Biopolitics â even when understood in its narrow sense of life itself being a political issue â comes in at least two different strands. The first, which historically precedes the second, was concerned with what Foucault called a âpolitics of public health.â In so doing, it takes on standard biopolitical issues of population optimization, public health and so forth as mass issues. The resulting policies included mass vaccination campaigns, the installation of proper municipal sewage systems, and so forth. These programs resulted in demonstrable and substantial gains in typical measures of public health, such as life expectancy.
The second strand, evident more recently, is much more individualistic. It emerges partly with the rise of genomics and partly with the rise of neoliberalism. For this new biopolitics, life is taken as potentially malleable: no longer are we to simply think in terms of removing obstacles to our health; we are to think in terms of manipulating the organism itself at the molecular level. As Nikolas Rose exhaustively documents, this new way of looking at health involves (among other things) viewing risk as both personal and actuarial, and centers around the idea that we can view ourselves as âpre-symptomaticallyâ diseased:
âBut like risk thinking, the idea of susceptibility brings potential futures into the present and tries to make them the subject of calculation and the object of remedial intervention. This generates the sense that some, perhaps all, persons, though existentially healthy are actually asymptomatically or pre-symptomatically illâ (19)
Two further aspects of this shift are, first, a reorientation of health policy around this new conceptualization of risk:
âAcross the twentieth century, the responsibilities of states in Europe and North America, and to some extent elsewhere, expanded from the collective measures to ensure health that were widely adopted in the nineteenth century â pure water, sewers, food quality, and so forth â to the active encouragement of healthy regimes in the home and interventions into the rearing of childrenâ (22)
And second, we see an emphasis on personal responsibility:
âThis is an ethic in which the maximization of lifestyle, potential, health, and quality of life has become almost obligatory, and where negative judgments are directed towards those who will not, for whatever reason, adopt an active, informed, positive, and prudent relation to the futureâ (25).
This thesis â that this second, neoliberal way of thinking about health is coming to supplant the first â seems basically sound to me. That doesnât mean that we should view the practice of healthcare as monolithic, however, and the ways that the conflict between the two strands plays out in contemporary medical practice are important. Any characterization such as the one above is dealing with ideal types and general tendencies. So the details matter.
One area where the details help is on the question of disease screening, such as debates over the actuarial value of PSA screening for prostate cancer (the USPSTF now recommends against it), and early mammograms (where the USPSTF recommended against routine screening for women aged 40-49, but survivor narratives were used by advocacy groups like the Komen Foundation to pushback against this). If you put on your neoliberal hat, youâll realize quickly that entrepreneurial, health-maximizing individuals will want to get themselves tested for diseases as early as possible, either because knowing the disease is coming allows you to make the most of your shorter life expectancy (as in the case of Huntingtonâs Disease), or to maximize your odds of avoiding or beating the disease (as in the case of the BRCA1/2 mutation). But for anything where environmental factors matter, thereâs difficult questions about health policy and the relative benefits of screening and old-style public health prevention.
Huntingtonâs is the standard example where the genetics are deterministic, but itâs the example that proves the rule going the other way: genetics accounts for relatively little of the overall risk for most diseases, even those with a defined genetic component. The disparity between what mass and individualized approaches consider is clear in the case of breast cancer screening. Although a woman carrying the BRCA1/2 mutation has a greater than 50% lifetime chance of developing breast cancer, the mutation only accounts for 5-10% of all breast cancers.
A current example is evident in the decision of Medicare not to cover lung cancer screening in high risk individuals, citing the lack of certainty that the benefits outweigh the risks (especially of false-positives). Although the decision is strictly actuarial, Medicare is very much a public health organization that makes policy for the population at large. Not surprisingly, many of the people opposed to the adoption of screening favor smoking cessation programs on the grounds that they are a better use of scarce resources, and the Affordable Care Act now requires insurers to cover smoking cessation programs, citing evidence that simply offering smoking cessation programs to patients reduced overall smoking rates by a significant amount. My own health plan â the one for North Carolina state employees â now offers a substantial rate preference to individuals who either testify that they donât smoke, or enroll in cessation programs.
But here is the point about tendencies: smoking cessation programs, recommended and supervised by your doctor, certainly move in the direction of public health. But thatâs a move toward public health mainly when compared to individualized screening regimes. If you step back a moment, you realize that all of this is happening instead of public campaigns to prevent smoking or to reduce the availability of cigarettes through older-style public health measures, like raising taxes on cigarettes, restricting advertising, and so forth. Indeed, most states arenât spending much on tobacco prevention, even though they have money from the tobacco settlement designated for that purpose. It's an approach that isn't getting much discussion, even if gains in public health are often gained in ways other than (or at least, in addition to) visits to the doctor.
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