Tải bản đầy đủ - 0trang
7 ‘Empowerment’ Through Health Apps
Technology and Health
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.
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
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.
Technology and Health
Adams, S. (2010). Sourcing the crowd for health experiences: Letting the people speak or obliging
voice through choice? In R. Harris, N. Wathen, & S. Wyatt (Eds.), Configuring health consumers: Health work and the imperative of personal responsibility (pp. 178–193). Basingstoke:
Arribas-Ayllon, M., Sarangi, S., & Clarke, A. (2008). Managing self-responsibility through otheroriented blame: Family accounts of genetic testing. Social Science and Medicine, 66,
Beck-Gernsheim, E. (1991). The social implications of bioengineering (L. Mazzarins, Trans.).
Atlantic Highlands: Humanities Press.
Cooper, M., & Waldby, C. (2014). Clinical labor: Tissue donors and research subjects in the
global bioeconomy. Durham: Duke University Press.
Deomampo, D. (2013). Transnational surrogacy in India: Interrogating power and women’s
agency. Frontiers, 34(3), 167–188.
Duden, B., & Samerski, S. (2010). “Pop genes”: An investigation of “the gene” in popular parlance. In R. Burri & J. Dumit (Eds.), Biomedicine as culture: Instrumental practices, technoscientific knowledge, and new modes of life (pp. 167–189). New York: Routledge.
Einsiedel, E., & Geransar, R. (2009). Framing genetic risk: Trust and credibility markers in online
direct-to-consumer advertising for genetic testing. New Genetics and Society, 28(4), 339–362.
Ems, L., & Gonzales, A. (2015) Subculture-centered public health communication: A social media
strategy. New Media and Society. doi:10.1177/1461444815570294.
Everts, S. (1998). Gender & technology: Empowering women, engendering development. London:
Felt, U., & Müller, R. (2011). Tentative (id)entities: On technopolitical cultures and the experiencing of genetic testing. BioSocieties, 6(3), 342–363.
Franklin, S., & Roberts, C. (2006). Born and made: An ethnography of preimplantation genetic
diagnosis. Princeton: Princeton University Press.
Gibbon, S. (2009). Genomics as public health? Community genetics and the challenge of personalised medicine in Cuba. Anthropology & Medicine, 16(2), 131–146.
Gibbon, S. (2011). Family medicine, ‘la herencia’ and breast cancer; understanding the (dis)continuities of predictive genetics in Cuba. Social Science and Medicine, 72, 1784–1792.
Gibbon, S., Kampriani, E., & zur Nieden, A. (2010). BRCA patients in Cuba, Greece and Germany:
Comparative perspectives on public health, the state and the partial reproduction of ‘neoliberal’
subjects. BioSocieties, 5(4), 440–466.
Hakobyan, L., Lumsden, J., O’Sullivan, D., & Bartlett, H. (2013). Mobile assistive technologies
for the visually impaired. Survey of Ophthalmology, 58, 513–528.
Harrison, L. (2014). “I am the baby’s real mother”: Reproductive tourism, race, and the transnational construction of kinship. Women's Studies International Forum, 47, 145–156.
Joyce, K. (2005). Appealing images: Magnetic resonance imaging and the production of authoritative knowledge. Social Studies of Science, 35(3), 437–462.
Konrad, M. (2003). Predictive genetic testing and the making of the pre-symptomatic person:
Prognostic moralities amongst Huntington’s-affected families. Anthropology & Medicine,
Lander, J., & Van Hoyweghen, I. (2014). Streitkultur and the governance of genetic testing and
insurance in Germany. New Genetics and Society, 33(1), 42–59.
Lawton, J., Ahmad, N., Peel, E., & Hallowell, N. (2007). Contextualising accounts of illness:
Notions of responsibility and blame in white and South Asian respondents’ accounts of diabetes causation. Sociology of Health and Illness, 29(6), 891–906.
Lemke, T. (2010). Susceptible individuals and risky rights: Dimensions of genetic responsibility.
In R. Burri & J. Dumit (Eds.), Biomedicine as culture: Instrumental practices, technoscientific
knowledge, and new modes of life (pp. 151–165). New York: Routledge.
Leontini, R. (2006). Looking forward, looking back: The narrative of testing positive to
Huntington’s disease. Health Sociology Review, 15(2), 144–155.
Leontini, R. (2010). Genetic risk and reproductive decisions: Meta and counter narratives. Health
Risk and Society, 12(1), 7–20.
Leve, M. (2013). Reproductive bodies and bits: Exploring dilemmas of egg donation under neoliberalism. Studies in Gender and Sexuality, 14, 277–288.
Lewis, N., Treise, D., Hsu, S., Allen, W., & Kang, H. (2011). DTC genetic testing companies fail
transparency prescriptions. New Genetics and Society, 30(4), 291–307.
Lippman, A. (1992). Led (astray) by genetic maps: The cartography of the human genome and
health care. Social Science and Medicine, 35(12), 1469–1476.
Lipton, B. (2008). The biology of belief (Rev. ed.). Carlsbad: Hay House Inc.
Lock, M. (2013). The Alzheimer conundrum: Entanglements of dementia and aging. Princeton:
Princeton University Press.
Lock, M., & Nguyen, V. (2010). An anthropology of biomedicine. Malden: Wiley-Blackwell.
Lupton, D. (2013) Digitized health promotion: Personal responsibility for health in the web 2.0
era. Sydney: Sydney Health and Society Group Working Paper No. 5.
Lupton, D. (2014a). Critical perspectives on digital health technologies. Sociology Compass,
Lupton, D. (2014b) Self-tracking cultures: Towards a sociology of personal informatics. Sydney:
OzDHI’14: Proceedings of the 26th Australian computer-human interaction conference:
Designing futures, the future of design, December 2014.
Lupton, D. (2014c). Health promotion in the digital era: A critical commentary. Health Promotion
International, 30(1), 174–183.
Lupton, D. (2014d). The commodification of patient opinion: The digital patient experience economy in the age of big data. Sociology of Health and Illness, 36(6), 856–869.
Lupton, D. (2015). Quantified sex: A critical analysis of sexual and reproductive self-tracking
using apps. Culture Health and Sexuality, 17(4), 440–453.
Mays, D., Cremeens, J., Usdan, S., Martin, R., Arriola, K., & Bernhardt, J. (2010). The feasibility
of assessing alcohol use among college students using wireless mobile devices: Implications
for health education and behavioural research. Health Education Journal, 69(3), 311–320.
Mozersky, J. (2012). Who’s to blame? Accounts of genetic responsibility and blame among
Ashkenazi Jewish women at risk of BRCA breast cancer. Sociology of Health and Illness,
Nahman, M. (2008). Nodes of desire: Romanian egg sellers, ‘dignity’ and feminist alliances in
transnational ova exchanges. European Journal of Women’s Studies, 15(2), 65–82.
Novas, C., & Rose, N. (2000). Genetic risk and the birth of the somatic individual. Economy and
Society, 29(4), 485–513.
Pande, A. (2010). Commercial surrogacy in India: Manufacturing a perfect mother-worker. Signs:
Journal of Women in Culture and Society, 35(4), 969–992.
Payne, J. (2015). Reproduction in transition: Cross-border egg donation, biodesirability and new
reproductive subjectivities on the European fertility market. Gender, Place and Culture: A
Journal of Feminist Geography, 22(1), 107–122.
Pickersgill, M., Niewöhner, J., Mϋller, R., Martin, P., & Cunningham-Burley, S. (2013). Mapping
the molecular landscape: Social dimensions of epigenetics. New Genetics and Society, 32(4),
Prasad, A. (2007). The (amorphous) anatomy of an invention: The case of magnetic resonance
imaging (MRI). Social Studies of Science, 37(4), 533–560.
Rapp, R. (1999). Testing women, testing the fetus: The social impact of amniocentesis in America.
New York: Routledge.
Raspberry, K., & Skinner, D. (2011). Enacting genetic responsibility: Experiences of mothers who
carry the fragile X gene. Sociology of Health and Illness, 33(3), 420–433.
Rose, N. (2010). Genomic susceptibility as an emergent form of life? Genetic testing, identity, and
the remit of biomedicine. In R. Burri & J. Dumit (Eds.), Biomedicine as culture: Instrumental
Technology and Health
practices, technoscientific knowledge, and new modes of life (pp. 141–150). New York:
Rowley, E. (2007). On doing ‘being ordinary’: Women’s accounts of BRCA testing and maternal
responsibility. New Genetics and Society, 26(3), 241–250.
Thomas, R. (2012). Genetics and insurance in the United Kingdom 1995–2010: The rise and fall
of “scientific” discrimination. New Genetics and Society, 31(2), 203–222.
Vora, K. (2013). Potential, risk, and return in transnational Indian gestational surrogacy. Current
Anthropology, 54(suppl. 7), S97–S106.
Vora, K. (2014). Experimental sociality and gestational surrogacy in the Indian ART clinic. Ethnos:
Journal of Anthropology, 79(1), 63–83.
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
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,
Promoting Public Health
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.
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
Public Health Foundations
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
Promoting Public Health
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.
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).
Health, the State and the Market
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
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
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