Forcing the Private into the Public; the Face of Exploitation in Public Health

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Forcing the Private into the Public; the Face of Exploitation in Public Health

Mo Convery

International public health policies attempt to reform the social and political systems which influence the health and safety of all citizens of the world. In the past, these policies have been created through the strong reliance on and exploitation of socially constructed systems of classification such as gender, sexuality, nationality, and economic class. It has been a system of correlation between the behaviors which seem prevalent within social groupings and chances that those behaviors will lead to disease transmition or infestation. In January 2004, the World Health Organization announced a radical change in their policies surrounding public health study and prevention in the 2004 World Report on violence and health. Instead of focusing on larger global and national trends, the WHO called for an expansion of policies and increase of resources which focused more on the experiences and support of individuals rather than groups. This value of individual experience holds extreme promise in the expansion and effectiveness of public health initiatives as well has changes many societal systems of classifications. However, there may be detrimental effects of this change that exploit the very subjects that they attempt to help. It is a question of forcing the private experience of disease into a public domain. Where are the lines of public verses private drawn?

Public health by its very definition emphasizes public classification over the individual body. Its basic goal is to establish effective general health services that meet the minimum health requirements for a majority of people. With this general goal in mind, there are two major assumptions made within the formation of public health policy. The first assumption is that there are discoverable uniformities in the behavior of a population that can be expressed as generalities or theories . Second, when a public health organization identifies these patterns and begins to work against them, the prevalence of disease and possible transmittion is expected to drop significantly. While, these goals and assumptions are the foundation on which public health policy is formed, there remains great variability in interpretation. This is particularly evident in the formation of institutional philosophies.

Since its conception in 1948, the WHO has consistently swayed between two differing philosophies of public health; the vertical and horizontal methods . The vertical method which dominated the initial years of the WHO focuses on identifying and policing the one disease which was deemed the most damaging to social, political, and economic systems. This analysis of disease is based in statistics. As such, the effect of a public health program can be clearly monitored. If there is a positive response, the numbers will reflect so and vice-a-versa. In reducing disease to statistics there is a removal the individual, culture, or social influence.

In stark contrast, the horizontal approach seeks to address health from a holistic perspective. Health and disease are defined by the groups which they affect and the social classifications which they worked within. Most of all, the horizontal approach attempts to identify the effect which sociological, economic, and political realms play on the spread and prevention of disease. It attempts to address these larger issues in addition to the basic medical care which patients receive. While the horizontal approach does expand the study of disease, it still is based in statistic classification. While it may now longer be a question of health verses disease, its statistical nature is based within social classifications. There is no I, there is no individual body. There is only the groups of which are diseased.

The horizontal model of public health has dominated WHO policies since the late 1970's . This valuation is highly reflected in the World health reports from 1995-2003. Such topics addressed in these years include: world poverty, social stigmatization of mental health, childhood vaccination policies, and a comparison of health systems. In all of the above cases, there is no respect for the individual body or the possibility of individual agency. As stated in the 1997 report on communicable disease, "Health is being increasingly affected by a number of factors over which an individual has little control...and over which the conventional health sectors have little sway". This statement above is followed by a call to respect international health policing. Not only is there a question of individual agency but there is a questioning of the health systems which work in closest proximity to the individual patient.

While it has held dominance and validity in the public health world for the last 30 years, the horizontal method was publicly questioned in the 2004 World Report on violence and health. In this report the World Health Organization announced a radical change in their policies surrounding public health study and prevention. Instead of focusing on the group dynamics and larger statistical patterns, the WHO urged public health organizations worldwide to place value on individual experience and expand the forums which public health initiatives are discussed. They announced several major policy amendments to solidify this initiative.

On the basal level, the WHO urged for the enhancement of data collection within community systems. Instead of relying on statistical correlation between group membership and behavior, the WHO pressed organizations to become more reliant on case studies and individual experience dialogue. Similarly, the WHO also urged for a more diverse and comprehensive range of social educational polices and initiatives on the community level. In both of these suggestions there is an increased admittance of the individual body and personal agency. Thirdly, the WHO pressed for promotion of and adherence to primary response for diseased patients. In ensuring such, public health agencies are communicating to individuals that they publicly value of personal rights and health. Moreover, these rights are and will be supported and monitored on the national and international level.

In these amendments there is an embrace of the individual by a powerful public agency. Such an authoritative and influential statement has the ability to pose dramatic implications. Now that the shift is publicly and officially stated, it is necessary to explore the implications and repercussions which this entails from three standpoints; the level of public health, socially classified groups, and the individual. How will this change impact the efficiency and effectiveness of public health programs? Secondly, will this change affect current systems of classifications positively or negatively? Finally, will our definition of individuality and personal agency change accordingly? Like many issues in public policy, there is no right answer. In fact in exploring the various responses to such questions, binary arguments begin to develop.

In regards to public health effectiveness, the switch to focus on the individual has many positive ramifications. First and foremost, it expands the discourse of health which is able to take place. Public health institutions are no longer forced to work inside the limits of social constructions. While certain individual groups may in the past be tied to disease, they are not the only ones affected. Further, in expanding the discourse, public health officials will expand their understanding of disease experience. Simply stated, they may develop a more complex and accurate view of disease and disease transmittion. From this, they will be able to form more effective and reasonable programs for prevention, treatment, and outreach. As Foucault states identifies as sex being in his History of Sexuality, health is also something, "one had to speak of it as a thing not simply condemned or tolerated but managed, inserted into systems of utility, regulated for the greater good of all, made into a function of according to an optimum (Foucault 24).

By listening to every individual affected by disease and violence, public health institutions are placing equal value on individuals from varying groups. Once marginalized groups become included in discourse and thus have the opportunity to feel the impact of health policies individually. Addressing the individual experience forces people to place themselves within the larger scope of disease. It also pushes individuals to embrace there personal risk and not to denounce this risk due to lack of affiliation to a "diseased group". For some this may include admitting responsibility in the transmitting disease. Once more individuals are able to assess their true risk and see how their behavior fits within the system of disease, they will be more apt to take a clearly defined role.

On the other hand, public health's main goal is to ensure the health of the majority of people while placing the least risk on the minority. It is an institution which utilizes classifications for the better good. In associating diseases with social classifications, public health institutions are able to identify those who are most at risk and react accordingly. Simply stated, they can reach the greatest effected population in the most efficient manner. From a preventative standpoint, certain behaviors or genetic makeup within classified populations maybe leading to disease. In identifying such patterns and associations, public health programs can gain further knowledge of a disease profile. In times where a fast solution is needed, such as in an outbreak of a communicable disease, this understanding of group correlation is imperative in prohibiting disease explosion. Further, resources, both economic and practical, are limited in public health organizations. Programs must not only be effective but practical. Working with classifications offers a quick and effective response to the majority of people being affected. While, this approach may work against the preventative angle of disease, it offers a solution.

Similar to the effect on the individual, the effect on group dynamics and classifications is bipolar. It is of no argument that group classifications can be oppressive and limiting in many ways. Classifications force individuals to live within a system of expectations based on the defining characteristics of their group identity. Individuals within group classifications can face stigmatization on two fronts. First, they can experience stigmatization from inside their group by deviating from the group norms. Deviation from such norms and values can be seen as a rejection or, in a more active way, a challenge to the basic group identity. This deviation or challenge can by seen as a threat when in actuality it is simply a person demonstrating their individuality. Why individuals may not claim affiliation with a particular classification, others my put them there. This is a form of oppression.

The second front of stigmatization comes from the outlying groups; those who are not included in the social classification. Groups themselves may have stigmatization associated due to their own deviation from societal norms or general patterns within their group. As such, all individuals associated with the group acquire the stigmatization whether justified or not. In a society which places severe stigmatization on disease, this system of group association can be most damaging and oppressive.

As stated earlier, shifting focus to the individual increases the discourse of disease. This allows an individual to challenge group stigmatization through embracing their individuality in a current socially accepted forum. As Foucault sates, "Modern Puritanism has a triple edict of taboo, nonexistence and silence" (Foucault 5). In opening up discourse and hence disrupting the silence, the individual is able to challenge the oppression. This challenge of oppression further confronts the systems of classifications.

In another regard, breaking down the sharp lines of classification allows for the formulation of a communal responsibility surrounding disease. If the diverse experiences of disease are expressed, disease is no longer limited to once associated groups. Thus, it is no longer one group of people responsible for disease presence; it is a problem for the whole of society. Thus the focus can be shifted from diversifying disease education to truly addressing preventative measures.

On a more negative note, once the previous systems of classifications are challenged, what prevents different, possibly more oppressive, classifications from forming? It is human nature to classify. As stated in The Embodied mind, "Since we are neural beings, our categories are formed through our embodiment...the categories we form are part of our experience" (Lakoff 19). It helps people to understand their surroundings and sets an ideal prototype of which to standardize identity. While there is hope that new classifications may be less oppressive in nature, there is also the chance that new classifications may be more harmful. Public health programs set out to confront disease causing behavior before it even begins. Under the newly reformed WHO model, education and reprimand of the individual diseased are used as preventative measures. As Judith Butler states in her essay Bodies that Matter, "The reprimand does not merely repress or control the subject, but forms a crucial part of the juridical and social formation of the subject" (Butler 121). Even though the focus is on the individual, the system of communication of the disease forces it to become subjectified in a social realm. Thus, it is possible for another system of classification based on social jurisdiction to form.

Now that the polar repercussions for public health policy and group classifications are understood, it is necessary to address the main focus of the reform; the individual. The individual is affected in 3 basic positive regards. On the basal level, this reform is an official and authoritative agency publicly stating value of the individual experience. Through this public identification, the WHO gives in the individual experience validity in social context. It is no longer a restricted personal experience, but it is a tool for the general good. Second, the basic programs which the reforms outline insure that each individual will feel the effects of public health policy. There is a new attention to ground level work with communities.

Most importantly, by including the individual in discourse, the public health institution is giving the individual power. It is the individual who dictates WHO's perception of disease. From this compellation of individual experiences, WHO can act accordingly. Further, the individual now has the power to choose what they do and do not disclose. They have a choice to remain silent or speak of their experience. Most importantly, the individual has a choice to the degree of silence they choose. It is not a system of binaries. As Foucault states, "There is not one but many silences, and they are an integral part of the strategies that underlie and permeate discourse" (Foucault 27). Silence is a tool. Individuals can include a personal stratagem in their dialogue by merely disclosing what they choose. Not only can they help to shape their personal experience of public health and disease, but further, they can control how others may experience such.

After understanding the power structure which develops when individuals are invited into discourse, it is vital to answer several questions. When does the reliance on the individual become an exploitation of private identity? In forcing the private into public discourse are we objectifying the subject? Henceforth in making the private public, are we not too making it unjustly political? To answer these questions it is necessary to address the systems of discourse. Silence is a very powerful and manipulative tool which each individual subject holds. One of the most restrictive forms of oppression is when an individual is forced into silence. On the other hand, it can be equally damaging to force an individual to lose their choice of silence for social gain. As Foucault describes in his essay The Repressive Hypothesis, " The forbidding of certain words, the decency of expressions, all the censorings of vocabulary, might well have been only secondary devices compared to the great subjugation: ways to make it technically useful"(Foucault 21). The reliance on case studies which the WHO projects suggests this forcing of individuals into disease discourse.

It is not an embrace of the individual for moral reasons. It is instead an embrace causing subjectification. The WHO has a desired outcome. The method in what they use to acquire this goal does little to protect the individual involved in discourse. As stated earlier, it is easy to slip from one mode of classification to another. In this instance, the individual is at particular risk. If further classifications occur, their identity and experience would be the foundation. Not only could their identity be harshly criticized, but their experience can be stigmatized.

As a student and an individual who strongly supports greater roles of international health organizations on the ground level, I was initially in great support the new amendments to the WHO policy on health. After the previous analysis however, I was struck by the unsettling implications to health policy effectiveness, group classifications, and the individual. On one level, the embrace of the individual allows for a more diverse group of experience to emerge into the public realm and policies to reflect accordingly. However, there are also some highly dangerous implications when it comes to the power balance of discourse itself. Public organizations such as the WHO have the opportunity and authority challenge systems of discourse in the name of social utility. However, my question remains; what is the cost? Currently, the WHO appears ready to give up the sanctity of individual experience when it may not in fact want to be given. There needs to be a system in place which upholds an individual "right" to choose in discourse. In making it a protected choice whether an individual speaks, the WHO is upholding the delicate balance between the subjectification and objectification of the individual. The main goal of the WHO is to uphold public health. However, the manner in which they perform their duties can have significant effects on communities throughout the world. They have a responsibility as an international public aid institution to reflect upon the affects which their actions and policies hold.


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