the very same values of equality or liberty that a modernist might appeal to in defending his or her political stance. The difference is that while the modernist would believe such values to be grounded outside of human history, in the human condition or society as such, the postmodernist has given up on that belief.7 How might such approaches be seen to have been incorporated into public health? The most relativist of postmodern perspectives would simply decry the use of any kind of universalising approach to public health, calling into the question the notion of ‘health’ itself and seeking to destabilise the assumption in all public health endeavours that ‘health’ should be privileged over other aspects of life. This more extreme end of the postmodern spectrum of thought, however, is rarely found in analyses of public health. The meanings that are ascribed to ‘good health’ as a universal social good and individual right are rarely challenged, even by the most trenchant critics of public health practices. The clear challenges to features of the practice of biomedicine, an archetypal modernist institution, evident in many of the discourses of contemporary public health, including ‘the new public health’, may be described as evidence of a postmodern critique towards the progressive claims of modernity. Rosenau, for example, labels such strategies as community participation, the consumer health movement, ‘holistic’ health promotion and the adoption of alternative therapies as postmodern.’ Kelly and Charlton also see health promotion as a particularly postmodern activity, singling out its rejection of medical science as the primary basis for action: its VOL. AUSTRALIAN AND NDN ZEALAND JOURNAL O PUBLIC HEALTH 1998 F 22 NO. 1 EDITORIALS emphasis on a social model of health; its broad conception of health which incorporates aspects other than the purely biomedical; and its focus on empowerment and community action for health improvements, as its principal postmodern characteristics.2 On the other hand, however, it may be argued that the vast network of expertise and bureaucratic organisation that has developed around the problem of public health over the past two centuries remains firmly wedded to, and indeed, inextricably embedded in, the principles of modernist approaches to public health.8.gDominant features of public health, such as epidemiology and the emphasis on personal responsibility for health evident in health promotion and community participation remain underpinned by traditional modernist ideals and practices. Medical, scientific, epidemiological and social scientific knowledges are routinely employed as unchallengeable ‘truths’ to construct public health ‘problems’ and find solutions for dealing with them. The current obsession for identifjmg ‘goals’and ‘targets’ for health ‘outcomes’ (that can be specifically enumerated, measured and evaluated) is a highly modernist approach to managing public health. Health economics, currently a reigning sub-field in public health because of the promises it offers in rationalising health spending, is a quintessentially modernist enterprise. While some practices of medicine and public health may be currently challenged by community advocacy groups, this is not in itself a particularly postmodern feature. In the nineteenth century, for example, there was vociferous community critique of, and opposition to, efforts on the part of western governments to vaccinate children against smallpox.’ Nor do the new social movements, so trenchant in their opposition to some aspects of science and medicine, reject altogether the knowledges offered by modernist institutions. The environmental movement, for example, relies for its own truth claims upon the expert knowledges of sciences such as toxicology, meteorology, ecology and biology, while feminist and gay health activist groups both critique biomedicine as well as continually call for greater access for their constituents to the benefits offered by biomedicine. Further, although the rhetoric of the new public health champions community involvement, in most public health endeavours professional expertise remains privileged over lay expertise. This is highly evident in health educational advice to populations on how they should regulate their lives to achieve good health. The current Commonwealth Department of Health mass media campaign exhorting smokers to give up their habit, for example, using revolting images of internal organs clogged with gunk and harshly-lit faces of smokers making them appear like living corpses, is highly coercive in its use of shock and fear tactics. Such campaigns go well beyond simply ‘giving people the facts’ so as to encourage them to voluntarily change their behaviour, retaining the paternalism that was a dominant feature of nineteenth-century public health. They single out a specific social group (‘smokers’) as the stigmatised ‘other’, requiring surveillance and discipline on the part of public health authorities. There is little recognition in such campaigns that individuals may possess rationales for continuing to smoke that they value over any health improvements that giving up the habit might allow them. ‘Good health’, as it is defined by experts, continues to be privileged over these other rationales. The ‘needs’ or ‘wants’ of this particular ‘community’ are here discounted as irrelevant and ignorant, as barriers to public health goals. The notion of the ‘ideal citizen’ as taking active steps to avoid ill-health for both personal and the public good is dominant in such campaigns (and virtually all other public health strategies) to the exclusion of other notions of citizenship. So too, ideas about ‘the community’ and the ‘healthy city’ in the new public health are often universalistic, tending not to acknowledge the differences between social groups within units that are defined as ‘communities’ or ‘ ~ i t i e s ’ . ~ . ~ If it is understood that selfhood and social identity are fragmented, dynamic and contextually-based,as is argued in much of the postmodern literature, it is difficult to continue to argue that individuals share fixed concerns related to membership of defined social groups. A social category is never homogeneous and itself is characterised by differences of experience and access to resources. However many times statistics may be used to show patterns, these always cover up difference. Social groups are not discrete or mutually exclusive entities but overlap with each other, involving multiple membership. There are competing interests and needs within as well as between social groups that cannot necessarily be reconciled. Challenges to the central ideals and tenets of public health are often met with scorn and hostility by those working within or researching the field. Postmodernist theory for some is regarded as impenetrable, irrelevant or useless, drawing attention away from the main issues and concerns in public health. Advocates of modernist principles may claim that to continue to scientifically measure health indicators, social disadvantage and access to health care; to rationally develop and use expert knowledge to advise populations about how best to prevent ill health; to calculate the most effective use of limited health care and preventive health resources, should all be regarded as important, if not the most important endeavours of public health. The trouble with such a position is that it ignores the important problems of such approaches identified by postmodern critics, some of which have been outlined above. Like it or not, public health at the end of the twentieth century is positioned inextricably within a context of uncertainty as is ‘the public’ with whom it concerns itself. In a social, economic and political context in which there has been a continuing undermining of modernist truths, a sense of growing disorder and an emerging distrust of social institutions and traditional authorities on the part of the public,’” an unexamined modernist approach to public health is no longer tenable. The ‘limits and limitations’ of public health need to be acknowledged. I VOL. AUSTRALIAN AND NEW ZEALAND JOURNAL O PUBLIC HEALTH 1998 F NO. EDITORIALS am not championing a wholesale turn towards postmodern perspectives as the way forward for public health. Hrowever, some awareness of, and debate about, the postmodern critique as it relates to public health may go some way to formulating important questions (if not necessarily neat answers) about the future direction of the field. Deborah Lupton School o Social Sciences and Liberal Studies f Charles Sturt University, Bathurst

Journal

Australian and New Zealand Journal of Public HealthWiley

Published: Jan 1, 1998

There are no references for this article.