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7 ‘Empowerment’ Through Health Apps

7 ‘Empowerment’ Through Health Apps

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From the mid-2000s, Web 2.0 applications, or the social web, started to take off.

It brought with it a wide variety of new possibilities. Patients can watch videos on

YouTube about their upcoming surgical procedures. They can rate their healthcare

providers on such sites as Patient Opinion. They can exchange experiences with

others, sign up for drug trials, and contribute to medical research on social media

sites such as PatientsLikeMe. They can track disease outbreaks, and contribute to

digital epidemiology on sites such as HealthMap. Mobile assistive apps such as

Voice Maps allow people with visual impairments to navigate using their smartphone. People can create personalized exercise programmes with apps like FitBit.

Self-tracking apps such as Easy Calorie Counter and DiabetesPal enable users to

track biometrics such as blood glucose, or health behaviors such as how much food

energy they ingest. Pedometers and other movement sensors can track exercise.

Digital games such as ZombiesRun! combine health promotion with pleasure. Data

generated by these apps can be uploaded to social media, and thus shared with

friends, healthcare providers and family (Adams 2010; Lupton 2013, 2014a;

Hakobyan, et al. 2013).

Along with these new possibilities, new concerns are arising. What, for example,

becomes of the data which is generated? Data from self tracking and social media

apps is generally uploaded to the app developers’ cloud, where it can be on sold to

medical researchers, government agencies and commercial interests. Privacy protections for this sometimes very personal data are underdeveloped. In some cases,

this data is used by employers and insurance companies as part of their wellness

programmes, where employees or clients can be penalized for not meeting exercise,

sleep or food targets (Lupton 2013, 2015). In another case, an app developer accidentally posted information about users’ sexual behavior on the internet (Lupton

2015). At the micro level, ‘small data’ relating to the details of a users’ bodily functions, health behaviors or health opinions, can act to change experiences of embodiment. As numerical measures replace the users’ own subjective assessments of their

well-being, a quantified and externalised form of embodiment may result (Lupton

2014b, 2015). These ‘self tracking cultures’, like somatic individuality, constitute a

new way of being in the world and new forms of embodiment.

Issues relating to privacy and boundaries also arise. In one health promotion

project, an integrated multi-channel approach to social media was used. While this

HIV clinic had an official page on Facebook which was rarely updated and noninteractive, the clinic unofficially used Instagram and Google+ to load risqué pictures of ‘hot’ young men, alongside safe sex information, in an effort to attract the

impoverished young men who have sex with men who were its marginalised clientele. Facebook and Twitter messaging was used to contact clients, or to keep tabs on

their whereabouts, and the gay dating site, Grindr, was unofficially used to inform

men that the mobile HIV testing van was coming to their locality, to contact clients,

and to distribute safe sex information (Ems and Gonzales 2015). While these strategies were very effective, they also overstepped traditional boundaries regarding the

limits of healthcare providers’ activities. Web 2.0 thus is accompanied by new ways

of organizing health promotion, medical surveillance and the biopolitics of population health.



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Health promoters have embraced these new technologies as a way of collecting

data on health behaviors, providing tailored reminders and interventions in an effort

to change behaviors, and creating interventions which are individualized and arrive

as the health behavior is unfolding in real time (Lupton 2013, 2014c; Mays et al.

2010). In a proof of concept study, mobile devices were used to collect real-time

self-assessments of college students’ drinking behavior; the students enjoyed participating; this showed it to be possible to collect such real-time data allowing the

future design of an intervention that depended on such data (Mays et al. 2010).

However, these apps rarely look at the social determinants of health, such as

poverty, inequality and pollution. Instead, they focus on health behaviors and biometrics at an individual level. They thus work against what is known about the

importance of the social determinants of health, even while they arguably increase

agency and self-efficacy, which are also determinants of health (Lupton 2013,

2014c). In relation to mobile health apps, we can see that understandings of health,

illness and well-being are socially produced and sustained, and the technologies

used to mediate these understandings play an important role in these conceptual

processes.



14.8



Conclusion



In this chapter we have explored the co-constitution of health technologies and new

socialities through multiple examples. We have seen how genetic testing is being

constituted alongside somatic individuality, a way of experiencing life through

forms of embodied risk which can be calculated and managed. Such forms of

somatic individuality are, arguably, intensified in the self-tracking cultures which

are being created in relation to mobile health apps. New forms of sociality are also

evident in the transnational reproductive chains that are being created as oocytes are

traded across borders, and as couples travel long distances to employ gestational

surrogates to carry a baby. In all of these instances, the intensely social nature of

technologies such as MRI, surrogacy and predictive genetic testing come to be naturalized; they come to be seen as neutral applications of scientific discovery.

Health and medical technologies range from the simple, such as stethoscopes, to

the embodied such as organ donation, and the cutting edge, such as nanotechnology.

The technological imperative is said to be one of the characteristics of biomedicine;

it involves a tendency to rely on high tech and cutting edge treatments rather than

more simple, community based and preventative, interventions. However, health

technologies do not have to be gleaming and high tech. Acupuncture, massage and

yoga are all health technologies as understood through Everts’ definition of technology provided at the start of this chapter. Regardless of their antiquity or modernity,

health technologies are what they are because of their social and cultural components. They do not just have effects on the social world. They are constituted socially

and culturally; they are shot through with social, political and cultural worlds.



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Chapter 15



Promoting Public Health



Abstract Public health touches everyone’s lives. This chapter discusses important

social and political dimensions of public health. It begins by exploring the founding

myths of public health, identifying the underlying values and tensions of these

myths, in particular regarding the relationship between public health and the state.

The relationship between the state, international bodies and citizens is expanded

upon through an examination of how public health relates to different cultures. The

role of citizens is analyzed through the concepts of popular epidemiology and

empowerment. A case study of tobacco control is outlined to illustrate public health

processes and activities. The chapter concludes by reflecting on the uses of public

health, in tempering commercial companies and the state itself, while also highlighting the need for citizens to remain alert to the potentially disempowering tendencies of public health.

Keywords Public health • Medical police • Biopower • Governmentality • Social

determinants of health • Racial hygiene • Popular epidemiology • Health promotion

• Normalization • Tobacco control



15.1



Introduction



Public health touches everyone’s lives – from birth to death. The standards set for

the food we eat, the fluoridation in the water we drink, the immunizations given to

our children, the screening at schools for glue ear – these are all public health measures, and there are very many more. Public health has been defined as “the science

and art of preventing disease, prolonging life and promoting health through the

organized efforts of society” (cited in Orme et al. 2007: 13). It can be divided into a

number of phases with different orientations to the objectives of public health and

its underpinning values. The sanitation movement in the nineteenth century had a

particular focus on infectious diseases. It concerned itself with issues of water quality, sewerage disposal, food quality, and the use of vaccinations. In the mid-twentieth

century, risk factor epidemiology developed which was oriented to chronic disease

such as respiratory and cardiac conditions with a downstream focus on lifestyle factors. In the latter part of the twentieth century the sub-discipline of social

© Springer International Publishing Switzerland 2016

K. Dew et al., Social, Political and Cultural Dimensions of Health,

DOI 10.1007/978-3-319-31508-9_15



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epidemiology came into its own with its emphasis on the social determinants of

disease – looking upstream at issues of housing, employment and social organization more generally. The World Health Organization’s Ottawa Charter for Health of

1986 illustrates the latter approach, where the prerequisites of health include social

justice and equity, sustainable resources, education, income and peace.

As public health initiatives involve collective action or treatments that affect the

population it is a thoroughly social and political enterprise. Many issues in public

health lead to disputes. Internationally there are regular debates about the benefits

and harms of water fluoridation, the causes of cot death and the efficacy and value

of mass screening programmes for such diseases as cervical and prostate cancer.

The stance people take on these issues may relate to many factors, such as whether

commercial or vested interests are involved, faith in experts and science, or the

political acceptability of a particular initiative. Views on how individual rights

should be balanced against the public good are central to public health debates.

This chapter discusses important social and political dimensions of public health.

The founding myths of public health are outlined, identifying its underlying values

and tensions. An ambivalent relationship between public health and the state is

noted – with public health being used to promote state interests in some contexts,

and contesting the state in others. The relationship between the state, international

bodies and citizens is expanded upon through an examination of how public health

relates to different cultures and its place in contemporary culture. The role of citizens in public health issues is explored through the concept of popular epidemiology and the use of empowerment in health promotion. The chapter concludes with

a case study of tobacco control to illustrate public health processes and activities.

Through understanding these dimensions of public health we can see the ways in

which it benefits citizens by tempering the activities of a range of other institutions,

such as commercial companies and the state itself. But in turn, citizens need to

remain alert to the disempowering tendencies of public health.



15.2



Public Health Foundations



Like most disciplines, public health has founding myths that practitioners are likely

to encounter early in any training. One such prominent myth is that of John Snow

and the Broad Street pump. The main elements of this story are that in 1854 Dr John

Snow hypothesized that a cholera outbreak in London was caused by drinking water

contaminated by sewerage. To prove his theory he removed the handle of the Broad

Street pump where the contaminated water was coming from, and so the epidemic

disappeared (Brody et al. 2000). The power of this story for public health lies in a

number of factors. John Snow believed that cholera was caused by some organism

in contaminated water, a theory that we now accept but was hotly contested at the

time. Miasmic theories of disease causation were popular in the nineteenth century.

It was believed that foul odours, bad air, or a noxious atmospheric influence could

be the source of a miasma and cause disease. Snow demonstrated that this theory



15.2



Public Health Foundations



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was incorrect, indicating the progressive nature of public health. In addition, Snow

is seen as being a founder of epidemiology, the study of patterns of disease. The

story goes that he drew a map to show where those who died from cholera lived, and

from this map arrived at his theory. Although it has been claimed that he drew the

map to support his theory (Brody et al. 2000), the story suggests that public health

and epidemiology are not driven by theories, but by observation. Another important

element of this story is that it shows that public health is about action. John Snow

did something about the disease by taking away the handle so people could no longer pump water. To paraphrase a famous saying by Karl Marx, public health is not

only about understanding the world, but changing it. This is despite the fact that the

disease had already abated before this action was taken and most officials of the

borough at the time were both reluctant to remove the handle and, after its removal,

were still wedded to miasmatic theory (Lock and Nguyen 2010).

Logical argument, empirical observation and action are then seen as the heart of

public health. In the foundation story of John Snow these can be opposed to superstition, tradition, ideology and mere description or analysis of the world. The discussion that follows indicates how such separations are not easy to attain, and that

even though this founding myth suggests the apparent ease by which logic can triumph over superstition, contemporary views of public health as solely an apolitical

scientific pursuit are hard to sustain.

Public health practitioners can also draw on a different foundation story. The

story of Rudolf Virchow took place at a similar time to that of John Snow. Virchow

studied a typhus epidemic in Prussia by living with the miners and their families in

the areas afflicted by the epidemic. He noted that these families were affected by

many other diseases, and that the reason for this lay in their social condition. These

families suffered from poor housing, poor working conditions and a poor diet. The

solution to this situation was not a technical one like ensuring a clean water supply,

but required a transformation in the way society was organized. It required better

wages, education, food production and progressive tax reform (Green and Labonté

2008). Virchow’s report was very poorly received by the Prussian authorities who

were dismayed at its revolutionary implications (Weisenberg 2009). This foundational myth provides a source of inspiration for public health practitioners advocating for state action to improve social and material conditions.

Another foundation story of public health is that measures such as vaccinations

have accounted for the dramatic decline in mortality rates from infectious diseases

in the Western world. In the late nineteenth and early twentieth centuries some diseases, such as measles, scarlet fever, diphtheria, whooping cough and tuberculosis

caused many deaths in the Western world, but there was an impressive drop in mortality from these. The fall in death rates from infectious diseases can be seen as an

outstanding success in public health. However, the role that medical intervention

played in this decline has been contested, most famously by Thomas McKeown, a

physician and historian, in his book The Role of Medicine published in 1979.

McKeown argued that improved diet and a rising standard of living were responsible for enhancing resistance to infectious diseases and so lowered the death rates.

The only real exceptions here, McKeown argued, are vaccinations for smallpox and



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sanitary improvements reducing the impact of diseases such as cholera and typhoid

(Hardy 2001). What accounted for the decline in other diseases, such as scarlet fever

(for which there was no available vaccine) and diphtheria is not absolutely clear, but

besides changes in sanitation and sewerage measures, nutritional changes, social

changes such as education and public housing, improvements in the health of children and changes in the virulence of the disease have all been suggested. Although

parts of McKeown’s theses have been contested the view that “curative medical

measures played little role in mortality decline prior to the mid-20th century” has

been accepted by demographers and historians as correct (Colgrove 2002: 728).

Public health, then, has foundation myths that are important elements in the

moral authority that public health exercises in contemporary society. The myths

may reflect aspects of the world, but have a symbolic or representative value that

support the central place that public health plays in our lives. They position public

health as an amalgamation of reason and action, and provide public health with different intervention points, from altering the immune systems of individuals through

vaccinations, to changing local environmental conditions, to national and international transformations.



15.3



Health, the State and the Market



Public health is by necessity related to national politics and policies. In German

states in the eighteenth century national policies and public health became closely

entwined in the development of the medical police (Rosen 1993). The medical

police were state bureaucrats whose goal was to regulate all aspects of life to promote the nation’s health. Appropriate diet, clothing, sanitation and recreation were

prescribed in detail to produce a population of healthy individuals. Advocates of

medical policing lobbied for bachelor taxes to encourage marriage, for legislation to

enforce periods of rest for new mothers and to place mothering and education of

children under police supervision. This concern of the state with the health of the

population so that the state itself is empowered is a recurrent issue in public health.

We see it in the aims of early public health measures in many countries to improve

the dominant racial group to strengthen the nation. The concept of medical police

openly acknowledges the social control aspect of public health. In order to bring

about communal changes in health, individual freedoms may have to be limited, and

non-conformists may need punishment, potentially bringing the concerns of a wellintentioned state and concerns about individual rights and freedoms into conflict

(Feingold 1998). The interlinking of state interests and the physiological functioning of the population has been termed by Foucault biopower, a concept we will

return to. Biopower is a manifestation of a form of governmentality, or a technique

of rule, which involves self surveillance as a form of social control, linking our

personal responses to health concerns to state aspirations for a healthy and productive population (Rose and Miller 1992).



15.3



Health, the State and the Market



219



Britain undertook early developments in public health being driven by concerns

over the economic impact of disease. Prior to the Public Health Act of England and

Wales in 1848 governments had responded to public health issues by using decrees,

where in response to epidemic diseases, beds could be burnt, houses fumigated and

towns whitewashed. But many families in nineteenth century Britain became reliant

upon state relief measures after the male breadwinner died from acute infectious

disease. Inadequate sewerage systems and water supplies were identified as possible

causes for this state of affairs and therefore legislation was developed to deal with

the problem (Hamlin and Sheard 1998). The economic impacts of disease became

an impetus for state interventions in the urban infrastructure and the living conditions of the poor.

At an international level the social approach to public health was apparent in the

founding documents of the World Health Organization (Borowy 2008). A watershed in public health activities at an international level was the Alma Ata conference on Primary Health Care in 1978. At the conference WHO’s very broad

definition of health was adopted (1985), with health conceived of as being a state of

physical, mental and social well-being, not just the absence of disease and disability. The principles of equity underlying Alma Ata, with a focus on the social determinants of health including education, housing and food provision, were thought to

be a mechanism to “reduce the scope of politics” (Gross Solomon et al. 2008: 2). In

other words, international public health efforts were situated as buffering nationstates against the vagaries of national politics.

Public health has also engaged with concerns about the possible exacerbation of

inequalities as a result of the expansion of global markets. Currency speculators

have been pointed to as a major threat to global public health (McClean 2007). The

establishment of the World Trade Organization in 1995 put in place agreements that

favoured the transnational corporations of richer nations (Labonté and Torgerson

2008). Its focus on removing barriers to trade and expanding private markets is seen

as a threat to state efforts, if they exist, to combat health inequalities (McClean

2007). One goal of trade liberalization is to expand private provision of services and

open these services to foreign ownership – and these services include education and

health (McClean 2007). Due to its broad definition of health and wellbeing, WHO

potentially stands in opposition to international moves that have the potential to

exacerbate inequalities.

It is clear then that public health has an ambivalent relationship with the state. As

a technique of governmentality public health activities can foster state objectives to

discipline and control the population, but they can also act to limit health-deleterious

activities of the state, particularly where the state fosters unregulated markets and

social inequalities.



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Promoting Public Health



The Culture of Public Health



Public health relates to issues of culture in a variety of ways. Public health interventions can be investigated for the ways in which they suppress particular cultures and

their values, or use culture as a means of leveraging change. Public health itself, in

its many forms, plays an important role in contemporary culture, both in terms of

symbolic representations and the rituals and activities that it fosters.

An example of the suppression of different cultures, ethnic groups and others in

the name of a nation’s health, is the racial hygiene policies of eugenicists, most

notoriously seen in Nazi Germany. Nazi Germany’s racial cleansing sat alongside

public health measures that valorised physical beauty and fitness, and also initiated

anti-smoking campaigns and cancer screening (Smith 2007). But public health measures have at times promoted the health of indigenous peoples and supported cultural revival. Public health interventions in rural areas of Europe and the Americas

in the early twentieth century supported indigenous development (Murard 2008).

Disease prevention was to occur through the targeting of “downtrodden villagers”

(Murard 2008: 142). Public health initiatives in Yugoslavia in the 1920s supported

“imaginative nationalisms” amongst villagers which, besides the establishment of

health cooperatives, included cultural cooperatives that reinvented traditions and

reanimated music societies (Murard 2008: 148). Cultural revivals could go hand in

hand with calls for major social transformations. A member of the League of

Nations Health Committee (a forerunner of the World Health Organization) in the

interwar years argued that “radical changes of an economic and social order were

necessary” to improve the health of rural populations (Zylberman 2008: 277).

Public health community-oriented programmes were taken up and applied in India

and elsewhere and social historians have argued that this community development

orientation in public health “nurtured the Third World aspirations that had become

moulded into an ideological hunger for nationhood” (Murard 2008: 154).

Within nation-states public health activities could challenge prevailing professional cultures and expertise. John Grant, a member of the International Health

Board of the Rockefeller Foundation, used training methods for health workers in

China that served as a model for the barefoot doctor. One of Grant’s public health

concerns was to keep high technology medicine at bay. This position was taken up

in radical form in North China leading to the development of the training of village

aides in 10 days to replace expensive physicians (Murard 2008). China introduced

a barefoot doctor system in 1958, which was a system of rural health workers who

undertook a range of activities, including anti-epidemic work (see also Chap. 6).

The training of barefoot doctors took substantially less time than the training of

conventional doctors and could be part-time and on-the-job (Koplan et al. 1985).

In contemporary times public health activities and discourses are also a source of

social solidarity. Public health can be viewed as a social practice that generates

moral forces that help to sustain social order (Dew 2012). Public health practitioners can be concerned with empowerment and social justice, with resisting the

impacts of rampant capitalism (advocating against the tobacco, alcohol and fast-food



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7 ‘Empowerment’ Through Health Apps

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