Neoliberal Governance and Health: Duties, Risks, and Vulnerabilities 9780773599543

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N e o l i b e r a l G o v e r n a n c e a n d H e a lt h

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N EOLIBERAL G OVER N A N CE AND

H EALT H

Duties, Risks, and Vulnerabilities

Edited by Jessica Polzer and Elaine Power

McGill-Queen’s University Press  |  Montreal & Kingston  |  London  |  Chicago

© McGill-Queen’s University Press 2016

ISBN 978-0-7735-4782-7 (cloth) ISBN 978-0-7735-4783-4 (paper) ISBN 978-0-7735-9954-3 (ePDF) ISBN 978-0-7735-9955-0 (ePUB ) Legal deposit second quarter 2016 Bibliothèque nationale du Québec

Printed in Canada on acid-free paper that is 100% ancient forest free (100% post-consumer recycled), processed chlorine free This book has been published with the help of a grant from the Canadian Federation for the Humanities and Social Sciences, through the Awards to Scholarly Publications Program, using funds provided by the Social Sciences and Humanities Research Council of Canada. McGill-Queen’s University Press acknowledges the support of the Canada Council for the Arts for our publishing program. We also acknowledge the financial support of the Government of Canada through the Canada Book Fund for our publishing activities.

Library and Archives Canada Cataloguing in Publication Neoliberal governance and health : duties, risks, and vulnerabilities / edited by Jessica Polzer and Elaine Power. Includes bibliographical references and index. Issued in print and electronic formats. ISBN 978-0-7735-4782-7 (cloth). – ISBN 978-0-7735-4783-4 (paper). – ISBN 978-0-7735-9954-3 (ePDF). – ISBN 978-0-7735-9955-0 (ePUB) 1. Medical care – Canada – Case studies.  2. Medical policy – Canada – Case studies.  3. Public health – Canada – Case studies.  4. Neoliberalism – Canada – Case studies.  I. Polzer, Jessica, 1969–, author, editor  II. Power, Elaine M., 1961–, author, editor

RA395.C3N45 2016  362.10971 C2016-901775-3 C2016-901776-1



Set in 10.5/14 Calluna with Gotham Book design and typesetting by Garet Markvoort, zijn digital

Con t en ts

Acknowledgments  ■ vii Introduction: The Governance of Health in Neoliberal Societies  ■ 3 Jessica Polzer and Elaine Power 1 Fat Children, Failed (Future) Consumer-Citizens, and Mothers’ Duties in Neoliberal Consumer Society  ■ 43 Elaine Power 2 Environment-as-Risk and Green Consumerism in Neoliberal Public Health Practices  ■ 66 Rebecca Hasdell 3 Tween Girls, Human Papillomavirus (HPV ), and the Deployment of Female Sexuality in English Canadian Magazines  ■ 82 Laura Cayen, Jessica Polzer, and Susan Knabe 4 Risk, Retirement, and the “Duty to Age Well”: Shaping Productive Aging Citizens in Canadian Newsprint Media  ■ 108 Debbie Laliberte-Rudman

5 The Political Is Personal: Breast Cancer Risk, Genetic(optim)ization, and the Proactive Subject as Neoliberal Biological Citizen  ■ 132 Jessica Polzer 6 Global Biopolitics and Pandemic Influenza Preparedness: Securitization and the Regulation of Viral Uncertainty and Mutual Vulnerability  ■ 167 Sarah Sanford 7 Risk and Resistance: Citizenship and Self-Determination through Health Governance in Nunavut, Canada  ■ 195 Sara Tedford 8 “So It’s Always a Dance”: The Politics of Gifts and Governance at a Drop-In Centre for Vulnerable Women in Southern Ontario  ■ 225 Treena Orchard 9 “You Are Free to Set Your Own Hours”: Governing Worker Productivity and Health through Flexibility and Resilience  ■ 247 Ellen MacEachen, Jessica Polzer, and Judy Clarke 10 Active Citizenship and the Management of Stigma in Contingent Work  ■ 280 Marcia Facey 11 Self-Management and the Government of Disability: Reinforcing Normalcy through the Construction of Able-Disabled Subjectivities  ■ 307 Erika Katzman Contributors  ■ 331 Index  ■ 335

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Acknow led g me n ts

We acknowledge the faculty and staff of the former Department of Behavioural Science and Social Science and Health Graduate Program, University of Toronto, who worked against the institutional grain to create a space within which graduate training in critical social science perspectives on health could flourish, with special thanks extended to Robin Badgley, David Coburn, Joan Eakin, Blake Poland, Ann Robertson, and Harvey Skinner. In particular we would like to acknowledge Ann Robertson whose supervision helped us craft our own distinct critical sensibilities and bring them together fruitfully in this volume. We express our thanks to Jonathan Crago at McGill-Queen’s University Press for his guidance throughout the process of bringing this manuscript to publishable form and the anonymous reviewers for their thoughtful feedback on previous versions of the manuscript. Thank you as well to Joanne Muzak for her fine editorial care and attention and to Ryan Van Huijstee for his assistance with the cover design.

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N e o l i b e r a l G o v e r n a n c e a n d H e a lt h

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In t r od u ct io n

The Governance of Health in Neoliberal Societies Jessica Polzer and Elaine Power Discourses on health come into and go out of fashion, but not arbitrarily. Rather, they emerge and gain widespread acceptance primarily because they are more or less congruent with the prevailing social, political and economic context within which they are produced, maintained and reproduced. In addition, because they are always attached to other interests and agendas – professional, economic, political, cultural, ideological – the ways in which we conceptualize and speak and write about health are never just about health; they also function as repositories and mirrors of our ideas and beliefs about human nature and the nature of reality, as well as about the kind of society we can imagine creating and how best to achieve it. Robertson, “Shifting Discourses in Health Promotion”

Since the stormy development of Medicare in Canada, the relationship between health, governance, and citizenship has been thrown into sharp relief. The provision of publicly funded, universal health insurance, conceived by Tommy Douglas as an inalienable right of citizenship (Redden 2002), has become a cornerstone of Canadian identity and a tireless target of political deliberation. Beginning in the mid-1970s, the right to health care, with its emphasis on the collective pooling of risks and government responsibility for health, has been

increasingly displaced by a discourse of individual responsibility for health and the prevention of disease through the identification and management of risk. This shift has in part stemmed from efforts to broaden policy frameworks concerning the determinants of health beyond curative biomedicine, which focus on the treatment of disease, to consider the various personal, environmental, and social determinants of health, which focus on the prevention of disease (see, for example, the Lalonde Report [Lalonde 1974], the Epp Report [HWC 1986], and the Ottawa Charter for Heath Promotion [WHO 1986]). However, the tendency in public and professional discourse to privilege individual behaviours and biological processes as explanations of health over social determinants and social well-being is symptomatic of a political shift that began in earnest in the 1980s. With this shift from welfare state to neoliberal approaches, the legitimacy of free market rationalities has become entrenched in social policy, emphasizing the principles of individualism, privatization, and de-centralization over those of universal social rights and collective welfare (Broad and Antony 1999; McGregor 2001). In health care, this has transformed the way in which patients in publicly funded health care systems are increasingly understood and represented as consumers of health services rather than recipients of care and social entitlements. More generally, neoliberal approaches to social policy favour a model of citizenship in which individuals are expected to demonstrate their duties to maintain their health through their own “free choices” and “informed decisions.” In this collection, we present a range of case studies that explore how neoliberal styles of governance idealize particular notions of health and citizenship and the implications for human well-being. The idea for this book has its origins in a panel called Health and Citizenship, organized and chaired by the editors for the 2008 Annual International Sociological Association Research Committee on the Sociology of Health meeting held in Montreal, Canada. This forum, which marked the inaugural meeting of the Canadian Society of the Sociology of Health (www.cssh-scss.ca/), provided us with an ideal opportunity to showcase critical health research that is empirically grounded and theoretically informed by the body of scholarship on governmentality inspired by the insights of French philosopher Michel Foucault (1991). Since the 1990s, this critical perspective has had a sig-

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nificant influence on the sociological study of health and illness as evidenced by the emergence of publications that actively draw on governmentality in their analyses of health promotion, public health, and health care (e.g., Armstrong and Murphy 2012; Lupton 1995; Petersen 1996, 1997; Petersen and Bunton 1997; Petersen and Lupton 1996; Pickard 2009), as well as a broad range of specific health-related topics (e.g., genetics and biotechnology, obesity, depression, harm reduction approaches, repetitive strain injury, social assistance, retirement) (Bunton and Petersen 2005; Evans and Colls 2009; Laliberte-Rudman 2006; MacEachen 2005; Polzer 2005; Power 2005; Robertson 2001; Roe 2005; Teghtsoonian 2009). We offer this collection as a contribution to this scholarly body of literature, with a uniquely Canadian focus. One of our central aims is to illustrate the complex and multifaceted character of the relationship between health and neoliberal forms of rule in our contemporary moment. In exploring this relationship, we cast our critical gaze beyond institutions and systems of health care: while universal access to quality health care is a right that should be shared by all citizens, it has long been recognized that the determinants of health extend well beyond the provision of curative biomedicine to include a number of social, political, historical, and economic forces and factors (e.g., Braveman, Egerton, and Williams 2011; Coburn 2004; DHSS 1980; Marmot 2005; Raphael 2004, 2007; Wilkinson 2005). Drawing on insights from studies of governmentality, we extend this conceptualization of health as a social product to consider the duties, risks, and vulnerabilities that are generated in relation to the proliferation of discourses on health under neoliberalism. A governmentality perspective is particularly well suited to examine the various ways in which the neoliberal governance of health operates at and through a diverse range of social sites. From the perspective of governmentality, the notion of government refers to the “conduct of conduct” or, more specifically, to any “activity aiming to shape, guide or affect the conduct of some person or persons” (Gordon 1991, 2). In its refusal to confine the analysis of the exercise of government, and power more generally, within the apparatus of the state, government is understood from this perspective as including the entire set of practices, both subtle and overt, that are implicated in directing and shaping the conduct of individuals and populations.1 This critical lens, in

Governance of Health in Neoliberal Societies  ■ 5

liberating the activity of government from the workings of the state (Dean 2002; Rose and Valverde 1998), opens up for scrutiny the ways in which individual actions (typically conceived of today in terms of “choice”) and freedoms are regulated and shaped at a distance from the centres of political authority and through a range of discourses, policies, institutions, and agencies. The chapters in this volume attest to the diverse sites through which neoliberal practices of governance effect their power at a distance from the state: genetic testing clinics; disability policy; public health discourse on environmental health and childhood obesity; community-based organizations that support poor, economically marginalized women; magazine articles about HPV vaccination; newspaper articles about retirement; workplace employee policies; and policy planning in relation to pandemic influenza and Aboriginal health care. As a flexible analytic framework, a governmentality perspective rejects universalizing theories and concepts and provides analytic tools that come with particular assumptions and enable empirical specificity (Rose, O’Malley, and Valverde 2006) in the critical analysis of health and social issues. This analytic approach recognizes the productive features of power that operate alongside its more repressive mechanisms and decentres the state as the primary arbiter of power, repositioning it as one important element of many within an entire network of power relations. In this respect, the state is understood as “historically specific and contextually variable – in multiple circuits of power, connecting a diversity of authorities and forces, within a whole variety of complex assemblages” (Rose 1999, 5). This critical approach to the analysis of governance involves more than the specification of individual or institutional interests and the ways in which they constrain or prohibit action.2 Rather, as Nikolas Rose and Mariana Valverde (1998) suggest, this approach involves the mapping and specification of: problematizations (e.g., how and under what conditions do particular issues become framed as problems for health that require regulation?); normalizations (e.g., towards what scientifically or socially established norms regarding health is conduct directed?); spatializations (e.g., what kinds of governable spaces are brought to light through discourses on health?); authorizations (e.g., who is authorized to define, delimit, and regulate health problematizations?); and subjectifications (e.g, what

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forms of subjectivity and modes of self-identification are privileged by health-related discourses?). Informed by a Foucauldian conception of power as a relational network of forces that produces and legitimizes particular areas of social and scientific research and categories of self-identification, this emphasis on the productive aspects of power is sometimes mistakenly interpreted as assuming a positive valence or “goodness,” a reading that is undoubtedly influenced by the positive connotations commonly associated with being “productive” in capitalist economies and contemporary work contexts. Rather, this emphasis on power-as-productive should be understood as exposing how power operates through the circulation of discourse that produces objects that are then governed through calculated measures and strategies, including, for example, surveillance, regulatory mechanisms, and self-discipline. In keeping with this productive view of power/knowledge, we include as part of our focus a serious engagement with how neoliberalism is a “political project of governing and persuasion intent on producing new forms of subjectivity and particular modes of conduct” (Giroux 2008, 1). This conceptualization of power importantly points to how discourse produces forms of subjectivity that privilege particular frameworks for self-understanding and categories of self-identification, and that thus shape individuals’ relations with themselves and with others (Foucault 1978; Rabinow 1994). In this sense, discourse is understood as a form of social action encompassing speech, written text, as well as practices through which people organize, use, and circulate knowledge and texts (Kendall and Wickham 1999). Many of the chapters illustrate how texts and practices embed neoliberal governmental objectives and are implicated in the formation of subjectivity: the child “at risk” for obesity, the “successful ager,” the “proactive manager” of genetic risk, the “good mother,” the “green consumer,” the “resilient worker,” the “self-managing” person with a disability. Because of its multidimensionality, health is a particularly illuminating lens through which to examine the multifarious constructions and effects of neoliberal practices of governance. From our perspective, the commonly accepted idea that health can be achieved through the adoption of risk-reducing and health-promoting behaviours is constructed through discourse. No longer the monopoly of scientific

Governance of Health in Neoliberal Societies  ■ 7

biomedicine, such individualizing discourses on health are embedded in educational institutions and comprise durable threads in the fabric(ation) of North American culture. Information about how to best attain and improve one’s health through individual will and effort, particularly in relation to diet and exercise, is widely available and accessible through a diffuse assortment of mass and social media. For many, health has become both an individual preoccupation and topic of casual conversation. These individualized constructions of health proliferated throughout North America in the 1970s through self-care and holistic health movements that resisted the stranglehold of biomedical discourses on health. Despite fierce opposition to medicalized understandings and approaches to health and health care, the individualistic ideology perpetuated by these health movements resonated deeply with the biomedical worldview in capitalist economies. In framing the maintenance of health as an individual responsibility and moral obligation, a prevailing ideology Robert Crawford refers to as “healthism,” these social movements helped solidify an individualized understanding of health, effectively obscuring the political and social determinants of health3 and disease from public view and debate (Crawford 1980). Despite ongoing efforts by researchers and practitioners working in public health and health promotion who wish to create conditions for health equity through community-based interventions and policy reform (e.g., Jackson and Riley 2007), many activities and interventions undertaken in these fields continue to prioritize such individual-level approaches (Raphael 1998) and the modification of individuals’ “risky” behaviours, while public policy interventions to improve the social determinants of health are seen as less feasible or even unintelligible (Ilcan 2009; Raphael 2011; Raphael, Curry-Stevens, and Bryant 2008). Just as individualized constructions of health have become regular features of the cultural landscape of neoliberal societies, we continue to witness the damaging effects of neoliberal styles of governance on individuals and populations. It is now well established that neoliberal policies, which increase income inequalities and dismantle welfare state programs (e.g., income assistance), are associated with poor health outcomes, in Canada and internationally (e.g., Coburn 2004; Coburn and Coburn 2007; Collins and McCartney 2011; Marmot 2005;

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McQuaig and Brooks 2010; Navarro 2007; Nkansah-Amankra, Agbanu, and Miller 2013; Raphael 2000; Stuckler and Basu 2013; Wilkinson 2005; Wilkinson and Pickett 2009). For those already marginalized by their subordinate positions along one or more axes of inequity (e.g., gender, “race,”4 socioeconomic status, indigineity), the effects of these policies are particularly harmful as they deepen poverty, intensify the experience of social exclusion, and exacerbate poor living conditions (e.g., Morrow, Hankivsky, and Varcoe 2004; Reid 2007; Varcoe and Dick 2008; Wallis and Kwok 2008). Despite such evidence, and far from the idealized post–Second World War imagining of health as an entitlement of citizenship and “state of complete physical, mental, and social well-being” (WHO 1946, 2), health in neoliberal societies is predominantly framed as an obligatory and lifelong pursuit of the individual. This discursive shift generates particular duties and vulnerabilities for citizens. For some, the active pursuit of health has assumed meaning as central to experiences of personal fulfillment and self-worth and as a symbolic marker of social status, class membership (Crawford 1984), and one’s deservingness of public goods and resources. However, for those who are excluded socially and economically by neoliberal policies, opportunities for well-being become elusive as access to the material and social resources and prerequisites for health steadily erode: a living income, a decent pension, shelter, peace, non-discrimination (based on age, sex, race, ability, sexuality, etc.), food, education, child care, health care, and meaningful employment. Within the moral economy of neoliberalism, those “Others” who are unable or who refuse to actively pursue health (e.g., through the conspicuous display of riskreducing activities) are not recognized as deserving/dutiful citizens with entitlements to public goods and resources, but are rather viewed as a “drain on the system.” Neoliberalism As a Rationality of Government

Distinct from a conception of neoliberalism as political philosophy or economic theory, neoliberalism from the point of view of governmentality is understood as a particular mentality or rationality of rule – that is, as a way of rationalizing the means and ends of government.

Governance of Health in Neoliberal Societies  ■ 9

Although neoliberalism is not meant to be an ideal or universal type (Rose, O’Malley, and Valverde 2006),5 there are some general features of liberal political rationalities and their specifically neoliberal form that are helpful to elucidate before we elaborate on the neoliberal governance of health specifically. From the perspective of governmentality, liberalism is not seen as an underlying philosophy, but rather as a practice that is guided by the concern that the state always governs too much (Dean 2002, Foucault 1994a, Osborne 1996, Rose 1996). As a perpetually skeptical political rationality, liberalism builds criticism of government by the state into its very logic and reflexively addresses the question of why the state must govern at all in order to rationalize its own exercise and existence (Foucault 1994a). In this respect, liberalism justifies government not in terms of the state but in terms of society “which is in a complex relation of exteriority and interiority with respect to the state” (Foucault 1994a, 75).6 It is within the general framework of liberal political rationality that life (and health) became a central concern for politics, both at the level of the individual body and the species body (Foucault 1978; Lemke 2011). This biopolitics, according to Foucault (1994a), refers to “the endeavor, begun in the eighteenth century, to rationalize the problems presented to governmental practice by the phenomena characteristic of a group of living human beings constituted as a population: health, sanitation, birthrate, longevity, race …” (73, emphasis added). As a specific configuration of power, biopower fosters life or disallows it to the point of death (makes live or lets die) in contrast to sovereign power, which focuses on life only insofar as it takes life or lets live (Foucault 1978; Lemke 2011). Comprised of both disciplinary technologies and technologies of security, biopower aims to increase the individual body’s capacity for economic productivity and political utility (e.g., through techniques of surveillance and examination) and regulate the population and its biological characteristics in order to protect it from internal threats (e.g., through monitoring of disease, birth rates) (Foucault 1978). While Foucault describes these as “two basic forms” of biopower, they are better understood as “two poles of development linked together by a whole intermediary cluster of relations” (Foucault 1978, 139). As with discourses on sexuality (Foucault 1978), discourses on health, as expressions of biopower, proliferate in relation to con-

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cerns at both individual (micro) and population (macro) levels, thus constituting a politically useful hinge between the individual body and the body politic with a number of intermediary targets (e.g., family, community, groups designated as “at risk” for poor health outcomes). Neoliberal rationalities of rule are characterized by their active withdrawal from state-directed programs, while the market is afforded a key role as the economy is re-coded from being one area of human existence (the management of the household) to the model for judging all human action and behaviour. This application of economic styles of thinking to the “social domain” is evident in relation to both individual and collective bodies, as Thomas Lemke (2001) describes: “Neoliberalism is a political rationality that tries to render the social domain economic and to link a reduction in (welfare) state services and security systems to the increasing call for ‘personal responsibility’ and ‘selfcare.’ In this way, we can decipher the neo-liberal harmony in which not only the individual body, but also collective bodies and institutions (public administrations, universities, etc.), corporations and states have to be ‘lean,’ ‘fit,’ ‘flexible’ and ‘autonomous’: it is a technique of power” (203). Thus, the preoccupation of liberalism generally, and neoliberalism specifically, with the question of excess governance should not be interpreted as an argument for the need to govern less, but rather refers to the concern that it is the state that is doing too much of the governing (Dean 2002). In this sense, withdrawal of support for statedirected programs is indicative of a “prolongation of government” that involves power relations between the state and a complex assemblage of agencies and authorities in “civil society,” including non-profit organizations (Rose 1999). In the Canadian context, Suzan Ilcan (2009) describes neoliberalism as a privatization of responsibility that governs through “the entrepreneurship of autonomous actors, such as individuals, families, firms, corporations, and nongovernmental organizations” (213), mobilizing new citizen-subjects through initiatives that range from social welfare reform to public-private partnerships to free trade agreements. Related to this, another fundamental aspect of neoliberal rationalities of rule is that government and freedom are not viewed as opposed or mutually exclusive. Rather, a principal strategy of neoliberal practices of governance is to govern through freedom, where freedom is

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conceptualized as “choice, autonomy, self-responsibility, and the obligation to maximize one’s life as a kind of enterprise” (Rose, O’Malley, and Valverde 2006, 91). As we discuss further in the conclusion to this Introduction, this governance through freedom poses difficulties for critical analytic approaches that view freedom and social regulation as oppositional, because, when the “ethic of freedom [is] itself part of a particular formula for governing free societies” (Rose, O’Malley, and Valverde 2006, 91), freedom can no longer be used as the ground and ends of one’s critique. Neoliberalism and the Production of (Health) Inequities: Responsibilization and Marginalization

The neoliberal governance of health involves practices of both responsibilization and marginalization. On the one hand, neoliberal policies and practices privilege the production and circulation of discourse that frames health as an individual responsibility and moral obligation, thus creating new expectations in relation to the maintenance of one’s own health, the health of one’s family, and the health of the population. At the same time, neoliberal practices of governance exacerbate social and economic inequities, and differentially allocate risks for disease and opportunities for health and well-being along existing and new lines of privilege and oppression. By positioning the market as the optimal way to distribute resources that affect health and well-being, and by undermining and fragmenting the social safety net, neoliberal policies and practices perpetuate health inequities, rendering even more vulnerable the bodies and lives of those who are unable to meet their health needs in the market. In focusing on the power dynamics of both responsibilization and marginalization that are integral to neoliberal modes of governance, we move beyond the general tenets of neoliberalism – which emphasize the state’s role in supporting processes of privatization, deregulation, and cuts to social spending – to focus specifically on how neoliberal thought is “concretized into specific practices” (King 2010, 91), and in specific contexts, to shape discourses on health, as well as opportunities for health. While the need for “less state” is often used

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as a mantra to promote the interests of business, general tenets and simplistic definitions of neoliberalism as laissez-faire are insufficient for critical sociological investigation. Neoliberal modes of governance involve more than a retreat from state intervention, as new relationships are drawn between the state, the market, individuals, and their families. The neoliberal state does not simply roll back welfare state programs but also invests in health-related technologies, programs, and health care and public health arrangements that aim to produce new kinds of citizens (King 2010). In cultures characterized by healthism (Crawford 1980), dominant discourses on health are major contributors to practices that individualize and privatize responsibility: whether located in viruses, faulty genes, or risky behaviours, emphasis is placed by such discourses on the proximal causes of ill health (i.e., those located in proximity to the individual), thus promoting individualized solutions to these problems and deflecting critical attention from sociopolitical forces that shape the social and material conditions that affect health. From a governmentality perspective, health promotion and public health activities, and the risk reduction practices and discourses they endorse, have been framed as central to the production of “at-risk” subject-citizens who are called upon to monitor and govern their conduct in everyday life through practices of self-examination and self-care (Petersen 1996). Such discourses are illustrative of how neoliberal forms of rule operate not through force, but rather by demarcating possibilities for action by “creating a sphere of freedom for subjects so that they are able to exercise a regulated autonomy” (Petersen 1996, 48). Within this sphere of freedom, those who are designated as “at risk” are encouraged to engage in processes of self-improvement as part of their “duty to be well” (Greco 1993). Neoliberal practices of governance thus specify a particular form of active citizenship whereby individuals are expected to exercise their personal responsibilities for health in relation to new spaces of decision making and action. As an “autonomizing and pluralizing” political rationality, neoliberal practices of governance operate through various techniques and forms of expertise that generate conditions that facilitate autonomous self-regulation or a form of “regulated freedom” (Rose 1993). Thus, neoliberal government is directed towards

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the creation of means through which citizen-subjects are called on to actively make choices, to realize and cultivate their freedom and autonomy in ways that are aligned with broader political and economic objectives. As Nikolas Rose (1996) describes, “Within this new regime of the actively responsible self, individuals are to fulfil their national obligations not through their relations of dependency and obligation to one another, but through seeking to fulfil themselves within a variety of micro-moral domains or ‘communities’ – families, workplaces, schools, leisure associations, neighbourhoods. Hence the problem [for government] is to find means by which individuals may be made responsible through their individual choices for themselves and those to whom they owe allegiance” (57). Alternate choices, however, are not morally equivalent. In the context of healthist societies, in which health is constructed as a supervalue towards which individuals should aspire to establish their personal and moral worth (Crawford 1980), choices that are framed as risk-reducing and health-enhancing (e.g., exercise) are seen as correct and “right.” In contrast, failure to take up health-enhancing behaviours or, worse, the display of conduct that is viewed as health-damaging (e.g., smoking), is viewed as uninformed at best and morally negligent at worst. As Alan Petersen (1997) has observed, within the neoliberal politics of health promotion, “individuals who are seen to be ‘at risk’ and who do not take what is deemed to be appropriate preventive action can potentially be charged as culpable in failing to fulfil their duties of citizenship” (56). Such moral connotations render “choice” a powerful discourse in framing new expectations for responsible citizenship. Neoliberal framings of choice are particularly powerful as governing discourses because they resonate with, appropriate, and co-opt resistant and counterdiscourses and forms of activism that have struggled for autonomy, justice, recognition, and self-determination. To the extent that the discourse of choice aligns with the goals of these movements, it may stifle their transformative potential as it seductively buttresses the powerful individualizing tendencies of neoliberal political rationalities. As feminist health studies scholars have pointed out (e.g., Batt and Lipp­ man 2010; Dubriwny 2013; Lippman 1999; Polzer and Knabe 2009;

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Polzer and Robertson 2007; Robertson 2001), neoliberal policies and governing practices are particularly effective at co-opting and capitalizing on competing resistant discourses, building them into their own governing strategies and suppressing deep critique and social change. For example, demands for greater autonomy over health care made by the women’s health movement, which actively resisted the medicalization of women’s bodies and lives, have been co-opted by postfeminist discourses7 in popular culture and risk management technologies that claim to provide women with the ability to make “informed choices” and decisions about their health (Batt and Lippman 2010; Dubriwny 2013). Indeed, the anticipation and co-optation of elements of resistant counter-discourses, such as those promoted by feminist health activism, comprise an important part of the neoliberal governance of health as the recognition of autonomy becomes intelligible strictly in terms of an individual’s capacity to self-govern in ways that are seen as health-promoting, while resistance to such self-governance becomes interpreted as irrational and judged as lacking in individual willpower and moral agency. This dynamic of neoliberal governance is explored in relation to predictive genetic testing for breast cancer in chapter 5, which draws attention to the ways in which women who opt against risk management technologies are viewed as morally incompetent, and thus how women’s choices to take up technology may be experienced as compulsory. Similarly, chapter 11 explores the mixed effects of resistive efforts by disability rights movements, providing a nuanced picture of the intimate and inextricable relation between power and resistance. Although celebrated as an achievement of the disability rights movement, which sought to demedicalize and deinstitutionalize care, the Self-Managed Attendant Services (SMAS ) program also reinforces the networks of normalizing power that are responsible for the ongoing oppression of disabled people. In drawing attention to this power dynamic, it is not our intention to overlook the important successes of resistant movements and efforts,8 but rather to question how neoliberal political rationalities transform demands for social change and greater autonomy into privatized solutions and “choices” that download responsibility onto individuals and

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families and support commercialized and biomedicalized approaches to health that dovetail with aims to stimulate the economy. In the context of women’s health, for example, Abby Lippman (1999) points out that such approaches and appeals to increasing women’s “choices” actually undermine the efforts of feminist health researchers and activists because they simultaneously perpetuate individualized framings of risk and foreclose a consideration of environmental health risks and structural constraints on women’s abilities to exercise autonomy over their health and bodies. Furthermore, and consistent with neoliberal governmental objectives to withdraw state support, such transformations occur alongside the defunding of national women’s health organizations that promote gender equity and collective awareness and action aimed at improving the social determinants of women’s lives and health.9 While individualizing discourses of risk and choice are instrumental in producing active and responsibilized, disciplined citizens, they also legitimize the exclusion and further marginalization of those who are unwilling or unable to conduct themselves in ways (i.e., “make choices”) that are construed as “useful” and “responsible” (i.e., economically productive and health-promoting). This aspect of neoliberal governance is often overlooked in governmental analyses applied to health promotion, which have tended to focus on the productive tendencies of neoliberal (risk) governance to incite entrepreneurial, self-regulating citizens, and which tend to overlook the more repressive aspects of neoliberal governance. However, as some governmentality and critical health studies scholars suggest, authoritarianism is an enduring feature of liberal approaches to government (Dean 2002; Hindess 2001a; Power 2005; Tang and Browne 2008; Valverde 1996) and is reserved for individuals and groups who are viewed as incapable of exercising their freedoms properly (e.g., children, the poor, women, Aboriginal peoples), that is, in ways that are aligned with governmental objectives. Unlike those who are governed through their freedom to tailor their lifestyles and participate in the market in ways that allow them to manage their own and their family members’ health needs, these marginalized “others” are marked by their inability (or unwillingness) to do either and come to be governed through more authoritarian measures

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of “unfreedom” (Hindess 2001a, 2001b; Power 2005; Valverde 1996). As suggested by some of the chapters in this volume, the subjectivities, habits, and forms of everyday conduct that are inspired by neoliberal political rationalities provide a basis of distinction between those who (are able to) work on themselves and (are willing to) demonstrate their commitment to their well-being and the nation-state and those who, by not conforming to the forms of regulated freedom circumscribed by neoliberalism, are marked as unwilling and/or unable to engage in such self-cultivation. Those who (can) mobilize their personal resources are elevated to the status of dutiful, good citizens – that is, those who do all they can to assume responsibility for, and take care of, themselves, their families, their own economic well-being and that of the nation. And those who don’t have resources, or who can’t mobilize them in accordance with neoliberal yardsticks of responsible citizenship and market consumption, are further excluded and viewed as problems requiring regulation and surveillance. The ways in which health-related risks, responsibilities, and vulnerabilities are constructed and allocated in relation to socially produced identities and populations (e.g., “mother,” “vulnerable women”) and axes of inequity (e.g., income, gender, race, age, able-bodiedness) are explored in many of the chapters in this volume. These insights resonate with recent momentum gained in applying intersectional approaches to the study of health and health care in Canada (Hankivsky 2011) and provide examples of how a governmentality theoretical lens and Foucauldian conceptualizations of power/knowledge can contribute to this research agenda by drawing attention to the inequities and idealized standards for conduct that are constructed and reproduced by health-related discourses, and the exclusions that are legitimized and contested in relation to these discourses in specific contexts.10 The economic exclusion that is effected by neoliberal rationalities, programs, and techniques of government – most notably the restructuring of and withdrawal from welfare state programs – together with other systemic forms of discrimination – racism, sexism, homophobia, ableism, and ageism – work to disenfranchise and marginalize groups through designations that typically frame them as risks to the body politic and the economic well-being of the nation-state.

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Duties, Risks, and Vulnerabilities

In neoliberal practices of governance, the duties necessary to acquire the status of healthy citizenship through intensified personal risk management regimes are increasingly tied up with the demands of consumer capitalism. Such duties are communicated, in part, by health authorities and expert recommendations, which, directly and indirectly, yoke the task of improving population health to the interests of the market. This is the case in some contemporary public health and health promotion practices in which citizen-consumers increasingly (are encouraged to) display their capacity to exercise responsible choices in the marketplace through the purchase of products that are purported to improve health or protect one against health risks. As Elaine Power elaborates in chapter 1, the neoliberal healthy citizen is one who demonstrates her responsibility for health through conspicuous, disciplined consumption. This ideal is distinct from the form of citizenship promoted by welfare liberalism that was popular in the middle of the twentieth century and reflected in the development of social welfare programs that sought to temper the negative social and health effects of capitalism. In contemporary childhood obesity epidemic discourse, mothers are held responsible for their failure to discipline their children’s desires and bodies and teach them to make proper choices in the name of health. Similarly, in chapter 2, Rebecca Hasdell describes the greening of consumerism and citizenship that is promoted in contemporary environmental health promotion practices. This greening, Hasdell argues, privileges an individualized approach to risk management through precautionary consumption, a marked shift from the precautionary principle, which emphasized the state’s responsibility to regulate potentially harmful products in the context of scientific uncertainty in order to protect the public’s health. In chapter 3, Laura Cayen, Jessica Polzer, and Susan Knabe focus on magazine representations of human papillomavirus (HPV ), a common sexually transmitted infection (STI ) that has been constructed as a risk requiring management with the pharmaceutical development of HPV vaccines and routinization of school-based HPV vaccination for girls across Canada. This chapter locates popular HPV vaccination discourse as a site for the production and deployment of nascent female sex-

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uality, which is framed as “risky” and thus as in need of technological management, and shows how magazine constructions of HPV vaccination capitalize on the social ambiguities associated with the construction of tweens as consumers. In consumption society, the uptake of the HPV vaccine, it is argued, becomes framed as one more feminized accessory (in addition to bras, makeup, etc.) to mark the rite of passage from childhood into tweendom. Similar to the points made by Elaine Power in chapter 1, this chapter points to the ways in which mothers’ responsibilities are specified in relation to the child’s body, which is constructed as “at risk” for obesity and for infection with HPV , both of which are linked to future disease. In the case of HPV discourse, the child’s body that is specified as “at risk” for future disease, and thus as in need of management, is explicitly female, particularly insofar as the magazine articles emphasize the risks of HPV for the development of cervical cancer, and downplay other health risks (e.g., genital warts, oral cancer, anal cancer). These chapters highlight the multiple roles played by the mother, and are suggestive of the gendered nature of neoliberal practices of responsibilization in relation to health. Just as Foucault identified “the family” as an important link “between [the] general objectives regarding the good health of the social body and individuals’ desire or need for care” (1984a, 281), these chapters highlight the particular utility of mothers’ multiple roles within contemporary neoliberal health politics; given their socially conditioned roles as caregivers and guardians of family health, mothers are a particularly useful node in the translation of neoliberal political imperatives and practices into private conduct and personal habits. This intersection of gender and governmentality has, to date, received some attention in the literature (Hannah-Moffat and O’Malley 2007; Reed and Saukko 2010). Focused attention on the gendered dynamics of the neoliberal governance of health is an area that deserves further exploration, particularly with regard to the dual responsibilities for women who are expected to consume new health-related products while picking up the slack of eroding welfare state programs through more intensive forms of domestic care and risk management. In addition to mothers’ duties to protect and maintain the health of her children, the neoliberal duty to stay well is apparent in the

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“healthy,” “positive,” or “productive” aging discourse discussed by Deb­ bie Laliberte-Rudman in chapter 4. As she argues, Canadian newspaper accounts of aging have contributed to an undermining of the social right to a publicly funded pension by age sixty-five and generated in the public domain a sense of uncertainty and unease about retirement. Laliberte-Rudman argues that retirement is constructed as both an economic risk for both the nation state and business, and as a personal risk to individual financial security and health. The antidote that is provided by positive aging discourses is to continue working past the traditional retirement age of sixty-five and engage in health promotion activities that promise a long, healthy life. In a time of intensified international competition for profit, the duty to age well expressed in these newspaper accounts inadvertently supports the minimization of state and employer supports for workers nearing retirement, reducing financial demands on the increasingly emasculated neoliberal welfare state. Such insights resonate strongly with labour disputes over proposals to weaken pension plans and the federal government’s decisions to raise the eligibility age for Old Age Security pension and enhance Canada Pension Plan incentives for later retirement (CBC 2012). The duty to stay well dovetails in interesting ways with the construction of health as something that can be optimized and the body as a malleable resource for biotechnology and source of “biovalue” and “biocapital” (Rose 2007; Waldby 2002). As risks to health are increasingly located within biological entities that are transmitted between bodies (e.g., viruses, genes), this corporeal malleability acts as a resource for technological and knowledge development in the life and health sciences. Rather than overshadow the need for self-governance, the corporeal frailties that are suggested by the identification of scientifically defined biological risks, such as genetic mutations, are often constituted as justification for individually tailored pharmaceutical and medical interventions and personal risk management strategies. As explored by Jessica Polzer in chapter 5, practices of predictive genetic testing for hereditary breast cancer transform embodied vulnerabilities into manageable risks, inciting women to acquire information about their genetic risks for disease and to act on this information by modifying their lifestyles and engaging in more intense surveillance in order to optimize their own future health outcomes, as well as those

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of their biological relatives. Drawing on interview data with women undergoing BRCA 1/2 mutation testing, Polzer argues that women pursue information about their genetic risks not merely as a passive response to discourse, but rather to become “proactive” in the management of their genetic risks. This intense form of personal commitment to health is provoked by emerging risk detection technologies, and is also formed in relation to women’s familial biographies of cancer and suffering and within the context of widely held public perceptions of problems and shortages in cancer care and treatment services. Polzer shows how the women in this study construct themselves as biological citizens who pursue and use genetic risk information in order to “prepare” for a potential future with cancer and optimize their health outcomes by compensating for perceived shortages and failures in the health care system and learning to navigate the heath care system prior to corporeal symptoms of disease. Chapters 6 and 7 contrast this focus on the construction of the individual body as a terrain of risk requiring self-management to illustrate how entire populations and territories are demarcated as risky and as targets for intervention from national and international authorities. Sara Tedford examines the reproduction of the Canadian North, and its Inuit inhabitants, as a source of risk to national public health in the context of the construction of Nunavut as a new territory. In a broader geographical context, Sarah Sanford focuses on the identification of China as a risk to global public health in pandemic influenza planning documents, and in the context of globalized trade and travel routes and a highly mobile global body politic. In chapter 6, Sanford focuses on the discourse of “preparedness” as a key technology in the governance of global population health in the context of the threat of viral risks that move easily across geo-political borders and corporeal boundaries, such as in the recent cases of SARS and pandemic influenza. Sanford illustrates how this discourse of preparedness, as it is constructed in the World Health Organization’s (WHO ) pandemic influenza planning documents, frames emerging infectious disease as an uncertain but imminent event, one that is a threat to global and national security and economic interests. The ways in which global infectious disease threats are constructed as problems of global public health security tend to racialize global health risk and re-inscribe

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global economic inequities. In this respect, Sanford points to how the WHO planning documents pinpoint China as a particular risk to global health by linking the possibility of viral re-assortment with China’s reliance on traditional (i.e., non-industrialized) farming practices, which bring humans and animals into close contact. A central tension that Sanford identifies is the problem posed by having to reconcile strategies that seek to control or contain unpredictable entities (such as viruses) with the demand for constant circulation of bodies and goods that characterizes neoliberal global capitalism. Sanford importantly points to the way in which the discourse of preparedness responsibilizes nation-states to respond to the risk of uncertain viral threats, an insight that extends recent concerns about the extent to which governmentality, as a theoretical frame, can be applied to issues concerning international relations and areas of the world that do not have advanced liberal states (Joseph 2009, 2010). Tedford’s analysis in chapter 7 similarly explores the racializing tendencies and tensions associated with the discourse of health risk that emerged as a central organizing feature of the governance of Canada’s newest territory, Nunavut, and how this has re-colonized Inuit knowledge and experience. In a culture with no specific word for health or health care, health risk discourse is an utterly foreign implant, and its individualism runs counter to the collective ethos of Inuit tradition. Despite the importation of individualistic models of health and discourses of health risk from the south, Tedford is cautiously optimistic about the capacity of the Inuit people, the Nunavummiut, to carve out an independent model of self-determination, and restore as central an Inuit approach to well-being that recognizes Innuqatigittarniq Qaujimajatuqangit – Inuit knowledge, expertise, and experience. The governance of health through risk and the making of marketable and response-able citizens contrasts sharply with the findings of chapter 8, which focuses on the constraints within which communitybased agencies and workers who support the needs of marginalized and vulnerable persons are forced to work within neoliberal regimes of governance. In this chapter, Treena Orchard details how these agencies and workers often find themselves with the difficult – if not impossible – task of balancing the competing health needs of their clients with political imperatives to restructure, downsize, and make do with

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inadequate resources. Orchard suggests that this is less of a balancing act than a “dance,” one that keeps agency workers on their toes and having to anticipate their “partner’s” next move. This chapter brings into focus the politics of philanthropic gift-giving within the broader context of provincial funding cutbacks and the tensions that emerge when agencies with conflicting mandates are forced into partnerships. As governments scale back their commitments to fulfilling social and economic rights that support the social determinants of health, community-based organizations and (well-intentioned) philanthropists have stepped in to help fill the gap. Orchard acknowledges that the philanthropic gift helped ensure the survival of a community-based agency, and demonstrates how the conditions of the gift – a merger with other organizations – extracted a high price in new bureaucratic procedures that undermined the agency’s client-centred mission to support some of society’s most marginalized and vulnerable citizens. While staff engaged in covert resistance to the new procedures, their ability to act has been significantly constrained, leaving some clients in extremely precarious conditions. Chapters 9 and 10 focus on the workplace as a site where conditions for social security and health have become increasingly precarious and uncertain. These case studies focus on the increase in “contingent” forms of employment characterized by a lack of employer commitment to workers, uncertainty regarding length of contracts and wages, reduced or no union representation, and few or no benefits or entitlements for workers in exchange for their labour. Both chapters provide thoughtful examples of the ways in which work arrangements and workplaces can be examined as sites for subjectification (Rose, O’Malley, and Valverde 2006) and offer contrasting accounts of the forms of worker subjectivity that are constructed in different types of precarious employment situations, highlighting the implications, contradictions, and tensions that emerge for workers in these specific contexts. In chapter 9, Ellen MacEachen, Jessica Polzer, and Judy Clarke illustrate how managers in mid-size software development companies in Ontario draw on the discourse of “flexibility” to construct the ideal worker as one who is “resilient.” Despite managerial framings of the worker as “free” to set their own hours, ideal workers in this setting are described as those who are resilient against the extremes of

Governance of Health in Neoliberal Societies  ■ 23

market volatility, able to withstand the intense work hours and demands imposed by competition among companies who race to get their products to market first. The findings of this study bear directly on Lemke’s comments regarding the entrepreneurial perspective endorsed by neoliberalism and the way in which, within flexible work scenarios, “work and leisure time are no longer inimical opposites, but tend to supplement one another” (Lemke 2001, 202). Because of the contractual nature of this work, these workers impose little burden on companies, which are accountable to stakeholders and commit to workers not through the promise of job security but in ways that help them to keep up the pace and quality of their creative labour during periods of intense work (e.g., through employee assistance programs, office designs, and amenities that accommodate long hours spent in the office). In contrast to this “high end” form of contingent work, Marcia Facey examines the experiences of day labourers and clerical workers hired through temporary employment agencies in chapter 10. Facey’s analysis of interviews with men and women employed in these “low-end” contingent jobs reveals how they manage the stigma associated with their jobs by espousing opposing views of this form of work as advantageous (described by the workers in terms of “flexibility” and “empowerment”) and disadvantageous (described by the workers in terms of “exploitation” and “powerlessness”). Facey argues that they draw on these discourses simultaneously to manage the stigma of this degraded form of labour and to maintain their sense of dignity and self-worth. This management involves both distancing themselves from negative depictions of contingent work and distinguishing themselves from these disreputable subject positions by (re)constructing temporary work as an opportunity for self-growth and autonomy. In this sense, workers depicted themselves as rational and calculating individuals who choose their temporary assignments carefully and thoughtfully. Importantly, this chapter illustrates the creativity that some of these workers used in framing their temporary, and sometimes mundane, work assignments as challenging and meaningful. Together, these chapters provoke insight about how precarious work arrangements shape worker subjectivity, with workers’ positive depictions of temporary work (described in chapter 10) resonating with the optimistic

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view of flexible work practices espoused by the software development managers (described in chapter 9). Chapter 11 concludes the volume with provocative insights into the tensions that are embedded in Ontario’s Self-Managed Attendant Services (SMAS ) program for people living with disabilities. In this chapter, Erika Katzman draws on critical disability studies and her own experiences as a former attendant to women with spinal cord injuries to illustrate how the SMAS specifies a new kind of “able-disabled” citizen (Titchkosky 2003) who conforms to norms of independence and self-sufficiency required by neoliberal models of citizenship. In this sense, the logic of self-management mimics the rehabilitation model of disability; while medical rehabilitation aims to restore the physical functioning of disabled bodies, the self-managed model aims to restore the societal functioning of disabled subjectivities. Whereas constructions of disability in terms of vulnerability and dependency have been used to exclude disabled persons from full citizenship, Katzman draws attention to how the able-disabled citizenship promoted by SMAS is premised on the ability to shoulder the responsibility for managing one’s care. In so doing, Katzman draws attention to the unpaid, and usually invisible and unrecognized, labour that goes into the task of managing attendant services. As in many of the other chapters, this analysis is suggestive of how responsibilization and marginalization are implicated in neoliberal modes of governance and in the creation of novel gradations of social stratification and forms of subjectivity. A Call for Critical Interdisciplinary Health Studies

In compiling the chapters that comprise this collection, we hope to stimulate interest in critical interdisciplinary health studies, a field we envision as having roots in medical sociology and drawing on other disciplines and fields of research in order to enable complex and deep understandings of how neoliberalism operates in relation to health in our present and what is at stake in this style of governance. The chapters in this collection contribute uniquely to the critical sociology of health and illness in Canada by illustrating interdisciplinary trends within the field, and the insights that can be generated when critical

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social theory is brought into conversation with theoretical and methodological insights from fields of study that are relevant to the study of health, including, for example, medical anthropology, cultural studies, food studies, fat studies, feminist theory and gender studies, labour market and workplace studies, postcolonial theory, critical gerontology, and critical disability studies. Although the topics and theoretical frameworks included in this volume are by no means exhaustive, we hope that they will serve as case studies to stimulate critical thinking about the character and effects of neoliberal governance as they pertain to other health-related fields of study and scholarship. We offer this volume and our critical approach to the study of neoliberalism and its influence on health as a complement to interdisciplinary research in critical health studies in the Canadian context and internationally (e.g., Metzl and Kirkland 2010; Moss and Teghtsoonian 2008; Orsini and Smith 2007; Patton 2010; Petersen and Bunton 1997). The range of case studies presented in this volume illuminates the diversity of sites through which neoliberal technologies of government operate at a distance from the state, and shows how a variety of health-related “problems” that characterize our present have been formulated in relation to neoliberal mentalities of rule. Similar to other areas that have been influenced by governmentality studies – sociology, criminology, social work and social policy, education, science and technology studies – these case studies provide further evidence of the disciplinary spread of governmentality theory and the ways in which its conceptual tools and theoretical insights resonate with intellectual trends in scholarly fields that concern the study of health (McKee 2009; Rose, O’Malley, and Valverde 2006). Through a theoretically informed and empirically grounded approach to analysis, one of our intentions in this book is to complicate the often “abstract and text centred approaches that have tended to dominate governmentality studies” (McKee 2009, 467). While theoretical concepts and insights are necessary tools to guide a critical examination of the complexity of the neoliberal governance of health, theory should help us apprehend our present and not foreclose the possibility of findings and surprises that emerge from close readings and rigorous analyses of health-related problematizations that emerge in specific contexts. This local specificity is commensurate with the

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methods of governmentality studies, which emphasize a focus on “detailed empirical studies, both historical and contemporary, of practices of government” (Rose, O’Malley, and Valverde 2006, 88). Through attention to empirical detail, we also hope to complicate the insightful yet, at times, homogeneous and somewhat uniform treatment of neoliberal governance that characterizes some health research conducted from Foucauldian and governmentality perspectives. This is particularly evident in research that emphasizes the disciplinary aspects of health discourse and their effects on surveillance, self-regulation, and the individual management of risk, and tends to neglect the marginalizing tendencies of neoliberal governance. Just as neoliberal practices of government rely on techniques of freedom and unfreedom (Dean 2002; Hindess 2001a; Rose 1999; Valverde 1996), we must also consider how the effects of neoliberal government extend beyond the individual whose constrained capacities are cultivated and harnessed in particular directions that align with specific political and economic objectives. The chapters in this collection build on this concern to suggest how dominant discourses on health, including discourses on risk, intersect other discourses of social identity and regulation (e.g., gender, race, sexuality, familial obligation, ageism) to produce particular forms of responsibilization and processes of marginalization. The combination of critical social theory and empirical specificity is crucial to develop situated critiques that challenge and complicate claims that health is a matter of individual empowerment and “choice,” and provide rich illustrations of the ways in which political, economic, and sociocultural forces are expressed and embodied in local health-related practices. A strength of governmentality as an analytic lens stems from its very concern with the nexus between political rationalities and everyday practices, thus avoiding the “political insulation” that characterizes many micro-level theoretical frameworks and sociological analyses of health (O’Malley, Weir, and Shearing 1997, 503). By providing analytic tools that decompose power/knowledge into empirically grounded rationalities, technologies, and techniques,11 the application of this perspective can help avoid high levels of theoretical abstraction and offers insight into the political aspects of mundane processes of rule, opening up everyday practices to scrutiny and “critical and tactical thinking” (O’Malley, Weir, and Shearing

Governance of Health in Neoliberal Societies  ■ 27

1997, 503). A governmentality perspective thus offers an opportunity to explore critically neoliberal rationalities in specific settings and how they become embedded and expressed in discourse, subjectivity, and the minutiae of everyday and institutional life. The perspective of governmentality is not without its critics who claim that Foucauldian models of government, and power more generally, privilege considerations of power at the expense of resistance and counter-discourse. This “misconceived criticism” (Rose, O’Malley, and Valverde 2006, 100) is incommensurate with the assumptions that inform a governmentality perspective that refuse to place freedom and government, technologies of the self and those of domination, and agency and structure in binary opposition. This criticism is related to the Foucauldian conceptualization of power as productive and relational, which necessitates a rethinking of the notion of resistance. As Foucault himself clarified, relations of power presume the capacity to act and necessarily involve the possibility for resistance, which may take multiple forms, including “violent resistance, flight, deception, [and] strategies capable of reversing the situation” (Foucault 1994b, 292). Conversely, practices of resistance necessarily involve the exercise of power and attempts to shift power relations. The problem that such reconceptualizations of power, resistance, and government pose for conventional models of freedom versus power/government are noted by Rose, O’Malley, and Valverde (2006), who argue, “It is not, then, that studies of governmentality neglect resistance to programs of government, or to techniques for the shaping of conduct; what they do refuse is the idea of resistance derived from the analytical framework of agency versus structure that has haunted so much contemporary social theory” (100). While the chapters in this volume do not focus substantively on activist discourses related to health, they should thus not be read as implying that resistance is not present or possible. We acknowledge the importance of work that has been published on activist and resistant movements in health and its contribution to understanding resistive power dynamics (e.g., Batt 1994; Klawiter 2008; Moss and Teghtsoonian 2008). Within the general theme of neoliberal governance and health, the chapters in this volume explore the complex ways in which the radical potential of critique and resistance is stifled

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through co-optation (e.g., via discourses on individual “choice,” “empowerment,” “the environment”; see chapters 2, 5, and 11), through coercive and illiberal measures (e.g., via increased surveillance of marginalized groups and regions; see chapters 6, 7, and 8), and through the construction of particular desirable and idealized subjectivities (e.g., via the “good mother,” the “proactive patient,” the “flexible” worker, the “able-disabled”; see chapters 1, 3, 5, 9, and 10). While tenacious and creative in their capacity to anticipate, coopt, and stifle resistance, neoliberal practices of governance are also uncertain and precarious, and the multiple sites at which they operate generate multiple opportunities for practices of contestation and possibilities for change. Insofar as they rely on the capacities and energies of individuals to “freely” govern themselves, neoliberal approaches to regulating populations and disciplining unruly bodies, in relation to health and elsewhere, are precarious. Indeed, there have been numerous examples of activism and resistance in the Canadian context and internationally that contest dominant neoliberal constructions of health and political rationalities of governance more generally (e.g., regarding income and social inequalities) and that may act as catalysts for social change and greater health equity, including, for example, the Canadian Centre for Policy Alternatives (CCPA ), the Council of Canadians, the Canadian Women’s Health Network, campaigns for basic income and living wages, and the international Occupy movement. Related to this concern, there are those who claim that governmentality scholars tend to privilege official discourse and rationalities of rule over the messy realities of how governmental technologies are implemented (O’Malley, Weir, and Shearing 1997; Petersen 2003). However, this critique imposes a false distinction between governing practices and ruling rationalities (or, speaking more generally, reality and representation) that is incommensurate with the assumptions that inform a governmentality lens. From this perspective, “a political rationality is not pure, neutral knowledge that simply ‘represents’ the governed reality. It is not an exterior instance, but an element of government itself which helps to create a discursive field in which exercising power is ‘rational’” (Lemke 2010, 55). In this volume, this is illustrated by Laliberte-Rudman’s analysis of how newspaper articles on retirement govern everyday life through the dissemination of

Governance of Health in Neoliberal Societies  ■ 29

discourses on productive aging, which “mark out possibilities for how aging citizens can and should understand themselves and act in relation to aging, retirement and work, as well as how policies, programs, and services can and should respond to aging citizens” (113). As with other texts used in governmental analyses, these newspaper articles are understood not as outside of, but rather as integral to, the exercise of government. Furthermore, this criticism does not preclude the possibility that researchers can use governmentality as an analytic frame to explore research questions that address how individuals negotiate, take up, and resist neoliberal technologies of governance, an analytic focus that has been taken up previously (e.g., Adam 2005; Howson 1998; Polzer 2005) and by many of the authors in this volume who draw on interviews and ethnographic methods. This is in keeping with the view that governmentality is not a universal or overarching theoretical framework, but rather an analytic toolbox that comes with particular assumptions about power and government and that can be used flexibly and creatively with other methodological tools (Petersen 2003; Rose, O’Malley, and Valverde 2006).12 The importance of interrogating the subtle operations and everyday practices of neoliberal workings of power is paramount. Because neoliberal technologies of governance operate through discourses of “choice” and “freedom,” they constitute a particularly insidious mode of power, the critique of which requires the cultivation of a critical sensibility that can discern how neoliberal imperatives “trickle down” and coalesce in particular practices and how they are taken up, embodied, reproduced, and contested in a variety of settings. For this reason, we advocate a critical stance to health research that is sensitive to the complexities of power relations and the politics of resistance that are invoked by neoliberal technologies of governance. Though not conducive to a universal template or recipe for social change, the critique of prevailing problematizations and discourses about health is a fundamental component of the critical scholarly project we aim to foster. This project goes beyond a mode of critique that says “that things aren’t good the way they are” (Foucault 1994d, 456) to cultivate a critical sensibility that makes not only possible but also necessary the act of questioning how particular understandings of health are mobilized, through what means, toward what ends, at what costs, and

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to whom. The critical stance we advocate enhances the possibility of resistance by enabling health researchers to contest the rationalities that inform dominant discourses and practices, and the techniques that render such discourses and practices as self-evident. This mode of critique is thus not just about fault-finding, but is one that enables and encourages researchers to reflect on and unsettle the familiarity of knowledge categories and interventionist practices that dominate our present with regard to health. Through a critical process of thoughtful unsettling, we can become attuned to the differential and marginalizing effects of neoliberal governance on the vitality and well-being of variously positioned individuals and communities. As well, we can become more acutely aware of how it is that we, as researchers and educators, govern and are governed, and thus reflexive with respect to our own knowledge production and teaching practices. With respect to the importance of educating researchers to develop such critical capacities in relation to the study of health, it is important to note that many of the chapters in this collection feature Canadian scholars whose academic training was cultivated by a core group of medical sociologists and social scientists in what was the Social Science and Health Graduate Program in the Department of Public Health Sciences at the University of Toronto (now known as Social and Behavioral Health Sciences in the Dalla Lana School of Public Health). One of the distinctive features of the academic training fostered by this graduate program was its emphasis on a critical social science perspective in health research (e.g., Badgley 1971; Coburn et al. 1996; Coburn 2004; Eakin et al. 1996; Robertson 1998) that combined the development of theoretical expertise and methodological skills, and the application of these to particular substantive issues in health, health care, and public health. As graduates of this program, and now as supervisors of graduate students who pursue critical perspectives in their own work, we recognize the importance of institutional support for creating scholarly environments in which students can safely and productively develop their critical capacities, and thus for maintaining momentum for critical health research in Canada. Related to the importance of institutional support for critical health research, it is also noteworthy that many of the research studies upon which these chapters are based were supported with funding from the

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Social Sciences and Humanities Research Council of Canada (SSHRC ), which withdrew its support for health-related research in 2009. The withdrawal of SSHRC from funding health research has been particularly challenging for interdisciplinary health studies scholars who actively draw on critical theoretical perspectives in the social sciences and humanities to frame our research questions and contest the status quo in health research, which tends to reproduce neoliberal, individualistic framings of health. Indeed, this shift in the landscape of health research funding in Canada has produced its own set of vulnerabilities for health researchers interested in pursuing a critical agenda and effecting social change through the application of theoretical insights from the humanities and social sciences. We are not suggesting that our approach is the only one to developing such a creative and critical sensibility, but we offer it as one possible route for health researchers to understand the ways in which personal troubles reflect public issues (Mills 1959). Such a critical sociological imagination is particularly important to apply to the contemporary study of health as neoliberal practices of governance continue to exacerbate social and health inequalities and legitimize particular forms of freedom and citizenship by yoking discourses on health to those of individual choice, responsibility, and disciplined consumption. While the outcomes of such vigilant, critical reflection – as part of a project of “hyper- and pessimistic activism” (Foucault 1994c, 256) – may not be immediately observable or measurable, the import and necessity of this style of critique lies in our ability to bring thought to bear on what we are doing in relation to health research, policy, and practice so that we may continue to consider “the kind of society we can imagine creating and how best to achieve it” (Robertson 1998, 155).

N ot e s

1 We use the terms government and governance interchangeably, and neither term should be conflated with political ideology or state-centred activities. 2 The productive aspect of power is expressed many times by Foucault throughout his writings and interviews. See, for example, Foucault

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(1984b), where he says, “If power were never anything but repressive, if it never did anything but to say no, do you really think one would be brought to obey it? What makes power hold good, what makes it accepted, is simply the fact that it doesn’t only weigh on us as a force that says no, but that it traverses and produces things, it induces pleasure, forms knowledge, produces discourse” (61). 3 According to Dennis Raphael (2004), the social determinants of health are “the economic and social conditions that influence the health of individuals, communities, and jurisdictions as a whole” (2). This approach to the study of health moves beyond the individual to emphasize the quality and quantity of resources (physical, social, personal) that are made available to society’s members so that individuals and communities can thrive. These resources include, for example, conditions of childhood, income, availability and quality of education, food, housing, employment, working conditions, and health and social services. 4 We acknowledge that both gender and race are socially constructed categories of difference and identity. We place “race” in quotation marks here to further acknowledge that essentialist notions of racial difference persist in public health research. We use these terms without quotations in the remainder of the volume for the ease of the reader. 5 Foucault characterizes neoliberalism as polymorphous and distinguishes between German and American versions of neoliberalism. Whereas the development of neoliberalism in postwar Germany recognized the importance of regulating and managing the economy through social interventions (e.g., unemployment assistance, health care), American neoliberalism sought to extend the rationality of the market to areas that are not considered primarily economic (e.g., family and birth policy, penal policy) (Foucault 1994a; Lemke 2001). 6 The guiding rationality of liberalism was one of maximizing the economy, a response to the governmental form of reason that preceded it, reason of state (raison d’état), which justifies governmental intervention in terms of maximizing the state’s power (Foucault 1994a). In contrast, liberal government starts from the notion of “society,” which is viewed as both “a precondition and a final end” of government (Foucault 1994a, 75). 7 Yvonne Tasker and Diane Negra (2007) define postfeminism as a set of ideas that circulates in popular media that assumes the “pastness” and obsolescence of feminism. Such ideas have a restricted view of feminist politics and include, for example, the valorization of gender equality in the workplace, the “enabling” features of surgeries and interventions that claim to provide women with greater choices and assist them in various ways (e.g., to improve themselves, gain a youthful appearance, ease the pain of childbirth). Tasha Dubriwny and Vandhana Ramidurai (2013)

Governance of Health in Neoliberal Societies  ■ 33

and Dubriwny (2013) provide critiques of postfeminism in the context of health, including childbirth and risk management for female cancers (breast, cervical). 8 For example, see Boscoe et al. (2004) for a concise overview of the women’s health movement in Canada specifically. 9 For example, in Canada the Women’s Health Contribution Program was eliminated in the 2012 federal budget. This program supported six women’s health organizations across Canada that aimed to enhance gender equity and provide action-oriented policy advice that reflected the concerns of researchers and community members. Two of these organizations have ceased their operations completely (the Atlantic Centre of Excellence for Women’s Health, the Prairie Women’s Health Centre of Excellence), while the remaining four are trying to develop alternative funding structures (National Network on Environments and Women’s Health, the  Réseau québecois d’action pour la santé des femmes, the British Columbia Centre of Excellence for Women’s Health, and the Canadian Women’s Health Network) (see http://voices-voix.ca/en/facts/ profile/national-network-environments-and-womens-health). The Canadian Women’s Health Network suspended its activities due to lack of funds in November 2014. 10 In their articulation of intersectional frameworks for the study of health and health inequities, Rita Dhamoon and Olena Hankivsky (2011) distinguish between theoretical approaches that focus on identities of individuals and social groups; categories of difference; and processes of differentiation and systems of domination. The latter resonates with governmentality because it shifts the focus from identities designated as “other” or “different” to the construction and legitimization of “difference” and “the examination of how identities and/or categories are constituted, resisted, and governed” (24). 11 Rationalities of government and technologies of government are related but not equivalent concepts. Rationalities can be thought of generally as ways of thinking (mentalities) or reasoning (rationalities); in this sense, neoliberal rationalities specify a particular way of thinking about the means and ends of government as political practice. Technologies of government refer to specific arrangements of discourse and resources that concretize power in particular practices. As Valverde (1996) notes, technologies are not reducible to, or mere expressions of, rationalities; rather, rationalities and technologies are co-constitutive: “technologies do not express or implement a previously constituted arrangement of knowledge/ power but rather help to constitute both the theory of the power and the power of the theory” (358, original emphasis). While technologies may be associated with particular rationalities, there is no necessary or direct correlation between the two. While the terms technologies and

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techniques are often used interchangeably, techniques can be viewed as specific components of technologies. 12 This flexibility is a key strength because it lends itself to a creative use of methods, as Rose, O’Malley, and Valverde (2006) suggest: Those who criticize governmentality for not doing what it never claimed to do can only make their criticism bite to the extent that they imagine governmentality as a systematic theory that can be regarded as having logical incompatibilities with other theories. If, on the other hand, it is regarded as part of an analytical toolbox, good for some purpose but not for others, and capable of being used in conjunction with other tools, then the problem appears more as a limitation of the critique than a critique of the limitations of governmental analyses … The analytic tools developed in studies of governmentality are flexible and open-ended. They are compatible with many other methods. They are not hard-wired to any political perspective. What is worth retaining above all from this approach is its creativity. (100–1)

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Ch a p t e r 1

Fat Children, Failed (Future) Consumer-Citizens, and Mothers’ Duties in Neoliberal Consumer Society Elaine Power

Introduction

It has become virtually impossible to avoid the message that we are getting fatter, and consequently, less healthy. The medical literature and the popular media warn that our growing corpulence will have dire consequences for our health, and thus for our employers and the health care system, as we succumb to the chronic diseases associated with obesity – diabetes, hypertension, heart disease, and some forms of cancer. Researchers have predicted that obesity will soon surpass smoking as the leading cause of “preventable” morbidity and mortality, making fatness “the new tobacco,” and claim that obesity is already an almost $4 billion annual drain on the Canadian economy (Eisenberg et al. 2011). The nature of the rhetoric about the “obesity epidemic,” the intensity of the concern, and the overwhelming consensus that something must be done, has led some scholars to conclude that we are in the midst of a moral panic about fat bodies (Lebesco 2010; Campos 2004; Gard and Wright 2005).

The most intense concern about the obesity epidemic is reserved for children and youth. As in other industrialized countries, children and teens in Canada are characterized as being afflicted by an “epidemic” of obesity and overweight. In 2006, Statistics Canada reported that obesity rates among children and youth tripled between 1979 and 2004 (rising from 3 percent to 8 percent) and rates of overweight children and youth rose from 12 percent to 18 percent, a combined prevalence of 26 percent (Shields 2006).1 The House of Commons Standing Committee on Health was so concerned by the Statistics Canada report that it quickly convened a series of expert panels to inform them about the problem of childhood obesity, so that it could make recommendations for the federal government to take action on an urgent public health concern (House of Commons Standing Committee on Health 2007). In this chapter, I do not question that the body mass of Canadians has risen in the past thirty years, but I take a step back from the rhetoric of obesity as a public health concern to consider “the obesity epidemic” as a metaphor for cultural anxieties in our neoliberal consumer society. Thinking metaphorically and symbolically about the body, I consider why concerns about obesity, particularly childhood obesity, have resonated so strongly in contemporary wealthy countries, such as Canada, while other social phenomena with stronger and clearer links to health, such as childhood poverty, have not. My analysis is guided by the question, what political imperatives and cultural anxieties about the social body are reflected in the panic about individual fat bodies and their purported links to disease and early death? Drawing on theoretical insights from governmentality studies (Foucault 1991; Rose 1989, 1999) and Robert Crawford’s (1984, 2000, 2006) insights about the body as a cultural symbol or metaphor, I argue that the governance of childhood obesity as a public health issue is informed by a generalized anxiety about the child’s body in neoliberal consumer society. I also draw on literature from health studies, the sociology of consumption, and child studies to think about why the childhood obesity epidemic has become the focus of such intense interest at this historical moment, what the construction of the childhood obesity epidemic tells us about our neoliberal consumer society and how we imagine the future, and the new possibilities it presents for

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the governance of the child’s body and family consumption and health practices. In bringing these theoretical insights together with literature from these fields, I emphasize how the dominant discourse on the childhood obesity epidemic governs children’s bodies, and sets up new expectations for maternal duties to govern those bodies, through the disciplining and cultivation of individual freedoms. Contemporary constructions of childhood obesity present new expectations for mothers to more intensely surveil and govern the child’s body, and instill the dispositions and practices required to make proper, responsible consumer choices in the name of health. As Laura Cayen, Jessica Polzer, and Susan Knabe demonstrate in chapter 3, it is mothers in particular who are responsibilized in neoliberal societies to protect their children’s health through the consumption of products that target their “risky” bodies. And as Rebecca Hasdell describes in chapter 2, the “good mother” of neoliberal consumer society is expected to be ceaselessly vigilant in her consumption practices, constantly on the alert to make the “right” consumer choices to protect her child’s current and future health. I also consider the broader cultural and political anxieties in consumer society that are symbolized by the child’s fat body in neoliberal consumer society. I begin by examining the construction of the childhood obesity epidemic in Canada, drawing on the House of Commons Standing Committee on Health report on childhood obesity as an example of the broader dominant discourse of childhood obesity. I then consider the historically contingent character of this contemporary construction by locating it within a general trajectory of social and cultural anxieties that are played out at the level of the individual body. Finally, I consider what the contemporary construction of the childhood obesity epidemic, and the child’s fat body specifically, can tell us about how both mothers and children are governed in neoliberal consumer society. Specifically, I illustrate how mothers’ duties to consume properly are constructed in relation to the spectre of the fat body of the child. In addition, the dominant discourse on the childhood obesity epidemic sets up expectations that mothers will teach their children how to exercise self-discipline, in the name of health, so that they learn to choose properly and responsibly amid the overwhelming array

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of consumer choices. By doing so, mothers inculcate the disposition of disciplined freedom in their children, preparing them for future success as consumer-citizens. The Construction of the Childhood Obesity Epidemic in Canada

In June 2006, the House of Commons Standing Committee on Health began a study of childhood obesity in Canada in response to Statistics Canada data that showed rising levels of overweight and obesity among children and youth. It invited over eighty experts to testify, including researchers, senior public servants from various federal and provincial ministries, clinicians, public health practitioners, representatives from non-governmental health organizations, and the food industry. The committee’s final report, Healthy Weights for Healthy Children (2007), laid out the evidence it gathered concerning the scope of the problem, reasons for rising obesity rates among children, factors affecting healthy weights, and recommendations. The Standing Committee Report is a useful example of the dominant construction of the childhood obesity epidemic. It summarizes the causes of increasing obesity rates as too little exercise, too few fruit and vegetables, and too much screen time, dietary fat, junk food, and sugary drinks. The Standing Committee reported that it was “shocked” at the increasing rates of overweight and obesity among children (2) and shared the concern of those who fear that, for the first time in generations, children may not live as long as their parents. The Standing Committee also described their “surprise” that Canadian parents don’t seem to understand the magnitude or importance of the issue, reporting that only about one-third of parents with overweight or obese children recognizing their child’s problem (3), and characterized this as “parental denial” of the risks childhood obesity presents to health. Although the report presents evidence of the complexity of the roots of rising rates of obesity, including social determinants of health, such as poverty and education, the committee’s recommendations were modest, particularly given its claims for the dire future health of the nation if action is not taken. Recommendations included more research, public awareness, and education, and inter- and intragovern-

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mental collaboration, improved access to nutritious foods and exercise, and limiting exposure to trans fats (which the committee recognized do not contribute to obesity per se, but complicate the health risks of being overweight.) The committee stopped short of recommending a ban on children’s food advertising, suggesting instead that the issue merits further study. Furthermore, the report provided no indication of anything controversial or possibly problematic about the ways in which the problem of childhood obesity is framed or the evidence supporting the claims about the severity and urgency of this public health crisis. The only dissenting voice was that of the Bloc Québécois members of the committee who were concerned that the public health program already in place to combat childhood obesity in Quebec not suffer any impediments or financial penalties because of any federal action on the issue. One would never know from the report that there is now a substantial internalist critique that questions the strength and validity of the science supporting the claims of an obesity epidemic (e.g., Campos 2004; Gard and Wright 2005). This internalist critique has led a few researchers to conclude that the evidence for an “obesity epidemic” is distorted, exaggerated or just plain wrong (e.g., Campos 2004; Oliver 2005), and that it is more of a “moral panic” than a real problem. In another internalist critique, a group of health professionals, the “Health at Every Size” (HAES ) movement, disputes the link between body size and health, arguing that healthy eating and regular physical movement are much more important for health than body size per se (Saguy 2013). There is no evidence in the Standing Committee’s report that the committee considered these critiques; instead, it presents a consensus view on the nature of the problem. Nor does the report contain any reference to another distinct body of literature that sidesteps the “truths” of obesity science to examine the social, political, and discursive aspects of the phenomenon. This externalist critique focuses on the ways in which power and dominant cultural ideas (e.g., about the body, femininity, and beauty) frame and construct the problem of obesity, and how this in turn limits our understanding of the problem and our responses to it (Saguy 2013). Indeed, there are fierce debates in some quarters of the academy about the “truths” and “politics” of the obesity epidemic (see Gard 2010;

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Patterson and Johnston 2012), but these debates seldom surface in the mainstream media or in public health and policy discussions, including the Standing Committee’s report. The Standing Committee’s report assumes the dominant “common sense” understanding of obesity and overweight as a simple function of excessive caloric intake relative to energy output despite significant scientific evidence that weight balance, gain, and loss involve complex physiological regulatory processes that are not yet entirely understood. The report also reflects and reproduces the taken-for-granted understanding of the relationship between body mass and health: that is, being overweight is unhealthy, and to be healthy, one must be slim. This common sense understanding ignores the growing body of scientific literature suggesting that it is not body mass per se that is a risk factor for disease, but rather inactivity, lack of fitness, and poor nutrition. This view that “health = thinness” and “thinness = health” serves to regulate and discipline bodies of all shapes and sizes, implying the need for weight control and weight loss (as necessary) in order to be healthy. The Standing Committee report also mobilizes bold rhetorical strategies that construct a sense of urgency about childhood obesity. Such strategies have enabled public health, health promotion and medical researchers, practitioners, and advocates to draw public attention to the issue of childhood obesity, helping to turn it into a pressing public health problem and attract funding for research. For example, a clear sense of fear and urgency was communicated to the public at large after the release of the report with media headlines repeating its warnings that this generation of children may not live as long as their parents (e.g., CBC News 2007; Montreal Gazette 2007). This demographic projection reflects the ways in which the language of “epidemic” is commonly used to describe childhood obesity as a self-evident crisis demanding immediate attention and action (Gard and Wright 2005; Saguy 2013). Once reserved for infectious diseases that spread rapidly through the population, the term epidemic is now used almost universally when referring to rising rates of overweight and obesity – conditions that are not diseases nor infectious and develop slowly, with an entirely different genesis than infectious diseases (Mitchell and McTigue 2007).

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Within the report itself, one of the most common and egregious rhetorical strategies is the conflation of obesity and overweight, which creates the impression that obesity affects many more people than it actually does. This pervasive rhetorical strategy is evident in the seamless slide between discussions of statistics for rates of “overweight and obesity” (which affect 26 percent of Canadian children and youth between ages two and seventeen) and a focus on the “childhood obesity epidemic” (when obesity affects only 8 percent of this age group). This produces a sense that the problem of obesity is widespread, affecting a quarter of Canadian youth, and thus requires immediate and serious intervention. This conflation also assumes that those who are overweight are “pre-obese,” well on their way down the slippery slope towards obesity and requiring similar interventions as those who are obese. This is misleading because, unlike the strong evidence of poor health outcomes for those who are significantly obese, such as hypertension, diabetes, heart disease, osteoarthritis, and some forms of cancer (Dixon 2010), the main health problem associated with being overweight is that it is a “risk factor” for obesity. In other words, being overweight confers no specific risk for health problems, and there is evidence to suggest that being overweight protects against premature mortality (Flegal et al. 2013). An important component of the construction of childhood obesity/ overweight as an urgent public health crisis is to finger parents as the primary agents responsible for safeguarding their children’s health and well-being by monitoring their body size, food intake, and physical activity. The Standing Committee report explicitly identifies Canadian parents as part of the problem because they apparently do not recognize that their children are overweight and obese. The report recommends that parents need to be “educated” and “involved” as part of the solution. However, like much of the discourse about the childhood obesity epidemic, no consideration is paid to the implications for parents of being responsible for managing their child’s “healthy” weight. While the report emphasizes “parents,” it is important to consider that the term parents is typically code for “mothers,” who, as many have discussed, still perform most of the domestic work to promote and maintain their children’s health (Beagan et al. 2008; Maher, Fraser, and Wright 2010; Thomas 1995; Zivkovic et al. 2010; Herndon 2010).

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Mothers’ health promotion work in the household has long been invisible, unrecognized, and undervalued (DeVault 1991; Graham 1985). With the vast majority of mothers carrying the double burden of workforce labour and domestic labour, some researchers have identified women’s management of work-life pressures and stresses as a significant public health issue in and of itself (e.g., Bryson et al. 2007), a concern unrecognized by the Standing Committee and most public health discourse. In the current framing of the childhood obesity epidemic, even mothers whose children are not obese or even overweight – the overwhelming majority of mothers – are positioned as having to exercise continual vigilance, monitoring their children’s consumption and activity patterns in our “obesogenic” environment to prevent their children’s weights from rising to “unhealthy” levels (Herndon 2010). Before examining further how maternal responsibilities are constructed in relation to the fat body of the child, in the next section, I consider how concerns about body size are not new but have intensified during periods of social change, reflecting anxieties about the regulation of desire, in relation to, for example, sexual freedoms and consumption patterns. The Fat Child’s Body and the Regulation of Desire in Consumer Society

Though the contemporary construction of the childhood obesity epidemic suggests that the increased body mass of children is a relatively new phenomenon, social anxieties about body mass are ancient concerns (Gilman 2008, 2010; Stearns 2002). Long before the twentieth century, for example, there were moral prohibitions against gluttony, and the thin body was associated with saintly virtue and a strong moral character. However, until recently, few people in the world had the necessary material resources for gluttony. The pursuit of thinness became a pervasive middle- and upper-class activity once prosperity began to spread and the opportunities for gluttony became more available (Bordo 1993). Peter Stearns (2002) argues that in the late nineteenth century, new arenas of constraint, especially bodily discipline and restricted eating, helped to compensate for the loss of religious discipline and

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increasingly indulgent levels of material consumption. The disciplining of diet also helped counterbalance the new freedoms that North Americans found in the realms of emotional expression and sexuality, and women’s new political freedoms. The thin body has long been a sign of moral virtue, but as religion began to lose its authority in the late nineteenth century, it came to be seen more generally as a sign of good character, as well as proof of health-consciousness and style (Stearns 2002, 54). By the late nineteenth and early twentieth centuries, as hours of work declined, and professional bureaucracies replaced entrepreneurship, “an appropriately slender figure could denote the kind of firm character, capable of self-control, that one would seek in a good worker in an age of growing indulgence … A good body, defined now by self-restraint, was a vital sign of moral quality” (Stearns 2002, 59–60). Just as the “good worker” could be identified by his body, his counterpart at home, the “good consumer,” could also be counted on to discipline her own desires and body, and do the same for their children, future workers and consumers. For women specifically, thinness became a visible marker of willpower, virtue, and self-discipline (Bordo 1993), reflecting a now persistent cultural obsession with female body size and shape (Bordo 1993; Chernin 1981). The concern with body discipline and the achievement of a slender body as a sign of virtuous self-control in a materialistic culture are not new preoccupations, and express broader cultural anxieties about the regulation of desire, particularly for women. In this light, the problem of childhood obesity can be read as a particular configuration of this cultural anxiety, in which the child’s fat body expresses the tensions of governing health and risk in the context of neoliberal consumer society.2 As levels of consumption have intensified over the course of the twentieth century, so too have anxieties about body weight, as reflected in the proliferation of discourse on the childhood obesity “epidemic” and knowledge that purports to link obesity and poor health outcomes. The definitive shift to a consumer society during this time also marks the beginning of the sharp upward trend in body mass among citizens of English-speaking Western countries. It is, perhaps, not surprising that anxieties about the fat child’s body have emerged at the end of the twentieth century, given the appeal of childhood obesity epidemic discourse across the political spectrum.

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Anxieties about obesity in children resonate with both the political right and the political left, and invoke shared, deeply held, socially constructed notions of childhood. For the political right, the fat child represents moral laxity and the weakening of the nuclear family, in which irresponsible and selfish mothers sacrifice their children’s interests, including homemade family dinners, to further their own careers. For the political left, the fat child symbolizes out-of-control corporate greed and its corruption of the innocent child through manipulative consumerism in the name of profit. In either case, the fat child’s body stands in for a defilement of the child’s purity and innocence. As well, and as I will go on to argue, the cultural obsession with the fat body of the child in neoliberal consumer society disciplines women by creating new expectations for mothers.

The Duties to Choose and Consume in the Name of Health

The ascendancy of consumer society in the 1970s and 1980s corresponds with a shift from welfare liberalism to neoliberalism and a concomitant shift towards holding the individual exclusively responsible for his or her health, including the regulation of body weight within prescribed medical limits. Crawford (2006) argues that the development in the 1970s of a health consciousness that defined health problems and solutions as mainly under personal control was fundamental to the ascendancy of neoliberal political ideology. As he states, the success of neoliberalism in promoting “privatized, market solutions to public problems cannot be grasped without a clear understanding of how personal responsibility triumphed over a political morality premised on collective responsibility for economic and social well-being” (Crawford 2006, 409). Zygmunt Bauman’s analysis of consumer society complements Crawford’s arguments by showing how the rise of the consumercitizen parallels the dominant construction of health as a moral obligation and personal responsibility in neoliberal society. As Bauman (1998) explains, consumer society primarily engages and governs its citizens as consumers, rather than producers. In consumer society, cit-

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izens seek identity, dignity, self-respect, and fulfillment in the market, buying, consuming, and disposing of goods and services in a continual cycle. In the context of producer society, citizenship was enacted through one’s work, and workers were expected to be disciplined, accustomed to monotony, and willing to delay gratification; however, the consumer-citizen is expected to gratify desires by constantly seeking stimulation and choice in the market: When waiting is taken out of wanting and wanting out of waiting, the consumptive capacity of consumers may be stretched far beyond the limits set by any natural or acquired needs or determined by the physical endurance of the objects of desire … [But] for all practical intents and purposes, it is the means, not the end, that counts. Fulfilling the vocation of the consumer means more choosing, whether or not this results in more consumption. To embrace the modality of the consumer means first and foremost falling in love with choice; only in the second, and not at all indispensable place, does it mean consuming more. (Bauman 1998, 25, 30) As Bauman explains, the virtuous citizen of contemporary neoliberal consumer society is governed by the twin, complementary imperatives to choose and to consume.3 In such a society, the fat body might well be considered a mark of virtue of the “good” consumer-citizen who seemingly indulges his/her desire by consuming more than biologically required. Instead, the fat body is read as a sign of improperly fulfilling the duties of citizenship, which include not only the duties to choose and consume, but also the duty to be healthy. Those who wish to be competitive and successful in neoliberal consumer society must continually balance the demands of these opposing duties, and the ambivalences and anxieties they create, by demonstrating that they can properly manage and discipline their desires. In neoliberal consumer society, conspicuous practices of health, such as diet and exercise, help resolve these contradictory duties (Crawford 2000, 2006). And it is the firm, toned, and thin body (which is read as “healthy”) that marks one’s success in navigating and mastering the complex and often contradictory duties of neoliberal citizenship.

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Thus, in addition to the duty to consume through self-indulgence, the production of proper neoliberal consumer-citizens involves the conspicuous demonstration of choices that reflect disciplinary values traditionally associated with the work ethic of production and reflected in the ideology of healthism (Crawford 1980). As Crawford (2000) explains, there is perhaps no better means to demonstrate such self-discipline, and judge an individual’s moral worth in secular culture, than through performances of health promotion activities and the conspicuous cultivation and display of the body’s health: In mobilizing anxieties and energies that speak to life and death, social action in the name of health validates individual worth and autonomy along with the institutions and forms of knowledge that are employed to protect and improve the body’s health. In our largely secular culture, health has become a key marker of identity and well-being – a code for signifying persons, qualities, moral capacities and situations. Health reveals the truth of a body that “cannot lie” and continues to provide one of modernity’s most effective “natural alibis” for masking the politically protected privileges of class, race and gender. In the body’s health, we search for and find confirmation of a life well lived or lived poorly, a nature within that discloses through signs and symptoms individual biographies and social trajectories. (225) In light of these ideas, the cultural conflation of health with the lean body, as reflected in popular discourse and contemporary problematizations of childhood obesity, has particular moral implications as individuals are expected both to consume and exercise self-discipline in the pursuit of health. The lean, muscular body is commonly read as an “unmistakable sign” of the disciplined virtues associated with the dominant, middle-class view of health, “an exemplar of mastery of mind over body and virtuous self-denial” (Crawford 1984, 70). Conversely, the soft, curvy, fat body is read as unhealthy, an ominous time bomb of disease that is read as gluttonous, out of control, undisciplined, disgusting, and immoral, beyond the boundaries of propriety. In neoliberal consumer society, the visible bodily signs of overweight

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and obesity signal a failure to properly balance the duties both to consume and be healthy. Food and the Duty to Consume Properly

One exemplary arena for understanding these features of proper citizenship in neoliberal consumer society is the “foodscape.” Medical sociologist Jeffrey Sobal describes the scope of this foodscape, created by the industrialized agro-food system: “Global corporations are establishing industrialized agro-food systems in almost all nations that will provide constant 24 hours a day/7 days a week/365 days a year consumer access to virtually unlimited volumes of relatively inexpensive calorifically dense foods to all people in all places at all times through supermarket, catering, vending, takeout, home delivered, drive through, and fast/snack foods” (Sobal 2001, 1137). Driven by the unending search for profit, the food corporations who dominate the global food system produce highly processed, highly marketed products, introducing thousands of new products every year. As a general rule, the more highly processed the product, the more profit there is to be made and the less healthy it is, such that corporate profit and individual health are usually in direct opposition (Nestle 2013). For the ideal consumer, who pays no attention to her health, the abundance of existing food products and the continual introduction of novel products is a dream-come-true – a veritable cornucopia of opportunities to make choices among the vast array of available food products. Such a foodscape would be an unimaginable paradise for the millions of people, including our ancestors, who lived in societies of scarcity, where most people struggled to ward off hunger, and fatness was a sign of wealth and success. But in contemporary consumer society, instead of representing success and wealth, the fat body is commonly reviled and held in distain. However, in societies like our own, where food is abundant and heavy physical exertion is optional for many, the thin, toned body is valued as a sign of distinction. In this context, the achievement and maintenance of the toned, muscular body requires resources, including time and money, and a healthist neoliberal disposition, one acquired through education, popular culture, and social networks, and oriented towards the unending pursuit of physical health.

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In the foodscape created by the industrialized agro-food system, where there are temptations on offer every moment of every day, the toned, muscular body can thus be understood as a sign of distinction, separating those who (appear to) exercise the moral virtues of restraint, discipline, self-control, and self-denial from those who do not (Guthman and Dupuis 2006). Julie Guthman and Melanie Dupuis argue that “to be worthy of more in a neoliberal polity, then, one must want less … while spending more” (445, emphasis in original). However, there is evidence that the toned, thin-bodied elites are not accorded distinction and virtue for wanting less; I argue instead that they achieve their sense of distinction by wanting, choosing, and consuming differently – and properly. For example, consider Whole Foods Market, an upper-class shrine to ethical, virtuous, responsible choice, where the signs exhort customers to “feel good about where you shop” (Johnston 2008). Whole Foods Market is a “natural foods” chain, with stores in upscale neighbourhoods across the United States, and a sprinkling in Canada (Vancouver and Toronto) and the United Kingdom (London, Glasgow, and Gloucestershire) in neighbourhoods where wealth is concentrated. It began in 1980 in Austin, Texas, during the critical time period identified by Crawford (2006) when individual responsibility for health was being cemented. Indeed, Whole Foods Market can be seen as a paradigmatic example of the shift that Crawford identifies in which concerns about health and the environment moved out of the collective, public realm into the private, individualized arena of the market, where profits can be made by trading on consumers’ desires and anxieties. Whole Foods Market assuages all the hot-button uppermiddle-class anxieties about consumption, especially concerning health and the environment, without sacrificing pleasure or choice. If one is not concerned about the expense, one can shop and eat guiltfree, feel virtuous about one’s choices, and maximize pleasure too – have one’s cake and eat it too. But, contra Guthman and Dupuis (2006), Whole Foods definitely does not encourage its virtuous customers to consume less. This would conflict with its core value of “creating wealth through profits & growth” (Whole Foods 2016). As Josée Johnston (2008) documents, one Whole Foods Market in Toronto offered “25 different varieties of

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natural macaroni and cheese, 129 varieties of boxed cereal, 147 different kinds of chips, puffs, popcorn and nachos, and 72 different kinds of bottled water” (250–1), what she describes, rather understatedly, as “an abundance of choice” (251). Along with this dizzying array of choice, Whole Foods offers exclusivity, products that are rarely, if ever, seen at run-of-the-mill grocery stores or even other specialty food shops, such as “hand-made coconut dusted marshmallows” (Johnston 2008, 230). As a particular niche in the foodscape, Whole Foods Market helps resolve some of the tensions between the demands of consumer society – to make choices and consume with glee and abandon, over and over again – with the neoliberal duty to be healthy, and further encourages its shoppers to consume ethically (Johnston, Szabo, and Rodney 2011), for example by buying green products (see Hasdell, chapter 2). By encouraging health through such virtuous consumption, Whole Foods Market thus offers its customers the opportunity to consume with distinction, markedly different than the “the culinary mainstream marked by fast-food and generic mass-market foods associated with ill-health, poverty, obesity” (Johnston 2008, 249). Similarly, the fitness industry, essential to the development and maintenance of a lean, hard, muscular body, produces good neoliberal citizens who consume commodities and services associated with keeping fit and maintaining health. As Roberta Sassatelli (2010) explains, fitness participants are good consumer-citizens because they see themselves as capable of making “good” choices. Moreover, fitness participants gain pleasure from their fitness choices, thus reconciling discipline and fun, and promoting their health through pleasure (Sassatelli 2010). The duty of a good, virtuous, neoliberal consumer-citizen, then, is to know how to make proper, responsible choices in the marketplace and to exercise restraint and responsibility in that freedom of choice – a disciplined, responsibilized freedom that is nonetheless associated with fun and pleasure. To resolve the tensions between the duty to consume and the duty to be healthy (i.e., self-disciplined, selfcontrolling, self-responsible), the proper choices are conspicuously healthy and ethical choices: fruit and vegetables (preferably organic and locally grown) not processed food; slow food not fast food; workouts

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at the gym not video gaming; eco-tourism vacations not casino vacations. The conspicuousness of these healthy, virtuous consumer practices is one more layer of defence, as is the symbolism of the toned, hard, muscled, thin body, that demonstrates to oneself and others one’s distinction and virtuousness, and repels the ubiquitous risks of excess, softness, and lack of discipline that consumption induces, as materialized in the fat body. Fat Children and Mothers’ Duties in Neoliberal Consumer Society

In its visual presentation of excess and softness, the antithesis of the disciplined and healthy body, the fat body creates unease, but no more so than when the fat body is that of the child. The figure of the child “has always been the focus of adult fears, desires and fantasies” (Buckingham 2000, 3) and is symbolic of the social order (Jenks 1996). Much as “the ways in which we conceptualize and speak and write about health are never just about health” (Robertson 1998, 155), the ways in which we think about the child are also about more than the child (Maher, Fraser, and Lindsay 2010; Maher, Fraser, and Wright 2010; Zivkovic et al. 2010). The figure of the fat child unsettles us because we read it as a potent symbol of social decay and moral failure that threatens the future of society. The fat child represents the failure to inculcate in the child the dispositions of proper, disciplined, responsible consumption that are required to produce “good” neoliberal citizens who can be governed through freedom. Though schools, Big Food, electronic devices, and others are often named as contributors to the childhood obesity epidemic, the blame, implicitly or explicitly, is most often laid at the feet of mothers (Kokkonen 2009; Bell, McNaughton, and Salmon 2009; Maher, Fraser, and Lindsay 2010; Maher, Fraser, and Wright 2010; Zivkovic et al. 2010), even, at times, before their children are born (McNaughton 2010). The duties of mothers in neoliberal consumer society represent a continual and practically impossible balancing act, in part because of conflicting constructions of childhood and the resulting expectations of parental responsibilities. The dominant North American construc-

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tion of childhood views children as impulsive, irrational, and prone to indulging sensual pleasures and as lacking the ability to make reasoned, responsible choices.4 Co-existing with this Dionysian construction of the child is an opposing Apollonian one (Jenks 1996) in which children are viewed as pure and innocent, untainted by the world and unaware of the guile and connivances of the adult world (Cross 2004). Together, these constructions constitute the child as vulnerable, requiring the protection, nurturance, guidance, and wisdom of adults to survive and develop successfully (Christensen 2000). The child is also the repository of adult projections, anxieties and fears, such that “whatever we say about children and childhood is not altogether really about children and childhood” (James Hillman qtd in Jenks 1996, 69). In this sense, the contemporary anxiety about childhood obesity is one in a long line of anxieties about the effects of popular culture on pure, innocent, untainted children (Gilbert 1986). As Nikolas Rose (1989) explains, “Childhood is the most intensively governed sector of personal existence. In different ways, at different times, and by different routes varying from one section of society to another, the health, welfare, and rearing of children have been linked in thought and practice to the destiny of the nation and the responsibilities of the state. The modern child has become the focus of innumerable projects that purport to safeguard it from physical, sexual and moral danger [and] to ensure its ‘normal’ development” (1989, 121). The child’s fat body particularly offends us because it represents the awakening of insatiable consumer desire in a period of life that has been constructed as innocent of desire. With so many of our anxieties about health, consumption, and the future projected onto the child, the figure of the fat child is a potent symbol of failed citizenship (Elliott 2007) and raises alarm about who we are as a society and who we will become in the future. In particular, the fat child symbolizes the failure of mothers to demonstrate disciplined freedom in making proper food and activity choices for their children, to cultivate the proper disposition required for their children’s future success in making their own responsible consumer choices, and to protect their children from the predatory marketplace and its endless evocation of desire. It also represents failure on the part of the state, which has neglected its duties

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to protect citizens from the excesses of consumer capitalism, for example, by banning unhealthy food advertising to children, or providing physical activity and healthy foods in schools. Discussion

Within these parameters of responsible citizenship in neoliberal consumer society, mothers walk a fine line, balancing the duty to protect their children from the predations of the marketplace while indulging them with unhealthy “treats” for pleasure and fun (considered a key component of childhood [James 1990]) with teaching their children to consume properly – in the name of health and, as Hasdell explains in chapter 2, according to the principles of precautionary consumption. In the overwhelming sea of choices, from what food to eat to what activities to engage in, where the individual must exercise freedom responsibly by making wise, healthy, and ethical choices, mothers must be constantly vigilant to protect their children from desire that grows out of bounds and keep intact the fortress of self-discipline. This is an individualized, privatized balancing act, much of which remains invisible, like domestic labour more generally, where mothers are expected to juggle work outside the home with the care and health promotion of their children. Mothers are expected to manage their children’s health by regulating their consumption of food and activities, much as they are expected to manage their tween girls’ sexuality in relation to possible future disease (see Cayen, Polzer, and Knabe, chapter 3), and mothers are also framed and blamed as a significant part of the problem of the childhood obesity epidemic (Maher, Fraser, and Wright 2010; Herndon 2010). Mothers’ abilities to ensure that their children consume properly and to teach them disciplined freedom in consumption is, however, always dubious and open to surveillance. As women, mothers are suspect as consumers, seen as emotional and flighty, slaves to their outof-control desires (Sassatelli 2007; Sandlin and Maudlin 2012). For mothers who fail to take up and successfully enact their duties of disciplined consumption, the state may enact harsher, disciplinary measures. For example, some jurisdictions have implemented mandatory surveillance of students’ weights at school, which are recorded on stu-

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dent report cards along with their grades. In the United States and the UK, state agencies have taken custody of severely obese children, charging parents with abuse and neglect (Herndon 2010; Lebesco 2010). In conclusion, the fat child’s body symbolically marks mothers as failed consumer-citizens and marks children as failed future citizens. Furthermore, the spectre of the fat child, as promoted in the childhood obesity discourse governs all mothers, even those whose children are not overweight. As the dominant discourse on the childhood obesity epidemic would have it, all children are “at risk”; danger lurks everywhere in the obesogenic environment that surrounds us. As the neoliberal state withdraws its responsibility to protect the vulnerable and promote children’s health (e.g., the cancellation of compulsory physical education and home economics classes), mothers are increasingly charged with the responsibility of having to promote their children’s health through responsible consumer choices (e.g., healthy food, sports, physical activity, and recreation). To ensure the success of their children in neoliberal consumer society, mothers must relentlessly perform the fine balancing act of protecting their children from insidious market forces, indulging them, and teaching them how to make disciplined, wise choices – to consume properly and responsibly – in the name of health.

Acknowledgments

I would like to thank Jessica Polzer, Gwen Chapman, Josée Johnston, and Jennifer Brady for their very helpful comments on earlier drafts of this paper.

N ot e s

1 Children are considered overweight if their body mass index (BMI ) is between the eighty-fifth and ninety-seventh percentiles for their age and sex, and obese if their BMI is above the ninety-seventh percentile for age and sex. 2 While historians suggest that we began the shift from a producer to a consumer society at the end of the nineteenth century, sociologists argue that it is only since the mid-1970s that our consumption practices have

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intensified to the point where we can rightly say that we live in a consumer society (Bauman 1998). 3 There has been perhaps no clearer popular indication of the importance of consumer spending to performing one’s duty as a good citizen than the admonitions of political leaders in the United States, Canada, and the UK to go out and “spend money” on consumer goods and services in the wake of the terrorist attacks of 11 September 2001. As one Florida mayor declared, “it has never been more patriotic to go shopping” (Vardy and Wattie 2001). In other words, shopping is a demonstration of being a good citizen, doing one’s part for the economy and thus for the nation. 4 With the intensification of the ethos of consumer society, there are many more opportunities for children themselves to choose, buy, and consume. As children have gained access to their own money, and now exert considerable influence over family spending decisions, a whole new domain of marketing that is oriented to children has opened up, and marketers have intensified their efforts to sell products to younger and younger children (Schor 2004). References

Bauman, Zygmunt. 1998. Work, Consumerism, and the New Poor. Buckingham, UK: Open University Press. Beagan, Brenda, Gwen E. Chapman, Andrea D’Sylva, and B. Raewyn Bassett. 2008. “‘It’s Just Easier for Me to Do It’: Rationalizing the Family Division of Foodwork.” Sociology 42 (4): 653–71. doi:10.1177/0038038508091621. Bell, Kirsten, Darlene McNaughton, and Amy Salmon. 2009. “Medicine, Morality and Mothering: Public Health Discourses on Foetal Alcohol Exposure, Smoking around Children and Childhood Overnutrition.” Critical Public Health 19 (2): 155–70. Bordo, Susan. 1993. Unbearable Weight: Feminism, Western Culture and the Body. Berkeley: University of California Press. Bryson, Lois, Penny Warner-Smith, Peter Brown, and Leanne Fray. 2007. “Managing the Work-Life Roller-Coaster: Private Stress or Public Health Issue?” Social Science & Medicine 65:1142–53. Buckingham, David. 2000. After the Death of Childhood: Growing Up in the Age of Electronic Media. Cambridge: Polity Press. Campos, Paul. 2004. The Diet Myth: Why America’s Obsession with Weight Is Hazardous to Your Health. New York: Gotham Books. CBC News. 2007. “Obese Children Will Die Younger than Their Parents: Report.” 27 March. http://www.cbc.ca/news/health/story/2007/03/27/ obesity-child.html. Chernin, Kim. 1981. The Obsession: Reflections on the Tyranny of Slenderness. New York: Harper and Row.

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Christensen, Pia. 2000. “Childhood and the Cultural Construction of Vulnerable Bodies.” In The Body, Childhood and Society, edited by Alan Prout, 38–59. Basingstoke: Macmillan. Crawford, Robert. 1984. “A Cultural Account Of ‘Health’: Control, Release, and the Social Body.” In Issues in the Political Economy of Health Care, edited by John B. McKinlay, 60–103. New York: Tavistock. – 2000. “The Ritual of Health Promotion.” In Health, Medicine, and Society: Key Theories, Future Agendas, edited by Simon J. Williams, 219–35. London: Routledge. – 2006. “Health as a Meaningful Social Practice.” Health 10 (4): 401–20. Cross, Gary. 2004. The Cute and the Cool: Wondrous Innocence and Modern American Children’s Culture. Oxford: Oxford University Press. DeVault, Marjorie. 1991. Feeding the Family: The Social Organization of Caring as Gendered Work. Chicago: University of Chicago Press. Dixon, John B. 2010. “The Effect of Obesity on Health Outcomes.” Molecular and Cellular Endocrinology 316 (2): 104–8. doi:10.1016/j.mce.2009.07.008. Eisenberg, Mark J., Renée Atallah, Sonia M. Grandi, Sarah B. Windle, and Elliot M. Berry. 2011. “Legislative Approaches to Tackling the Obesity Epidemic.” Canadian Medical Association Journal 183 (13): 1496–1500. Elliott, Charlene D. 2007. “Big Persons, Small Voices: On Governance, Obesity, and the Narrative of the Failed Citizen.” Journal of Canadian Studies 41 (3): 134–49. Flegal, Katherine M., Brian K. Kit, Heather Orpana, and Barry I. Graubard. 2013. “Association of All-Cause Mortality with Overweight and Obesity Using Standard Body Mass Index Categories: A Systematic Review and Meta-Analysis.” JAMA 309 (1): 71–82. doi:10.1001/jama.2012.113905. Foucault, Michel. 1991. “Governmentality.” In The Foucault Effect: Studies in Governmentality, edited by Graham Burchell, Colin Gordon, and Peter Miller, 87–104. Chicago: University of Chicago Press. Gard, Michael. 2010. “Truth, Belief, and the Cultural Politics of Obesity Scholarship and Public Health Policy.” Critical Public Health 21 (1): 37–48. doi:10.1080/09581596.2010.529421. Gard, Michael, and Jan Wright. 2005. The Obesity Epidemic: Science, Morality and Ideology. New York: Routledge. Gilbert, James. 1986. A Cycle of Outrage: America’s Reaction to the Juvenile Delinquent in the 1950s. New York: Oxford University Press. Gilman, Sander L. 2008. Fat: A Cultural History of Obesity. Cambridge: Polity Press. – 2010. Obesity: The Biography. Oxford: Oxford University Press. Graham, Hilary. 1985. “Providers, Negotiators, and Mediators: Women As the Hidden Carers.” In Women, Health, and Healing, edited by Ellen Lewin and Virginia Olesen, 25–52. New York: Tavistock Publications.

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Guthman, Julie, and Melanie Dupuis. 2006. “Embodying Neoliberalism: Economy, Culture and the Politics of Fat.” Environment & Planning D: Society and Space 24:427–48. doi:10.1068/d3904. Herndon, April Michelle. 2010. “Mommy Made Me Do It: Mothering Fat Children in the Midst of the Obesity Epidemic.” Food, Culture & Society 13 (3): 332–49. House of Commons Standing Committee on Health. 2007. Healthy Weights for Healthy Kids. Ottawa: House of Commons. http://www.parl.gc.ca/ HousePublications/Publication.aspx?DocId=2795145. James, Allison. 1990. “The Good, the Bad and the Delicious: The Role of Confectionery in British Society.” Sociological Review 33 (4): 66–88. Jenks, Chris. 1996. Childhood. London: Routledge. Johnston, Josée. 2008. “The Citizen-Consumer Hybrid: Ideological Tensions and the Case of Whole Foods Market.” Theory and Society 37:229–70. doi:10.1007/s11186-007-9058-5. Johnston, Josée, Michelle Szabo, and Alexandra Rodney. 2011. “Good Food, Good People: Understanding the Cultural Repertoire of Ethical Eating.” Journal of Consumer Culture 11:293–318. Kokkonen, Riina. 2009. “The Fat Child – A Sign of ‘Bad’ Motherhood? An Analysis of Explanations for Children’s Fatness on a Finnish Website.” Journal of Community & Applied Social Psychology 19 (5): 336–47. doi:10.1002/ casp.1020. Lebesco, Kathleen. 2010. “Fat Panic and the New Morality.” In Against Health: How Health Became the New Morality, edited by Jonathan M. Metzl and Anna Kirkland, 72–82. New York: New York University Press. Maher, JaneMaree, Suzanne Fraser, and Jo Lindsay. 2010. “Between Provisioning and Consuming?: Children, Mothers and ‘Childhood Obesity.’” Health Sociology Review 19 (3): 304–16. Maher, JaneMaree, Suzanne Fraser, and Jan Wright. 2010. “Framing the Mother: Childhoood Obesity, Maternal Responsibiilty and Care.” Journal of Gender Studies 19 (3): 233–47. McNaughton, Darlene. 2010. “From the Womb to the Tomb: Obesity and Maternal Responsibility.” Critical Public Health 21 (2): 179–90. doi:10.1080/ 09581596.2010.523680. Mitchell, Gordon R., and Kathleen M. McTigue. 2007. “The US Obesity ‘Epidemic’: Metaphor, Method, or Madness?” Social Epistemology 21 (4): 391–423. doi:10.1080/02691720701746557. Montreal Gazette. 2007. “Child Obesity an Epidemic in Canada: Report.” 28 March. http://www.canada.com/montrealgazette/story.html?id=150adf76 6487-4779-abb9-e7d527a14f63. Nestle, Marion. 2013. Food Politics: How the Food Industry Influences Nutrition and Health. Edited by Darra Goldstein. Revised and expanded Tenth Anniversary ed. Berkeley: University of California Press.

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Oliver, J. Eric. 2005. Fat Politics: The Real Story behind America’s Obesity Epidemic. New York: Oxford University Press. Patterson, Matt, and Josée Johnston. 2012. “Theorizing the Obesity Epidemic: Health Crisis, Moral Panic and Emerging Hybrids.” Social Theory & Health 10 (3): 265–91. doi:10.1057/sth.2012.4. Robertson, Ann. 1998. “Shifting Discourses on Health in Canada: From Health Promotion to Population Health.” Health Promotion International 13 (2): 155–66. Rose, Nikolas. 1989. Governing the Soul: The Shaping of the Private Self. Lon­don: Routledge. – 1999. Powers of Freedom: Reframing Political Thought. Cambridge: Cambridge University Press. Saguy, Abigail C. 2013. What’s Wrong with Fat? New York: Oxford University Press. Saguy, Abigail, and Kevin Riley. 2005. “Weighing Both Sides: Morality, Mortality and Framing Contests over Obesity.” Journal of Health Politics, Policy and Law 30:869–921. Sandlin, Jennifer A., and Julie G. Maudlin. 2012. “Consuming Pedagogies: Controlling Images of Women as Consumers in Popular Culture.” Journal of Consumer Culture 12 (2): 175–94. Sassatelli, Roberta. 2007. Consumer Culture: History, Theory and Politics. London: Sage. – 2010. Fitness Culture: Gyms and the Commercialisation of Discipline and Fun. Basingstoke, UK : Palgrave Macmillan. Schor, Juliet B. 2004. Born to Buy: The Commercialized Child and the New Consumer Culture. New York: Scribner. Shields, M. 2006. “Overweight and Obesity among Children and Youth.” Health Reports 17 (3): 27–42. Sobal, Jeffery. 2001. “Commentary: Globalization and the Epidemiology of Obesity.” International Journal of Epidemiology 30:1136–7. Stearns, Peter N. 2002. Fat History: Bodies and Beauty in the Modern West. 2nd ed. New York: New York University Press. Thomas, Carol. 1995. “Domestic Labour and Health: Bringing It All Back Home.” Sociology of Health & Illness 17 (3): 328–52. Vardy, Jill, and Chris Wattie. 2001. “Shopping Is Patriotic, Leaders Say.” National Post, 28 September. Whole Foods Market. 2016. “Our Core Values.” Accessed 21 January. www.wholefoodsmarket.com/mission-values/core-values. Zivkovic, Tanya, Megan Warin, Michael Davies, and Vivienne Moore. 2010. “In the Name of the Child: The Gendered Politics of Childhood Obesity.” Journal of Sociology 46 (4): 375–92.

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Ch a p t e r 2

Environment-as-Risk and Green Consumerism in Neoliberal Public Health Practices Rebecca Hasdell

Introduction

In Canada and elsewhere, climate change and other forms of environmental damage have been identified as leading public health challenges for the twenty-first century (Costello et al. 2009). Recent research suggests that while the scale and scope of climate change and ecosystem degradation might be accelerating faster than initially predicted, these threats have not been met by commensurate shifts in policy. Environmental damages produce both direct and indirect health concerns. Direct impacts include temperature-related morbidity and mortality, water- and food-borne contamination, health effects from extreme weather events, a decrease in air quality, and an increase in vector-borne and zoonotic disease (Catford 2008; Health Canada 2008). Indirect effects may include resource shortages and economic instability (Health Canada 2008), as well as political unrest and mass population displacement and migration (Catford 2008). Public health efforts to examine the health impacts of climate change have primarily focused on “risk management” approaches, as expressed by activities such as the surveillance and monitoring of, and rational planning for, the health consequences of environmental

change (Catford 2008; Poland, Dooris, and Haluza-Delay 2011). John Catford (2008) comments on the limitations of such risk-based strategies in a critique of the United States Centers for Disease Control and Prevention’s (CDC ) priority areas of action on climate change, noting that such approaches focus on the downstream management of the health effects of climate change rather than upstream engagement with mitigation and adaptation measures. In the Canadian context, early efforts made by Health Canada to assess vulnerabilities and adaptive capacity to climate change take a similar risk management approach. While efforts to manage the health consequences through epidemiological and technical means may have a place in the public health response to climate change and other forms of environmental risk, such critiques raise questions concerning the extent to which focusing narrowly on the management of specific health risks defers attention from upstream strategies on the causes and determinants of environmental change in order to prevent exposures to health-compromising environmental conditions. The prevalence of such risk management approaches has taken shape in the face of accumulating sociological analysis that the root causes of environmental challenges result from growth-oriented capitalism and the demand it creates for growing consumer markets (Beck 2010; Smart 2011; Urry 2010). The growth paradigm has flourished in a neoliberal social and political climate marked by limiting and retrenching state services and programs oriented to monitoring and regulating industrial activity and production. While the hyperconsumerism associated with demands for the relentless pursuit of profit has become a global icon for economic “progress,” continual growth in production and consumption has resulted in undeniable ecological, social, and economic consequences. In other words, while the embrace of neoliberal policies to ensure “growth at all costs” engenders continued planetary destruction (Urry 2010), public health attention remains focused on the “risks” rather than the roots of these concerns. In this chapter, I draw on poststructural conceptions of risk and Foucauldian notions of governance in order to better understand the assumptions underlying current public health activities aimed at the management of environmental threats to health. First, I situate public health as a form of governance that operates by directing individual

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practices towards a particular type of “responsible citizen” who manages individual risks through bodily self-discipline. Then, I draw on examples from environmental health to examine how public health discussions about environmental health risks place further demands on citizens to participate in “green consumerism” in the interest of their own health, the health of others (e.g., family members), and the health of the environment. I draw from literature on “green governmentality” to demonstrate how health citizenship is being absorbed into the governance of nature, producing a subject whose practices of self-care are implicated in their care for the environment. I conclude by considering how these practices constitute a form of precautionary consumption that reinforces and perpetuates neoliberal market rationality, and contributes to deepening health inequities by creating new forms of stratification through demands for citizens to be both “healthy” and “green.” Neoliberal Governance in Environmental Public Health

The idea of the “risk society” (Beck 1992) rose to prominence in the last twenty years in the sociology of health literature and drew attention to the way that risk has become a central concept in both professional and lay understandings of health. Risk discourses are particularly pervasive in the “new public health” (Petersen and Lupton 1996) where the focus is on the management and control of risk to prevent disease and promote health. The new public health includes practices and techniques of monitoring, measuring, and surveying to delineate categories of risk, taking as foci both “populations” and “environments.” Alan Petersen and Deborah Lupton (1996) provide a comprehensive historical examination of environment in the risk society, detailing how contemporary forms and practices of public health construct and focus on environmental “risks” to health at dispersed sites and sources of danger that originate beyond localities. Citing such examples as chemical proliferation, food contamination, and the rise of the nuclear industry, these authors argue that the pervasive yet invisible nature of these risks bring them into the purview of experts who have the knowledge and capacity to identify and interpret potential dangers.

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Citizens are expected to digest and adhere to these expert knowledges, and thus to be “ever vigilant, seeking to both protect themselves from the risks generated by others and to reduce the damage they inflict upon the environment” (Petersen and Lupton 1996, 99). This poststructural analysis of risk draws attention to the “ways in which the discourses, strategies, practices and institutions that have developed around risk both reflect and construct a distinct approach to selfhood, society and the government of populations” (Lupton 1999, 86). On the surface, the individualization of risk has the appearance of promoting freedom of choice amid the hyperconsumerist options offered in the globalized economy. Yet, as Jessica Polzer and Elaine Power articulate in the introduction to this book, this very “freedom” of choice is produced, shaped, and constrained by notions of “responsibility” and “health” that are promoted by institutions such as public health. As such, individual choices are inextricably caught up in the neoliberal political rationality associated with growth-oriented capitalist production and consumption. In this markedly individualized approach, the neoliberal shaping of environmental concerns is revealed in the emphasis placed on the individual management of environmental health risks through lifestyles “choices” (Petersen and Lupton 1996). Neoliberal governance displaces political and public attention from the duty to protect the public’s health through the development of policies that aim to remove contaminants and ensure the provision of safe and clean environments, emphasizing rather individuals’ duties to protect themselves and others (e.g., family, community) through their own management of environmental health risks, typically through the promotion of particular consumption and lifestyle “choices” (Batt and Lippman 2010). Within this logic of risk management, individual citizens are charged with the responsibility to adopt particular practices to protect their own health, the health of others (e.g., family members), and also the health of the environment. It is within this context of environmental risk management that a particular type of “environmental health citizenship” emerges, one that individualizes political responses to environmental damages and places dual demands on citizens to be both “healthy” and “green.” Some authors have attempted to reconcile these practices through the theoretical lens of “ecological modernization”

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or “free market environmentalism,” whereby market solutions to environmental health risks are rendered compatible with economic growth. However, others have surfaced the many tensions and contradictions of such conciliatory approaches (Hobson 2013; Teelucksingh and Poland 2011). In the following section, I offer new insights into how the “healthy citizen” – who is also the “environmental citizen” – is made in public health, using examples from environmental health. In doing so, I bring into conversation a poststructural analysis of the governance of health in neoliberal societies with work by geographers and environmental scientists on the governance of nature, or “green governmentality.” These overlapping analyses illuminate how discourses of environmental risk management extend the poststructural conception of the disciplined, self-governing healthy citizen to incorporate an obligation to the environment, both for the sake of one’s health and for the prosperous continuation of the planet (Petersen and Lupton 1996). Green Governmentality, Consumerism, and the Greening of the Self

“Green governmentality” offers a reading of how the environment on which humanity subsists, and the techniques and forms of expertise that render it visible and knowable, shape environmental subjectivities to incite particular forms of environmental action, and subsequently forms of “environmentalism” (Hobson 2013; Rutherford 2007). As outlined in the introduction, in critical health studies, governmentality has been used as a conceptual framework to interrogate how public health practices and discourses on health risk more generally are implicated in the government of individual and collective bodies (e.g., Petersen and Lupton 1996; Polzer 2005; Robertson 2001). Green governmentality scholars focus on the calculation of the natural world with which these bodies rely on and interact, offering another analytic layer to recurring arguments, including those made by the authors in this collection, concerning how individual bodies are disciplined and populations regulated through neoliberal governance. Specifically, these authors note that, in the case of the natural world, “to know, to measure, to assess, to document risk and propose its necessary rem-

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edies are the tools that the environmental sciences use to construct and circumscribe the problems and their self-evident solutions” (Rutherford 2007, 298). The monitoring and regulation of the environment by the state, civil society, and private actors produces types of knowledge that construct nature as an entity that requires human intervention, and proposes who, and by what means, it can be “saved.” A number of authors (Dar­ ier 1996a, 1996b; Hobson 2013; Rutherford 2007; Watts 2012) suggest that, given the far reach of globalization and free-market economics in a neoliberal era, a market- and civic-driven “environmental citizenship” takes shape. Individual practices are positioned at the centre of this form of citizenship, and citizens are steered towards lifestyle and consumption choices that are packaged as attractive and simple, such as turning off lights, composting, using recyclable materials, and the like (Hobson 2013; Rutherford 2007). For example, scholars have applied a green governmentality lens to examine individual education and behaviour change programs such as Canada’s Green Plan (Darier 1996a), recycling programs (Darier 1996b), and household energy saving programs (Hobson 2013). More recently, the individualizing nature of environmental citizenship has begun to embed itself in the field of public health, in part due to the remarkable growth in the availability and marketing of “green” or “sustainable” consumer products (Connolly and Prothero 2008; Wall 2000). An emergent body of research has begun to explore the move towards viewing environmental problems through a health lens, suggesting that there is a growing imperative for individuals to manage environmental risks with the aim of producing a healthy body and a healthy environment. This research includes Norah MacKendrick’s (2010) frame analysis of media representations of chemical bioaccumulation, or “body burdens,” and qualitative research with mothers about how they negotiate ideals of organic, local, and ethical feeding practices (Cairns, Johnston, and MacKendrick 2013) and how they perceive and cope with everyday home and neighbourhood environmental contaminants (Crighton et al. 2013). Safeguarding the health of children, family, and home are activities typically conducted by mothers. Thus, the imperatives of green governmentality and consumerism to manage environmental health risks intersect with and

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inform practices of “good mothering” and incite considerable stress and anxiety since constant vigilance is required in order to protect the child’s health, as well as the innocence and purity of childhood, against multiple potential threats, whether these threats are constituted as the “obesogenic” environments that Power describes in her analysis of the childhood obesity “epidemic” in chapter 1, or the damaged physical environments described in this chapter. Taken together, this research suggests similarly gendered strategies and experiences of governance aimed at mothers who are expected to control environmental dangers through individualized practices such as the purchase of organic, sustainable, and ethical food (Cairns, Johnston, and MacKendrick 2013; Toronto Public Health 2009) and green cleaning products (Crighton et al. 2013). MacKendrick (2010) captures the “ideological congruence” of green consumerism with neoliberalism with the term “precautionary consumption,” defined as the selective choosing of goods marketed as enabling “green” or “healthy” choices. Precautionary consumption can be considered as the “better safe than sorry” language of the precautionary principle, but applied at the individual-level of the consumer (MacKendrick 2010). While the precautionary principle takes as its aim the protection of the collective from risk through policy and regulatory action, precautionary consumption prioritizes self-protection from risk through individual acts of consumption and “choices” that are framed as “green” and, therefore, “ethical.” The research outlined above suggests that public health messaging about environmental health risks and individuals’ interpretations of those messages indicate a shift away from the priorities and mentalities of the “precautionary principle” to “precautionary consumption.” The precautionary principle “dictates that we frame and enforce our environmental and health regulations to emphasize safety instead of risk” (Batt and Lippman 2010, 54), and mandates the state to restrict and regulate industrial activity in favour of protecting public health and safety in cases of scientific uncertainty (for example, by controlling the production of toxic chemicals). The precautionary principle embraces the uncertainty of risk, meaning that “evidence of a potential risk is not required before action is taken to mitigate the effects of the potential risk” (Weir et al. 2010, 396). “Green” or “precautionary” consumption reflects the same

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embodiment of uncertainty, but shifts the burden of action toward the individual, who is urged to make consumption choices that minimize risk. Public health discourse on environmental health is thus shaped by neoliberalism in that concerns about the environment and health are constructed so as to not interfere with maintaining industrial activities and promoting market growth and corporate profits through consumption practices. The examples of precautionary consumption detailed above (e.g., the purchase of “green” cleaning products) extend the responsibilities of the entrepreneurial, neoliberal healthy subject that has been widely described in critical accounts of health promotion (Gastaldo 1997; Nettleton and Bunton 1995), a subject who devotes time, attention, and energy to a range of preventative health behaviours. The individualization of environmental health risk circulated through institutions and practices of social life expand the range of work on oneself that is required for healthy citizenship beyond the disciplining of the body through diet, exercise, and control of potentially “risky” behaviours (e.g., sex, alcohol and tobacco consumption) to include particular forms of green consumption practices. In a neoliberal climate where “risk prevention” is actively promoted by both the market and public institutions, public health practices become implicated in naturalizing green consumption practices construed as healthy for self and environment. To be healthy is no longer sufficient for responsible citizenship; the responsible citizen must be both healthy and green. Less research attention has been paid to how the institutions and practices of public health are implicated in promoting individualizing discourses of environmental risk and how they may reinforce or resist precautionary consumption for individual and environmental protection. An instructive example comes from the Canadian Partnership for Children’s Health and the Environment (CPCHE ), an affiliation of public and non-profit health and environmental organizations. Noting that “every day, from the beginning of their lives, children in Canada are exposed to potentially hazardous substances where they live, learn, and play” (CPCHE 2005, 2), CPCHE provides a host of educational materials with tips and strategies to reduce or eliminate exposures from air, water, soil, food, and products from before conception to the early years. Such an approach is not unique, but embedded in normative

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educational aims adopted by most environmental organizations and guided by government policy objectives (Darier 1996a). The outreach materials of CPCHE similarly reflect many of the naturalized “protective” practices described by the mothers in Cairns, Johnston, and MacKendrick (2013) and Crighton et al. (2013) to protect environmental health. Along with tips addressing behavioural practices concerning home care tasks such as cleaning, renovating, and waste disposal, consumption practices such as eating a diet high in fruits, vegetables, and grains, choosing organic or unprocessed foods, picking glass over plastic for food storage, using non-toxic toys and craft supplies, and decorating with low-VOC products are encouraged (CPCHE 2005). In raising this example, I am not suggesting that such educational and behavioural approaches to risk reduction don’t have a place in the suite of strategies that public health has as its disposal to promote and protect health. It is also noteworthy that CPCHE engages the public to put pressure on businesses, industry, and all levels of government to enact legislations and regulations to protect children from environmental hazards (CPCHE 2005), suggesting that multiple discourses circulate on how risk may be averted. In bringing a Foucauldian perspective to understand the governance of environmental health risks, my aim is rather to draw attention to how discourses of risk in relation to both the environment and health are mobilized and taken up within neoliberal modes of governance, and how citizens are “‘worked up,’ through what means, and to what ends” (Hobson 2013, 57) by these discourses. As suggested earlier, the orientation of public health programs towards individualized and market-based messaging is instrumental in shaping predominantly individual – and particularly maternal – approaches to the management of risk to self, child, and environment (Cairns, Johnston, and MacKendrick 2013; Crighton et al. 2013). However, as both Cairns, Johnston, and MacKendrick (2013) and Crighton et al. (2013) point out, mothers are reflexive towards the material constraints of meeting obligations towards “greener and cleaner” forms of consumption and engage in a give and take between “ideal” forms of consumption and what is feasible within the situated contexts of their daily lives. Despite their expressions of tension and conflicted feelings, the difficulties of meeting this ideal were described by these women as personal failures rather than structural deficiencies,

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thus deflecting critique from the sources of environmental health risks and strengthening the expectation that individuals conform to naturalized (i.e., maternal) protective actions. Discussion

In this chapter, I have explored how environmental health risk discourses harness the strategies of neoliberal governance to discipline individuals towards practices that purport to serve the interests of the individual and society but most certainly benefit the interests of the market. I have applied Foucault’s concepts of risk and governance to explicate how current definitions of environmental health risks aim to organize individual practices in ways that reinforce the individualization of risk in modern society. I have suggested that this individualization of risk cannot be extricated from the prevailing neoliberal political rationality that shifts responsibility from state intervention to individual practices, reinforcing the idea that individuals have both a duty and the ability to act to protect their health through consumption activities in lieu of regulatory actions provided by the state to protect the public’s health. While this analysis offers a small window into what is certainly a more nuanced picture, a number of implications for research and future efforts by public health may be inferred. First, while green consumerism is promoted as a type of risk management, concurrent recognition is required that not everyone has the financial resources to participate in these practices. Surfacing questions of who is able to participate in green consumerism to make the “healthiest of healthy” choices raises the larger discussion of who benefits from individualized approaches to the management of environmental health risks. Critical engagement with these questions is necessary to avoid validating – and exacerbating – existing stratifications in health through multiple pathways. While those who are financially well-off can afford to participate in green consumption, economically marginalized populations continue to be subjected to potentially harmful environmental exposures. Of additional concern is the potential for increasingly normalized consumption practices to further marginalize individuals who cannot exercise the ability to participate in the seemingly virtuous

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activities of “good environmental citizenship.” Those individuals who cannot manage these practices might be vilified for their inability to protect their own health and that of their families, and also for how their “un-green,” or unhealthy, choices are implicated in wider envi­ ronmental and societal degradation. By conflating such choices with the exercise of individual responsibility, this construction of responsible citizenship positions those who take up green consumption practices as making ethical and healthy decisions that are beneficial to both the individual and communal body. It is also critical to consider how individuals who are already rendered vulnerable by the retrenchment of welfare state benefits and programs under neoliberal policies are further marginalized by their inability to consume products that demonstrate commitment to health – their own, as well as that of their families, the community and the planet. To deepen our understanding of how public health may be implicated in perpetuating and challenging such inequities, theoretically informed research is required that explores how discourses related to the “environment” and “health” converge to shape public health practice and position individualized risk-based approaches against more collective efforts. For example, research could examine how public health practitioners position themselves in relation to, and potentially resist, individualized approaches to the management of environmental health risks. As Treena Orchard notes in this volume, those who work in community-based health-related organizations may take considerable risks to work against the grain of institutional practices. Where resistive efforts are present they are likely to occur at the margins of formal policies and practices in a neoliberal political and economic climate that discourages organizing efforts by those who advocate for social change. There is thus an imperative to reignite critical consideration of the relationship between individual and environmental health with particular attention paid to the socio-political and economic dimensions of ecological crisis (Melo-Escrihuela 2008). The existing individualized focus on consumption practices as a risk management strategy obscures an understanding of environmental health as a social issue that is “bound up in the workings of capitalism, economic growth and the market economy” (Wall 2000, 250). Current attempts to respond to en-

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vironmental threats that fail to address the conditions that perpetuate them occur at the same time that vulnerable populations continue to bear a disproportionate burden of environmental damage associated with industrialization and the aftermath of “natural” ecological disasters (Pastor et al. 2006). In particular, poor and racialized communities are often subject to both distributional and procedural injustices, the former referring to the uneven distribution of environmental harms (e.g., the location of polluting industries) and the latter to the exclusion of these communities in decision-making about environmental development (Teelucksingh and Poland 2011). In light of such inequities, it would be productive to critically examine and contest the neoliberal governance of environmental health risks by drawing on notions of environmental racism, environmental justice, and environmental dispossession (Brulle and Pellow 2006; Richmond and Ross 2009), and in order to explore in greater depth how environmental risks and health inequities are constructed and unevenly distributed along racialized, gendered, and socioeconomic dimensions. Indeed, a wider body of literature suggests that a (re)politicization of public health is necessary for more collective efforts to take hold and effect change. For many authors (e.g., Harris 1999; Higgs 1998; Petersen 1998; Rose 2001; Szreter 2002), the political project of public health has declined with the increased emphasis on individual (consumer) responsibility for health in neoliberal societies. Despite the vast body of research suggesting that the greatest gains in human health come from investments into social and economic conditions, a number of recent critiques note how the social determinants of health continue to be disregarded in lieu of lifestyle-oriented programming rooted in the management of individual risk (Low and Theriault 2008; Poland 2007; Robertson and Minkler 1994). Blake Poland observes that “there has been widespread failure to ‘deepen the social analysis’ regarding underlying root causes of socio-economic, ethno-racial and gender disparities in health” (2007, 8). The adoption of individualized approaches thus subjugates a social determinants of health discourse that takes aim at the social, economic, political, and environmental conditions that perpetuate disparities in health. Critical scholars in the field of public health describe the need for a more substantive engagement with issues of equity and social justice

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in public health responses (Low and Theriault 2008; Poland 2007; Poland, Dooris, and Haluza-Delay 2011), including responses to environmental damage (Teelucksingh and Poland 2011). These authors note that privileging issues of equity and justice entails a shift from prevailing individual approaches to a collective emphasis on health and well-being, which extends our understanding of health settings to larger aggregate levels. The growing pressures of environmental health threats can therefore be thought of as an opportunity to engage in new ways of thinking in public health, and to reinvigorate discussion of the precautionary principle as a standard to guide government protection of the public’s health. Refocusing the discourse on environmental health risks towards issues of precaution rather than risk management is an inherently political project that will challenge public health to move beyond the agenda set by green consumerism and individual acts of precautionary consumption to include efforts that aim to effect broader social and structural change. Such shifts in public health discourse on environmental health risks are necessary to respond to what is one of the most pressing challenges of our time. Acknowledgments

I would like to thank Jessica Polzer and Elaine Power for their invaluable comments on earlier drafts of this paper. References

Batt, Sharon, and Abby Lippman. 2010. “Preventing Disease: Are Pills the Answer?” In The Push to Perscribe: Women and Canadian Drug Policy, edited by Anne Rochon Ford and Diane Saibil, 47–66. Toronto: Canadian Scholars’ Press. Beck, Ulrich. 1992. Risk Society: Towards a New Modernity. Newbury Park, CA : Sage. – 2010. “Climate for Change, or How to Create a Green Modernity.” Theory, Culture and Society 27 (2/3): 254–66. Brulle, R., and D. Pellow. 2006. “Environmental Justice: Human Health and Environmental Inequalities.” Annual Review of Public Health 27:103–24. Cairns, Kate, Josée Johnston, and Norah MacKendrick. 2013. “Feeding the ‘Organic Child’: Mothering through Ethical Consumption.” Journal of Consumer Culture 13 (2): 97–118.

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Canadian Partnership for Children’s Health and the Environment (CPCHE ). 2005. Playing It Safe: Childproofing for Environmental Health. Toronto: CPCHE. http://www.healthyenvironmentforkids.ca/resources/playing-itsafe-childproofing-environmental-health. Catford, John. 2008. “Food Security, Climate Change and Health Promotion: Opening up the Streams Not Just Helping Out Down Stream.” Health Promotion International 23 (2): 105–8. Connolly, John, and Andrea Prothero. 2008. “Green Consumption: LifePolitics, Risk and Contradictions.” Journal of Consumer Culture 8 (1): 117–46. Costello, Anthony, Mustafa Abbas, Adriana Allen, et al. 2009. “Managing the Health Effects of Climate Change.” The Lancet 373:1693–733. Crighton, Eric, C. Brown, J. Baxter, Louise Lemyre, Jeff Masuda, and Franca Ursitti. 2013. “Perceptions and Experiences of Environmental Health Risks among New Mothers: A Qualitative Study in Ontario, Canada.” Health, Risk and Society 15:295–312. Darier, Eric. 1996a. “Environmental Governmentality: The Case of Canada’s Green Plan.” Environmental Politics 5 (4): 585–606. – 1996b. “The Politics and Power Effects of Garbage Recycling in Halifax, Canada.” Local Environment 1 (1): 63–86. Gastaldo, Denise. 1997. “Is Health Education Good for You? Rethinking Health Education through the Concept of Bio-power.” In Foucault, Health and Medicine, edited by Alan Petersen and Robin Bunton, 113–33. London: Routledge. Harris, Patricia. 1999. “Public Welfare and Liberal Governance.” In Poststructuralism, Citizenship and Social Policy, edited by Alan Petersen, Ian Barns, Janice Dudley, and Patricia Harris, 23–60. New York: Pantheon Books. Health Canada. 2008. Human Health in a Changing Climate: A Canadian Assessment of Vulnerabilities and Adaptive Capacity. Ottawa: Health Canada. http://publications.gc.ca/collections/collection_2008/hc-sc/H128-1-08528E.pdf. Higgs, Paul. 1998. “Risk, Governmentality and the Reconceptualization of Citizenship.” In Modernity, Medicine and Health, edited by Graham Scrambler and Paul Higgs, 177–98. London: Routledge. Hobson, Kersty. 2013. “On the Making of the Environmental Citizen.” Environmental Politics 22 (1): 56–72. Low, Jacqueline, and Luc Theriault. 2008. “Health Promotion Policy in Can­ ada: Lessons Forgotten, Lessons Still to Learn.” Health Promotion International 23 (2): 200–5. Lupton, Deborah. 1999. Risk. London: Routledge. MacKendrick, Norah. 2010. “Media Framing of Body Burdens: Precautionary Consumption and the Individualization of Risk.” Sociological Inquiry 80 (1): 126–49.

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Melo-Escrihuela, Carme. 2008. “Promoting Ecological Citizenship: Rights, Duties and Political Agency.” ACME Editorial Collective. http://acme-journal.org/index.php/acme/article/viewFile/799/657. Nettleton, Sarah, and Robin Bunton. 1995. “Sociological Critiques of Health Promotion.” In The Sociology of Health Promotion: Critical Analysis of Consumption, Lifestyle and Risk, edited by Robin Bunton, Sarah Nettleton, and Roger Burrows, 39–56. London: Routledge. Pastor, Manuel, Robert D. Bullard, James K. Boyce, Alice Fothergill, Rachel Morello-Frosch, and Beverly Wright. 2006. In the Wake of the Storm: Environment, Disaster, and Race after Katrina. New York: Russell Sage Foundation. http://www.racialequitytools.org/resourcefiles/pastor2.pdf. Petersen, Alan. 1998. “Risk, Governance and the New Public Health.” In Foucault, Health and Medicine, edited by Alan Petersen and Robin Bunton, 189– 206. London: Routledge. Petersen, Alan, and Deborah Lupton. 1996. The New Public Health: Health and Self in the Age of Risk. London: Sage. Poland, Blake. 2007. “Health Promotion in Canada: Perspectives and Future Prospects.” Revisita Brasiliera em Promocao de Saude (Brazilian Journal of Health Promotion) 20:3–11. Poland, Blake, Mark Dooris, and Randy Haluza-Delay. 2011. “Securing ‘Supporting Environments’ for Health in the Face of Ecosystem Collapse: Meeting the Triple Threat with a Sociology of Creative Transformation.” Health Promotion International 26:ii202–15. Polzer, Jessica. 2005. “Choice as Responsibility: Genetic Testing as Citizenship through Familial Obligation and the Management of Risk.” In Genetic Governance: Health, Risk and Ethics in the Biotech Era, edited by Robin Bunton and Alan Petersen, 79–92. London: Taylor and Francis. Richmond, Chantelle, and Nancy Ross. 2009. “The Determinants of First Nation and Inuit Health: A Critical Population Health Approach.” Health & Place 15 (2): 403–11. Robertson, Ann. 2001. “Biotechnology, Political Rationality and Discourses on Health Risk.” Health 5:293–309. Robertson, Ann, and Meredith Minkler. 1994. “New Health Promotion: A Critical Examination.” Health, Education and Behavior 21 (3): 295–312. Rose, Nikolas. 2001. “The Politics of Life Itself.” Theory, Culture and Society 18 (6): 1–30. Rutherford, Stephanie. 2007. “Green Governmentality: Insights and Opportunities in the Study of Nature’s Rule.” Progress in Human Geography 31: 291–307. Smart, Barry. 2011. “Another ‘Great Transformation’ or Common Ruin.” Theory, Culture and Society 28 (2): 131–51. Szreter, Simon. 2002. “Rethinking McKeown: The Relationship between Pub­ lic Health and Social Change.” Health Policy and Ethics 92 (5): 722–5.

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Teelucksingh, Cheryl, and Blake Poland. 2011. “Energy Solutions, Neo-liberalism and Social Diversity in Toronto, Canada.” International Journal of Environmental Research and Public Health 8:185–202. Toronto Public Health. 2009. Childproofing for Environmental Health: An Examination of Food-Related Exposures. Toronto: Toronto Public Health. http://www.healthyenvironmentforkids.ca/resources/childproofing-foodrelated-exposures. Urry, John. 2010. “Consuming the Planet to Excess.” Theory, Culture and Society 27 (2/3): 191–212. Wall, Glenda. 2000. “Recent Representations in Popular Environmental Discourse: Individualism, Wastefulness and the Global Economy.” Canadian Review of Sociology and Anthropology 3 (3): 249–65. Watts, Michael. 2012. “Green Capitalism, Green Governmentality.” American Behavioral Scientist 45:1313–17. Weir, Erica, Richard Schabas, Kumanan Wilson, and Chris Mackie. 2010. “A Canadian Framework for Applying the Precautionary Principle to Public Health Issues.” Canadian Journal of Public Health 101 (5): 396–8.

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Ch a p t e r 3

Tween Girls, Human Papillomavirus (HPV), and the Deployment of Female Sexuality in English Canadian Magazines Laura Cayen, Jessica Polzer, and Susan Knabe

Introduction

In July 2006, the human papillomavirus (HPV ) vaccine Gardasil was approved for use in Canada for girls and young women aged nine to twenty-six years (Morris and Nguyen 2008; NACI 2007). This was quickly followed in 2007 by a $300 million commitment by the federal government to support the development of a national HPV vaccination program (Colucci, Hyrniuk, and Savage 2008). Although the vaccine immunizes against four strains of HPV (9, 11, 16, and 18), two of which are associated with 90 percent of cases of anogenital warts (types 9 and 11) and two of which are associated with the development of approximately 70 percent of cases of cervical cancer (types 16 and 18) (NACI 2007), it has been marketed by its producer, Merck, primarily as a cancer prevention vaccine (Casper and Carpenter 2008). Currently, all thirteen of Canada’s provinces and territories have developed immunization programs in public schools that offer the three-dose schedule of the vaccine free of charge for girls aged nine to thirteen (Public Health Agency of Canada 2011). Prince Edward Island and Alberta are the first provinces to include boys in their HPV vaccination

programs in 2013 and 2014, respectively. Though these programs vary in terms of the age at which the first dose of the vaccine is administered, the rationale for introducing the programs in schools is based on National Advisory Committee on Immunization’s recommendation that efficacy is greatest prior to first sexual encounter (NACI 2007; Colucci, Hyrniuk, and Savage 2008). A flurry of media attention accompanied the approval of the vaccine and the subsequent introduction of the publicly funded immunization program. These stories ranged in focus and viewpoints; some stories hailed the vaccine as a technological breakthrough in cancer prevention (e.g., Gulli 2006), while others expressed concerns about the potential effects of the vaccine, both in terms of its unknown physical effects (e.g., Gulli, George, and Intini 2007) and its potential moral effects in promoting promiscuity and unsafe sexual practices among girls (e.g., Herizons 2006). In this chapter, we focus on HPV vaccination discourse as it appeared in popular Canadian magazines published in English around the time of the approval and introduction of the vaccination programs. Our concern is not to evaluate the efficacy of the vaccine, nor to examine the specific politics that were involved in the decision-making process for approval or implementation of vaccination programs (see Haas et al. 2009; Lippman 2008; and Lippman et al. 2007 for a discussion of these issues). Rather, our concern is to show how popular media discourses on HPV vaccination constitute a particular form of female tween sexuality as risky, and reinforce a construction of parental, and specifically maternal, responsibility to manage that risky sexuality through the uptake of new technologies. Because the vaccine is not mandatory in Canada, popular media discourses on HPV and HPV vaccination are important sites of persuasion through which the female tween sexual body is problematized and through which mothers are responsibilized to respond to that sexualized body. Our work is located within a particular branch of critical health sociology that examines how discourses on health risk are implicated in the disciplining of individual bodies and the regulation of groups and populations (e.g., Petersen and Lupton 1996; Petersen 1996, 1997). Informed by Foucault’s work on governmentality and biopower (Foucault 1978, 1991; see introduction in this volume), this approach

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focuses on the ways in which health promotion discourses dissolve the traditional boundaries between health and ill health, and thus open up and multiply opportunities for governance through the production of “at-risk” subjects (Castel 1991; Petersen 1996). These self-regulating subjects are recruited into various risk reduction practices that purport to prevent disease and that constitute the self as an ongoing project. This entrepreneurial self is characteristic of neoliberal political rationalities, which govern by “creating a sphere of freedom for subjects so that they are able to exercise a regulated autonomy” (Petersen 1996, 48). In healthist societies (Crawford 1980; also see introduction), risk discourse is particularly effective as a form of governance through regulated freedom since one’s uptake of risk minimization practices are interpreted culturally as upholding one’s moral obligation to preserve health, and caring for oneself and for others. Furthermore, the risk reduction practices that characterize the regulated freedom of the neoliberal entrepreneurial subject are consistent with the idea of the body as a malleable substance that can be shaped through the consumption of various forms of expertise and health-related products that aim to reduce risk. As Batt and Lippman (2010) note, the increase in the number of devices and drugs that are marketed to women to manage their risks for future disease is characteristic of neoliberal policies that seek to download responsibility for health onto individuals and families while stimulating the economy. We add to these insights a gender dimension by examining how the production of particular notions of tween female sexuality in popular media operate in conjunction with the incitement of mothers who are responsibilized to take charge of their daughters’ sexuality. Similar to Connell and Hunt’s (2010) observations about how HPV vaccination advertisements act as a form of moral regulation and maternal responsibilization, we draw on Foucault’s notion of biopower (1978) to develop our analysis. In the following section, we situate our analysis in relation to relevant literature on media representations of women’s health and sexuality, and in relation to Foucault’s notions of biopower and the deployment of sexuality. Second, we describe our sampling and analytic strategies. Then, we present two related analytic themes that emerged from our critical discourse analysis. The first theme pre-

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sents data to illustrate how a particular form of female tween sexuality is produced in these media accounts, one that constructs the female tween body as emerging into sexuality and thus as at risk for future sexually transmitted infection. The second theme focuses on how parents – mothers in particular – are mobilized through these media constructions to respond to this pre-sexual and pathologized female body. Media Representations and the Deployment of Tween Female Sexuality

Female-focused and general interest magazines are important avenues to examine discourses on women’s health. In their integration of “expert discourse on health found in medical journals with everyday practices and knowledges” (Roy 2008, 464), magazines combine expert and lay understandings to construct and present unique messages about health to readers. For example, expert medical knowledge is made accessible to a popular audience through magazine articles, which depict the personal health troubles and testimonies of “reallife” women. Further, popular magazines have become understood as a “taken-for-granted aspect of daily living,” while they simultaneously create, reflect, and mediate social realities and gendered power relations (Clarke 2009, 416). Although there is some evidence that magazines “are approached in contradictory ways by their audiences and with a combination of cynicism, resistance and acceptance” (Jackson qtd in Clarke 2009, 418), they are nonetheless widely read and valued as a source of information about issues related to health and sexuality. For some women, whether they are actively seeking health-related information or not, magazines are a principal source of this information, used more frequently than other sources, including other media, family, friends, and health professionals (Kassulke cited in Bonner and McKay 2000). Magazines also constitute important sites for the communication of ideas about responsibility for health. In her analysis of English Canadian women’s magazines, and drawing on Crawford’s (1980) notion of healthism, Stephannie Roy (2008) argues that women’s magazines frame health primarily as an individual responsibility. She argues that the magazines construct a moral obligation to “pursue good health …

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through personal, individual adherence to the many and varied protocols for healthy living” (465). Additionally, particular forms of self-discipline and self-surveillance are invoked in magazine readers through the presentation of norms about health and healthy behaviour. Roy (2008) draws on Foucault’s arguments about disciplinary power to argue that magazine representations of women’s health issues encourage readers to police themselves without the need for threats of violence or force. McGregor (2001) connects this individual responsibilization to the role of neoliberal rationalities in shaping health care policies in Canada. Within this mindset, the state is framed as ineffective in providing care to its citizens, and the market is positioned as the most cost-effective and consumer-friendly method of delivering health care, which in turn justifies cuts to social spending. Further, within the neoliberal mindset, the concept of health as a public good is replaced with individual and familial responsibility for health (McGregor 2001). While critical analyses of media representations of women’s bodies and women’s health have drawn attention to the disciplinary function that these media play in idealizing slender and “fit” female bodies (e.g., Bordo 1993; Duncan 1994) and promoting individual responsibility for health (Roy 2008), few have examined the popular media explicitly as a site for the exercise of biopower. The role of the popular media in contemporary expressions of biopower is particularly relevant when considering Foucault’s (1978) discussions of the deployment of sexuality. In The History of Sexuality, Foucault (1978) asserts that the increasing interest in and production of knowledge about sexuality in the Victorian era was intimately connected to the exercise of biopower, which, in contrast to sovereign power, is dispersed and circulated through multiple sites and functions to discipline the body and regulate the population. Foucault challenges the idea that sexuality was repressed during this time and rather shows how “sex” and sexuality emerged as effects of discourse. In his words, sexuality emerged as a result of an “explosion of numerous and diverse techniques for achieving the subjugation of bodies and the control of populations, marking the beginning of an era of ‘biopower’” (140). Foucault identifies four problematizations that emerged in relation to this proliferation of discourse on sexuality in the eighteenth century, with each acting as a “dense transfer point for relations of power: between men and women … parents

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and offspring … an administration and a population” (103). Although he did not frame his analysis of biopower in terms of gender, women’s bodies and children are identified by Foucault as two such problematizations. Foucault uses the term “pedagogization of children’s sex” to describe the ways in which children came to be defined at this time as “preliminary sexual beings” (104) who were seen as inevitably prone to sexual activity. The form of pedagogization that emerged in relation to this sexualization involved parents, teachers, doctors, and eventually psychologists who were called upon to “take charge of this precocious and perilous, dangerous and endangered sexual potential” (104). As we go on to illustrate, in the context of HPV vaccination discourse, this pedagogization has clearly gendered dimensions both in terms of how the female tween body is problematized and how the responsibilities to take charge of the sexualized tween body are directed predominantly at mothers. In our analysis, we use the term tween to encapsulate teens, as well as the “in between” ages that span childhood and teenagehood. The term tween reflects the range of ages when the vaccine is first administered in Canada’s HPV vaccination programs (which target girls aged nine to thirteen), as well as the way in which girls were consistently described in our media sample as being on the cusp of becoming sexually active and as being in between sexual naïveté and sexual activity. Furthermore, and consistent with the focus of this volume on neoliberal governance, we use this term to draw attention to the recent historical development of tweens as a market demographic whose subjects are constructed as predominantly feminine, white, middle-class, and heterosexual (Cook and Kaiser 2004). Young girls and tweens have a significant and evolving history of being recognized as decision makers and consumers; the modern tween “registers social ambiguities regarding maturity, sexuality and gender that call attention to uncertainties as to when a girl becomes, and ceases to be, a tween physically, chronologically or culturally” (Cook and Kaiser 2004, 205). These role ambiguities are often negotiated by tween girls through purchases made in the marketplace. For example, it has been suggested that contemporary rites of passage out of childhood and into tweendom are acted out through purchases of particular, feminized products such as bras, makeup, and high heels, or “grown-up” privileges

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such as ear piercing, which allow tweens to pursue and display their aspirations to be regarded as properly feminine and as older than they are (Cook and Kaiser 2004). Although tweens can be understood as persons who make such choices based on their own wants, they are also “universalized as a category of social being who remains in need of training, direction, and some measure of protection” (Cook 2004, 96). In other words, mothers and other adults are necessary in guiding the child through childhood and into the proper role of tween consumer. Popular representations of HPV vaccination target both tween girls and their mothers, and are thus consistent with the ways in which Foucault (1978) and Cook (2004) identify the family as integral to the management of the preliminarily sexual child who requires protection and guidance to ensure her health and life. In this sense, the family is situated as a primary locus of biopower with mothers acting as the “chief agents of a deployment of sexuality” (110) who draw their support from various experts (e.g., doctors, educators, psychiatrists). This deployment of sexuality operates through what Foucault calls the parent-child axis (108); for example, the personage of the “precocious” child appears through this axis, and the family responds to this burden by appealing to medical experts for help in managing the “misfortunes of sex” emerging in their child (Foucault 1978, 111). The responsibility of parents, and mothers in particular, to manage the health and sexuality of their children has been suggested by other analyses of popular magazines. For example, Roy (2008) found that women are framed as caretakers who are responsible for ensuring that proper medical care is provided to their children. This responsibilization is achieved through particular rhetorical devices such as cautionary tales in magazine articles, which present worst-case-scenario results if mothers do not follow recommended guidelines (e.g., fail to comply with medical advice, are not persistent advocates for their children’s health). In one magazine article discussed by Roy that focused on medical misdiagnosis, the mother was framed as ultimately responsible for her child’s death because she neglected to do the “right thing” by not demanding a second opinion and thus ensuring that her child received further medical care. Through such cautionary tales, readers are responsibilized; these rhetorical strategies communicate to mothers that they can avoid a similar fate if they follow the advice provided

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in the articles and that ignoring or refusing such prescriptions comes at a significant cost. Similarly, in her analysis of the portrayal of sexual health in American magazines, Clarke (2009) found that strong imperatives are communicated to mothers regarding their children’s sexuality, who are told that they “should worry about the sexual behaviors of their teenage, particularly girl, children” (424). Women are instructed that this concern should revolve around the risks associated with promiscuity and sexually transmitted infections (STI s) (Clarke 2009). With regard to media representations of HPV vaccination, concerns that vaccination will incite promiscuity and increased sexual behaviour, and the risks that accompany such sexual activity, have been identified by Forster, Wardle, Stephenson, and Waller (2010) in their analysis of newspaper coverage in the United Kingdom. However, as these authors note, concerns over promiscuity are countered in these newspaper accounts by citing evidence that the vaccine does not protect against other negative consequences of unprotected sex, such as pregnancy or other STI s (Forster et al. 2010). Casper and Carpenter (2008) argue that the firmly established link between HPV and cervical cancer in the media has facilitated the marketing of Gardasil as a cancer prevention product targeting young girls. These authors argue that Merck Canada (the producer of Gar­ dasil) and other pro-vaccine organizations in the United States have framed HPV predominantly as a risk for cervical cancer, rather than an STI, to deflect controversy surrounding teenage promiscuity and the medicalization of women’s bodies. These authors argue that the framing of HPV vaccination as cancer prevention enables sexually transmitted health risks among youth to be presented in “culturally palatable ways” by news media and facilitates public and parental acceptance of the vaccine. In what follows, we examine how discourses on female tween sexuality and risk for cervical cancer converge in English Canadian magazine representations of HPV and HPV vaccination. We present themes to illustrate how the connection between HPV and cervical cancer produces a particular notion of emergent female tween sexuality to which the family, and in particular, the mother, must respond. In so doing, HPV vaccination discourse, as it appears in our sample of women’s

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magazines, necessitates intervention into this potentially sexual, and thus potentially diseased, female tween body through the uptake of pharmaceutical products such as Gardasil. Before we turn to these findings, we first discuss our methodology and sampling strategy. Methodology

This analysis of magazine representations emerged from a larger study of the forms of female sexuality that are privileged in media representations of HPV vaccination discourse (Polzer and Knabe 2012). The magazines from which we drew the articles were selected to promote diversity in our sample and included those with high readership levels that appeal specifically to women in Canada with school-aged children and young women aged twenty-six years and under, the recommended age limit for the vaccine (Chatelaine, Today’s Parent) and to more general, gender-neutral audiences (Maclean’s, Time [Canadian Edition]). As well, a feminist publication (Herizons) was selected as a point of contrast despite its comparatively lower readership levels. After locating each of these magazines through the ProQuest Canadian Business and Current Affairs (CBCA ) search engine, a search of each magazine’s archive was conducted using the term HPV , which generated forty-eight articles published from 1996 to 2008. The articles appearing earlier in the period of our sample discussed HPV primarily in terms of its status as an STI that causes genital warts. However, later articles focused primarily on the link between HPV , cervical cancer, and the HPV vaccine. The majority of articles were published around 2006 when the vaccine was first approved for use in Canada, and these articles constitute the primary focus of our analysis. The media articles were analyzed using an approach to critical discourse analysis (CDA ) that is consistent with our Foucauldian theoretical frame (Cheek 2004). This approach to CDA assumes that media texts and images are not mere reflections of social reality, but that they actively constitute and construct social reality by framing issues (e.g., female sexuality) in particular ways. These framings are not arbitrary, but are informed by the socio-cultural norms (e.g., about gender) and political-economic objectives in which the media texts are produced

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(Cheek 2004). To ensure methodological rigour and trustworthiness, all authors reviewed the same subset of ten media articles independently and recorded her impressions. The authors then met to review their impressions in order to develop an initial set of descriptive codes that were grounded in the texts (e.g., female sexuality and subjectivity, responsibility, and communication). For example, the code “female sexuality and subjectivity” was used to gather together descriptions of female sexuality, including sections of text that described female sexuality in relation to risk, reproduction, age, and abstinence. Once agreement was achieved on an initial set of codes, the first author manually applied this coding template to the remaining articles. This involved applying the codes through close and multiple readings of the text, and then separating the coded text into individual documents for analysis. While this initial coding template was retained throughout the analysis, the structure remained flexible so that new codes could be added. Codes were then combined into broader categories that reflected our concern to elucidate the constructions of female sexuality that were privileged in these texts. For example, the category “the tween body as soon-to-be-sexual” combined the codes female sexuality, vulnerability, and risk. These categories were then read explicitly through our Foucauldian lens to generate theoretically informed analytic themes (e.g., in this example, the analytic theme “pathologizing tween sexuality” combines the categories the “tween body as soon-to-be-sexual” and “risky yet resistant”). In the following section, we present two analytic themes that illustrate the deployment of tween female sexuality in these media texts and the construction of maternal responsibilities to manage this emergent sexuality. In describing our themes, we have selected excerpts from the magazine articles for their brevity and clarity in illustrating our key points. The first theme, “pathologizing tween sexuality,” addresses how our sample of magazine articles produced a particular notion of female tween sexuality as soon-to-be-sexual and thus as at risk for future disease. The second theme, “responsibilizing mothers,” illustrates how mothers in particular are encouraged to exercise their responsibilities to protect their daughters’ health and life by acknowledging and learning to respond to their daughters’ impending sexuality.

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Findings Pathologizing Tween Sexuality

In this section we present two categories to illustrate how the media articles function to pathologize female tween sexuality. The first category represents the construction of the female tween body as on the cusp of sexuality, where the risks associated with sexual activity are imminent. The second category represents the depiction of tween girls as risky yet resistant and as therefore requiring surveillance and intervention for protection. The female tween body as soon-to-be-sexual

The depiction of tween girls as on the cusp of sexuality is discussed consistently in our sample of Canadian magazine articles. Accompanying this construction is the need for parents to learn to recognize their tween’s emergent sexuality. In a 2006 Today’s Parent article called “Inside Your Teen-To-Be,” Saleema Noon, a sexual health educator, indicates that it is important for parents to recognize that their children will be engaging in sexual activity “a little sooner” than parents may think or wish. Sexuality is positioned as an inevitable fact of life, and the need for parental vigilance is heightened by emphasizing the variation in children’s sexual development: “Noon urges parents to talk openly about puberty, sex and sexual health … Keep in mind that it’s better your child learns the facts from you than from furtive experimentation. As for what to say when, Noon advises: ‘a little more than you think, a little sooner.’ Kids develop at different rates, and you don’t want your early bloomer to be caught off guard” (Benson 2006). Similarly, the following passage, from an article called “Sex, Cancer, and Your Child” also in Today’s Parent, reiterates the inevitability of tween girls becoming “sexual beings” and parents’ reluctance to this development. It also introduces the pathologization of female tween sexuality by linking parental reluctance to the vaccine to the inevitability of onset of sexual activity: “I think there’s going to be some reluctance [to the vaccine]. They don’t want to deal with the fact that their daughters are going to be sexual beings” (Lewis 2006).

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Risky yet resistant

Depicted as soon-to-be-sexual, tween girls are conceptualized as particularly vulnerable to the health risks that accompany sexual activity, such as risks for STI s. It is through this specification of the female tween body’s potential for sex that her potential for risk for cervical cancer is established. Female tweens are depicted in the magazine articles as especially vulnerable to the risks associated with sexual activity because they are considered too young to appreciate these risks, and thus are assumed to fail to engage reliably in safe-sex practices. In the 1999 Maclean’s article titled “Be Safe, Not Sorry,” youth aged fifteen to twenty-four were identified as particularly at risk for STI s as a result of their assumed ignorance and poor sexual health practices: “[Studies] indicate that those in the highest risk group – young people age 15–24 – dramatically underestimate their risk of contracting an STD and do not use condoms regularly. While the reasons for this are complex, young Canadians appear to be more concerned about pregnancy than STD s” (Wong 1999). In a more recent article called “Our Daughters,” published in Chatelaine, the author explains that her daughter is engaging in sexual activity, and that sexual activity at her daughter’s age is more acceptable than it was in her own generation. Despite this normalization, the author expresses concern that changing mores regarding what is classified as “sex” may lead to her daughter to overlook safe-sex practices: “I realize how different life is for teens today than it was for me when I was an adolescent in the 1970s … I’m not surprised that teen pregnancy is at an all-time low, but I am startled when she tells me that today the word ‘sex’ refers only to intercourse. To her peers, oral sex does not count as sex” (Clark 2007). Similar to the above concerns regarding female tweens’ resistance to safe sex practices, it is interesting that the following example from Herizons, a feminist publication, indicates that young women fail to consistently submit themselves to medical surveillance in the form of routine Pap smears or STI screening following sex without a condom. Although Herizons was included in our sample to provide an alternative perspective to more mainstream magazines, this article reinforces the construction of female tweens as vulnerable to risk and as resistant to

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managing those risks. For example, in the Herizons article “On Guard,” note how the language of “young patients” contributes to the medicalization of sexuality as it relates specifically to HPV : “At Planned Parenthood, we knew that condoms and Paps could stop the virus [HPV ] in its tracks. But we also knew that our young patients were notoriously immortal. Young women were unreliable about getting their Paps, just as they were about using condoms” (Downton 2007). By establishing the emergence of sexual activity for tween girls as an inevitable part of sexual development, and by connecting this emergent sexuality to risk for cervical cancer, HPV vaccination discourse pathologizes female tween sexuality, and privileges a view of young female bodies as risky and thus as in need of intervention. Furthermore, some of the magazines pointed to the reluctance of female tweens to engage in preventative activities. Responsibilizing Mothers

In this section, we discuss how mothers are responsibilized to protect, manage, and respond to this pathologized and “at-risk” female tween body. This responsibilization is accomplished through three recurring ideas and rhetorical strategies within our media sample. First, parental anxiety about their daughters’ emerging sexuality is managed medically by framing nascent sexuality in relation to risks for future disease. Furthermore, mothers are depicted as having a duty to communicate the risks of sex to their daughters, and any discomfort related to having open discussions about sex is neutralized through the urgency and necessity of protecting tween girls from HPV and the risks of cervical cancer. Finally, HPV vaccination is highlighted by the magazine articles as a key form of protection from the risks of sexual activity. Medical management of parental anxiety

Parents are compelled in these magazine articles to protect their children by overcoming their anxieties about their daughters’ impending sexuality and learning to respond to their daughters’ soon-to-besexual bodies in a way that privileges cancer prevention. In the article “Inside Your Teen-To-Be,” published in Today’s Parent, parents are urged to overcome any difficulties they may experience in talking with

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their tweens about sex. This is accomplished by emphasizing tweens’ lack of awareness of STI s and through the use of statistics that convey the unlikelihood that tweens will approach parents about matters concerning their sexual health: “A recent study by the Canadian Association for Adolescent Health (CAAH ) showed that 31 percent of teens feel uncomfortable talking or learning about sexual health information. When faced with such resistance, many parents back off … Bad plan. The study also found that teens between the ages of 14 and 17 are woefully unaware of the STI s (sexually transmitted infections) most likely to threaten their health. For example, 81 percent of them had never heard of human papillomavirus (HPV ) – the most common STI and the cause of genital warts and cervical cancer” (Benson 2006). The articles in our sample described parents as sharing an initial reluctance to get their daughters vaccinated, since doing so would mean acknowledging their daughter as a “preliminary” sexual being, subject to the physical and moral risks that accompany sexual activity. Such reluctance is depicted as temporary and eventually overcome by assuming the role of responsible parent who acts early to protect their daughters from these established physical and moral risks. As suggested in the following excerpt from “Vaccine Update” in Today’s Parent, since sexual activity is inevitable, an “ideal” mother considers her daughter’s sexual health even before her daughter may be thinking about it herself: “Studies suggest three doses of Gardasil given over six months prevent 95 to 100 percent of infections from these specific viruses – but only if they’re given before an individual is exposed. So it’s ideal for a girl to get immunized before she’s even thinking about becoming sexually active, which is why the Society of Obstetricians and Gynaecologists of Canada (SOGC ) recommends the shot for girls aged nine to 26” (Haaf 2007). As this quotation suggests, parents are presented with evidence regarding the medical necessity of acknowledging the impending sexuality of their tween daughters. The result is that parents are responsibilized to respond to the risks that accompany sexual activity through vaccination. Despite the use of the term “parent” in the quotations above, it is typically mothers who are tasked with the duties to manage their children’s health, and thus to communicate these risks to their daughters and protect them by getting them vaccinated.

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The duty to communicate the risks of sex

By establishing female tweens as “high risk” for unsafe sexual practices, and as unaware of the threat posed by STI s, the magazine articles position them as in need of protection from others. Mothers are specifically targeted as the ideal parent to provide this protection and guidance. Consistently, good, responsible mothers are constructed as ones who acknowledge their tweens’ sexuality and, in response, accept the duty to communicate to their children the risks that accompany this inevitability, as suggested by the strong moral overtones in this passage from Maclean’s: “These moms understand that talking to their daughters about physical and sexual health, and ensuring they undergo regular Pap smears, is the smartest way to help protect them from HPV ” (Maclean’s 2008). Mothers are also encouraged to frame their discussions with their daughters about sexuality in terms of risk for HPV and future disease. Within our sample, the HPV vaccine is presented as a good way for mothers to instigate conversations about sex with their children that may otherwise be uncomfortable to begin. In this way, HPV vaccination facilitates maternal intervention into, and helps to organize, the emergence of the sexual lives of female tweens. By providing an opportunity to discuss sexually transmitted health risks, HPV vaccination is constructed as an essential component of a healthy sex life, as the following excerpt from a 2006 Maclean’s article illustrates: “Another benefit, says Davis, is that the HPV shot will give parents, teachers, and youth a chance to talk openly about sex and its consequences. ‘It certainly isn’t carte blanche to participate in any kind of activity that they want,’ says Davis. ‘But it is an opportunity to discuss options and give them the information that they need to continue with a safe and healthy sex life in the future’” (Gulli 2006). Any hesitation a mother may make in talking to her daughter about sexuality is neutralized in these media accounts by establishing and emphasizing the link between HPV and cervical cancer. In the passage below, excerpted from a Time (Canadian Edition) article called “Saying Yes to the Shot,” “good” mothers are described as those who are willing to consider vaccination to “protect” their child from sexually transmitted health risks despite any discomfort they may feel. This is con-

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trasted to mothers who “resist” vaccination and who are framed as “totally in denial” about the risks and realities of their child’s emergent sexuality. These mothers, as suggested by the following excerpt from “Saying Yes to the Shot,” require carefully edited education from medical practitioners: “To me, protecting my child from cancer outweighs any reluctance to ponder her sexual future. ‘But some parents are totally in denial,’ says my longtime pediatrician, Dr. Marc Wager of New Rochelle, New York. It’s his practice to discuss the vaccine when parents bring a daughter for a checkup at 11 or 12. But he doesn’t force it on those who resist, and he’s willing to edit his discussion of HPV transmission for those who don’t want a child to hear it” (Wallis 2007). The obligation to discuss HPV -related risks and HPV vaccination with one’s doctor or pediatrician, as well as with one’s child, is framed as a necessary step to protect one’s daughter from the risks of sexual activity. It is important to note that, although some articles briefly described mothers as having concerns about the safety of the HPV vaccine, it was maternal communication with daughters about HPV that was consistently underscored as an essential aspect of sexual health management and responsible motherhood. Protecting daughters through vaccination

In addition to the duty to communicate the risks of sexual activity, mothers are informed that they can protect their daughters by submitting them to pharmaceutical intervention, with the HPV vaccine highlighted as an important and ground-breaking preventative measure against HPV and cervical cancer. Since tweens are represented as persons who cannot be trusted to protect themselves from the hazards of sex, the responsibility to protect these soon-to-be-sexual bodies falls on parents, and mothers in particular, who are encouraged to “say yes to the shot” (Wallis 2007). In the following excerpt from Time, one mother discusses getting her thirteen-year-old daughter, Alice, vaccinated despite her daughter’s resistance to discussing some of the issues related to HPV and HPV vaccination: “Luckily, she didn’t put up much resistance, and so we plunged into the heart of the most heated public-health matter of the moment: vaccinating tweenage girls against a sexually transmitted virus long before (one hopes!) they become

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sexually active … Alice managed to tolerate our brief discussion of HPV without rolling her eyes … My next challenge: persuading my 18-yearold daughter to go for the shots” (Wallis 2007). Although vaccination is positioned as the appropriate and responsible response for mothers to protect their tween daughters against the risks of sexual activity, there is some concern in these magazines regarding the possibility of vaccination encouraging sexual activity. In our media sample, fears regarding the incitement of promiscuity are introduced but then quickly allayed or discredited. This is accomplished by comparing the attitudes of Canadian parents with those parents from other countries and “conservative groups” who favour abstinence as a response to female tween sexuality: “Conservative groups in the U.S. and the U.K. have argued that the HPV shot may encourage young girls to become promiscuous. They stress that abstinence is the best protection against sexually transmitted infections” (Gulli 2006). A second example of this comparison is found in Today’s Parent: “Monique MacFarlane Conrad, a medical student in Halifax, recently did a research study on public opinion about this vaccine. She found reports from the US suggesting some parents have been concerned that the vaccine would encourage sexual activity in teen girls. But in her research, Canadian parents rarely expressed these fears” (Pitman 2007). Similarly, maternal concerns are incited by alluding to the inevitability of tween sexuality, and then allayed through the promise of the vaccination as a form of protection. In this excerpt from Today’s Parent, this is accomplished through the powerful voice of the president of the Society of Obstetricians and Gynaecologists of Canada (SOGC ): “Considering some parents’ concern that the vaccine will encourage sexuality in young girls, Donald Davis, president of the SOGC , says: ‘we don’t expect our kids to go out and look for measles, but we do immunize them against that’” (Haaf 2007). In summary, this popular media discourse on HPV vaccination not only constructs female tween sexuality in relation to risks for future disease, but also serves to quell maternal anxieties that may become heightened as they come to acknowledge their daughters as (soonto-be) sexual and potentially diseased beings. In these ways, HPV vaccination discourse not only constructs tween sexuality as a health risk but is also implicated in the construction of responsible motherhood.

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Discussion

Our analysis illustrates how the young, female body is problematized and pathologized in popular magazine representations of HPV vaccination, and how mothers are incited and responsibilized to protect their daughters by communicating the perils of impending sexual activity and submitting their tween’s soon-to-be-sexual and risky body to pharmaceutical intervention. We suggest that these media constructions offer a particular way of medicalizing female sexuality, where acknowledgment of this impending sexuality is presented as “naturally” resulting in maternal discomfort. This discomfort was rarely questioned in the media accounts, and was framed as a minor barrier that responsible mothers are able to overcome as they learn to respond to the media appeals to preserve the future health of their daughters through open communication about sexually transmitted health risks and, ultimately, vaccination. In our study sample, maternal anxieties about female tween sexuality are generated through the link between HPV and cervical cancer, and are simultaneously quelled by the possibility of managing that risk through vaccination. In this sense, HPV vaccination discourse is implicated in the deployment of female tween sexuality through the discourse of risk for cancer. By linking HPV to cervical cancer, the young and “sexually naïve” female body is subject to a “hystericization,” pathologized as at-risk and in need of integration into the sphere of medical practices and preventive intervention (Foucault 1978, 104). Although concerns about cervical cancer were prioritized in our media sample, it is important to note that other concerns about sexuality were also raised. For example, reluctance to consider a child’s impending sexuality was not the only stance presented in the magazine articles as justification for a mother’s potential resistance to HPV vaccination. Issues related to the safety and efficacy of the HPV vaccine were raised infrequently, yet emphatically, in some of the articles (e.g., Downton 2007; Gulli, George, and Intini 2007). Although these articles endorsed a more cautious approach to HPV vaccination, what was striking in our media sample was the consistency of the discourse across sources: namely, that tween girls are at risk for cancer as a result of their burgeoning sexuality, and that mothers are

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obligated to respond to this pre-sexual and pre-diseased female tween body. Although the alternative, feminist magazine Herizons was included in our sample to provide a potential challenge to the assumptions made in mainstream women’s and general interest magazines, it failed to yield any significant discursive divergences. Additionally, concerns that vaccination might lead to increased sexuality among youth were identified but discredited in our media sample. These findings are commensurate with the complexity of power and resistance that we discuss in the introduction of this chapter. From our theoretical perspective, we view these media messages not as an attempt to repress sexuality; rather, the proliferation of these concerns constitute a discourse that constructs female tween sexuality as a problem requiring and justifying intervention from the family and other institutions (e.g., medical, pharmaceutical) through which sexuality is deployed (Foucault 1978, 106). This construction of tween sexuality firmly situates the female child’s body as a biopolitical hinge linking maternal responsibilities to manage child health with state-directed goals to increase vaccination uptake. There are limitations to these results, and future research should be conducted to address them. For example, future research should seek to include an analysis of the images that accompany the popular magazine articles we have discussed above. Further, our focus on English Canadian magazines limits our ability to understand how these messages might vary in French magazine publications. Comparisons of popular media representations of HPV vaccination between countries would enable a greater understanding of how links between risk, tween sexuality, and maternal responsibility compare in different national contexts (see Abdelmutti and Hoffman-Goetz 2009 for a comparison between risk messages found in Canadian versus US newspaper articles on HPV vaccination and Hilton et al. 2010 for newspaper coverage of HPV vaccination in the UK ). Last, a genderbased analysis of HPV vaccination discourse is suggested by the 2010 NACI recommendation of HPV vaccination for boys and young men aged nine to twenty-six (Merck 2012) and increasing pressure across Canada to include males in HPV vaccination programs. Such comparisons would enable a critical examination of how tween male sexuality

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is (and is not) constructed in popular representations of HPV vaccination, and an assessment of the extent to which the success of HPV vaccination discourse relies on and reproduces pathologized notions of female sexuality. Our analysis contributes to the literature on media representations of women’s health and sexuality by illustrating how constructions of pathologized tween female sexuality emerge in HPV vaccination discourse, and how these operate to responsibilize mothers, a finding that resonates strongly with Foucault’s claim that the family operates as a locus of power for the deployment of sexuality (Foucault 1978, 108). As we have illustrated, these magazine articles create expectations that communication about sex can and should occur through the parent-child axis in order to protect the health of female tween bodies against the risk of HPV and cervical cancer, with the responsibility to protect daughters from the potential health risks that accompany sexual initiation falling predominantly on the mother. Our interpretation of maternal responsibilization is supported by Connell and Hunt (2010), who examined the HPV vaccination campaign in Canada with a specific focus on the promotional materials used by the Society of Obstetricians and Gynaecologists of Canada. Our findings regarding maternal responsibilization are also consistent with arguments made by others in this volume who explore how risk discourse in neoliberal societies operates to shift responsibility for health onto the shoulders of individuals and families (Petersen 1996). In her discussion of public health constructions of the environment as a source of risk, Rebecca Hasdell (chapter 2) outlines that participation in green consumption practices is constructed as a parental responsibility of neoliberal citizenship. This includes child care practices, where mothers are encouraged to integrate organic or locally grown produce into their child’s diet and respond to climate change and other forms of environmental damage through the support of environmentally sound practices of food production. Similarly, in her discussion of the “obesity epidemic,” Elaine Power in chapter 1 emphasizes how mothers are specifically implicated in governing the child’s body and cultivating future consumer-citizens. She argues that the obesity epidemic “sets up expectations that mothers will teach their children how to exercise

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self-discipline, in the name of health, so that they learn to choose properly and responsibly amid the overwhelming array of consumer choices” (see 45–6). These discourses on environmental damage, the obesity epidemic, and HPV vaccination underscore the ways that mothers are implicated in a particular gendered governance of their children’s bodies and draw attention to different dimensions of inequity mothers face as they are called on to exercise this governance in a neoliberal consumer society. Discourses on HPV vaccination privilege specifically gendered forms of responsible motherhood and health consumption and give rise to new forms of social stratification based on women’s abilities to respond to these risks. The ways in ways in which women’s abilities to respond to risk are stratified along various axes of inequity (e.g., class, race) deserve further theoretical and empirical elaboration. In the context of HPV vaccination, this is particularly salient given that recent immigrants, women with low socioeconomic status, and First Nations women bear a disproportionate burden of morbidity and mortality in Canada (Amankwah, Ngwakongnwi, and Quan 2010; Booth et al. 2010; Lofter et al. 2007; Mackillop et al. 1997; Ng et al. 2004; Xiong et al. 2010). In our media sample, these dimensions of inequity were rarely pointed out. One exception was an article in Herizons, which identified that, in Canada, the women most at risk for HPV infection and cervical cancer “may be immigrants or Aboriginal women with language and cultural barriers, or they may be isolated, living with disabilities or be women whose immunity is compromised by stress and poor nutrition” (Downton 2007, 22). Furthermore, our analysis draws attention to the ways in which pharmaceutical products, such as Gardasil, are marketed strategically through the proliferation of popular discourse on HPV vaccination, and in relation to the ambiguous boundaries of maturity and sexuality that characterize tweendom and are negotiated through particular consumption activities (Cook and Kaiser 2004). Similar to how feminized products such as makeup and bras mark entry to sexual maturity, HPV vaccination may additionally function to mark the beginning of one’s entry into responsible and healthy citizenship. It is important to consider how tween girls are recruited by HPV vaccination discourse as particular kinds of health consumers who

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are socialized to accept technological interventions to manage sexually transmitted health risks. For both tween girls and their mothers, resistance is configured primarily in relation to the uptake of the vaccine. Indeed, the question posed through the discourse is whether or not to choose to get vaccinated. Through this emphasis, neoliberal values of individual consumer “choice” and personal “responsibility” for health remain unquestioned. Polzer (chapter 5) explores this in her discussion of predictive genetic testing for breast cancer risk. Polzer suggests that this discursive emphasis on the “choice” and the “right” to have access to testing contributes to a form of medicalization that conveniently co-opts feminist efforts to challenge medical dominance through demands for bodily autonomy and increased choice in health care services. In both case studies, regardless of the “choice” made (to accept or decline HPV vaccination or genetic testing), women remain neoliberal subjects implicated in a health care system that emphasizes technological management of risk and an intensification of personal responsibility for health. This chapter contributes to critical sociological analyses of risk discourse by showing how mothers specifically are responsibilized in relation to the construction of “risky” tween female sexuality, and how both of these are produced through the proliferation of discourse about technologies (HPV vaccination) that claim to help girls and young women manage their risks for future disease. As our findings suggest, mothers are compelled to overcome any anxieties they may have about their daughters’ emergent sexuality by emphasizing the link between sexual initiation and risk for HPV infection. As well, mothers are encouraged to protect them from these risks by submitting them to pharmaceutical intervention (e.g., vaccination) and initiating conversations with them about the risks of sex. In so doing, female tween sexuality is not repressed but is rather produced within a particular pharmaco-medico-family matrix. The regulated forms of freedom that take shape within this discursive configuration include the mother whose autonomy is shaped by her desire to protect her daughter’s health and the child whose potentially risky body and sexuality is managed through maternal care and guidance, medical expertise and pharmaceutical technologies. Within this web of power relations, the mother–daughter relationship becomes a particularly

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effective transfer point for medical expertise and pharmaceutical products, which are framed as necessary measures to secure sexual health, prevent cervical cancer, and preserve life.

Acknowledgments

This research was supported with funding from the University of Western Ontario Academic Development Fund.

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Roy, Stephannie. 2008. “‘Taking Charge of Your Health’: Discourses of Responsibility in English-Canadian Women’s Magazines.” Sociology of Health & Illness 30 (3): 463–77. Wallis, C. 2007. “Saying Yes to the Shot.” Time (Canadian ed.), 19 March, 64. Wong, T. 1999. “STD : Be Safe, Not Sorry.” Maclean’s, 21 June, H 14. Xiong, Hui, Madonna Murphy, Maria Mathews, Veeresh Gadag, and Peizhong Peter Wang. 2010. “Cervical Cancer Screening among Asian Canadian Immigrant and Nonimmigrant Women.” America Journal of Health Behavior 34 (2): 131–43.

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Ch a p t e r 4

Risk, Retirement, and the “Duty to Age Well”: Shaping Productive Aging Citizens in Canadian Newsprint Media Debbie Laliberte-Rudman

Introduction

The focus of this chapter is the discursive shaping and promotion of “productive aging” – that is, continued involvement in paid work in the labour market into what have traditionally been defined as the retirement years. This chapter presents a critical discourse analysis of Canadian newspaper media texts that builds on existing critical gerontological scholarship by focusing specifically on how notions of risk operate within productive aging discourses to produce new idealized forms of subjectivity and duties to “age well.” In addition, attention is paid to the “occupational possibilities” that are privileged by productive aging discourses. In this sense, occupational possibilities refer to activities promoted by discourse and other technologies of government as ideal and responsible and to those promoted as non-ideal and irresponsible (Laliberte-Rudman 2010). The intersections of discourses on risk and productive aging are considered in terms of the implications for the construction of boundaries for subjectivities and occupational possibilities for aging individuals, and for what such constructions mean for social inequality and exclusion.

Problematizing the “Aging Population”: Reconfiguring Risks and Responsibilities

The “aging population” is a central problematic of contemporary governance, frequently constructed in policy documents and organizational reports as a risk to global and national economic and health systems. This problematization of the aging population is often framed in relation to rising dependency ratios resulting from a decrease in the proportion of the working age population relative to the population aged sixty-five and older; questionable sustainability of public pension systems; and overburdening of health care systems (Carmel, Hamblin, and Papadopoulos 2007; Mann 2007). The increasing proportion of global and national populations expected to be over the age of sixtyfive within the next ten to forty years is recurrently presented as an impending economic and social crisis that requires action at governmental and individual citizen levels (Neilson 2009; Powell, Wahidin, and Zinn 2007). A 1994 World Bank report titled Averting the Old Age Crisis: Policies to Protect the Old and Promote Growth exemplifies this trend, as does a Canadian report of the Expert Panel on Older Workers, which warned of the economic implications of the “oncoming tidal wave of retirements” (Beach 2009). Asquith (2009) points to the construction of the notion of “boomageddon” and argues that “at the core of the construction of the ‘aging population problem,’ is the perceived economic disaster that is awaiting ageing nations that are unwilling to make (or incapable of making) the hard economic decisions about reducing government expenditure on income, social and service support for older people” (26). This discursive construction of population aging as an economic crisis has been tied to the promotion and enactment of policy responses involving a particular redistribution of responsibilities and risks amongst the state, aging citizens, and business interests (Biggs and Powell 2001). Such policy responses, while varying within national contexts, have generally been in line with recommendations by international and multinational bodies, like the Organization for Economic Co-operation and Development (OECD 2006, 2009). Commensurate with neoliberal approaches to governing, these policy responses are characterized by privatization of previously publicly funded services

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and supports (Cardona 2008). For example, while pensions were once viewed as a collective responsibility met by the state, pension reforms in several nations since the mid-1980s have shifted towards individual responsibility and market-based solutions. For example, increases in the age of eligibility for public pensions in the United States and several European nations, and the introduction of mandatory privately managed individual accounts to replace parts of public pension schemes in Hungary, Sweden, Mexico, and Poland (OECD 2007) have resulted in reduced access to public pensions, decreased public benefits, and increased options for privatized pensions (Carmel, Hamblin, and Papadopoulos 2007; Neilson 2009). Within the health sector, “healthy” and “active aging” policies increasingly emphasize the need for aging individuals to continue to engage in a range of activities, such as staying physically active and following healthy eating guidelines, to proactively and individually manage health risks that are understood to accompany aging (Asquith 2009; Neilson 2009; Laliberte-Rudman 2015). Overall, policy directives in multiple areas aim to remake aging citizens at risk of dependency into those who proactively manage their lives and risks, particularly within the private market through the consumption of consumer goods and privatized insurance (Carmel, Hamblin, and Papadopoulos 2007; Mann 2007). “Positive Aging”: Neoliberalism, Risk, and the “Duty to Age Well”

Policy changes addressing population aging have contributed to, and been sustained by, discursive reconstructions of aging that establish new standards for “aging well” and shape new types of “active” aging citizens (Biggs et al. 2006). Since the 1980s, so-called “positive aging” discourses have become pervasive in academic, media, and policy texts. While various terms are used, such as active, successful, or productive aging, these “positive aging” discourses similarly present continued activity as the key to health and happiness in later life, dissociate aging from disease and disability, and emphasize the possibility of expanding mid-life and postponing old age. Such discourses have been labelled “positive” because they shift attention away from negative representations of aging that emphasized social isolation, dependency, illness, disability, and passivity (Dillaway and Brynes 2009; Katz 2000–01). 110  ■  D E B B I E L A L I B E R T E - R U D M A N

Although “positive aging” discourses may open up new possibilities for being and doing (i.e., subjectivity and occupation) for aging citizens, a growing body of research in critical gerontology has questioned the inherent positivity assumed by such discourses by examining their implications and effects. For example, concerns have been raised regarding how such discourses sustain ageism by promoting perpetual youthfulness and draw attention away from structural conditions that create and exacerbate poverty and disability in later life (Dillaway and Byrnes 2009; Holstein and Minkler 2003). Concerns have also been raised regarding how “positive aging” discourses have been constructed and enacted within various OECD -member countries in ways that are shaped by, and reinforce, neoliberal modes of governing (Asquith 2009; Carmel, Hamblin, and Papadopoulos 2007). These critical perspectives illuminate how contemporary constructions of “positive aging” are part of the “wider political assault on the risk of dependency” (Katz 2000–01, 148), characteristic of neoliberal approaches to governing, which aim to decrease public sector expenditures and promote individual responsibility, consumerism, and “active lifestyles” (Polivka and Longino 2002). Such constructions of positive aging are, thus, a central characteristic of the neoliberal governance of the aging population, which involves a shift away from citizens’ rights for adequate pensions and health care, emphasized in previous configurations of welfare systems, towards individual risk management as a “duty to age well.” As I will go on to suggest, this “duty to age well” involves a discursive reframing of risks associated with aging, such as poverty and social isolation, from social to individual risks, and a concomitant shift in responsibility for the management of these risks from the state onto aging individuals. “Productive” Aging: Reshaping Retirement and Retirees

By the 1960s retirement was framed within policy and academic texts in many Western nations as a social right earned through previous productive contributions to society, and as a life phase characterized by freedom and leisure. This social right was to be guaranteed primarily by the state through public pension systems, which were variously supplemented by private pensions that provided employers Risk, Retirement, and the “Duty to Age Well”  ■ 111

and unions with additional means to manage labour force relations (Quadagno and Hardy 1996). Policy responses to the aging population problem have involved major reforms since the 1980s not only directed at minimizing public pensions, but also aimed at extending labour force involvement (Mann 2007; Neilson 2009). For example, the 2006 OECD document Live Longer, Work Longer offers extended involvement in paid work as the solution to the problem of population aging: “The bottom line is that population ageing is both a challenge and opportunity. It will put upward pressure on public expenditures while dragging down economic growth. But it is also a tremendous opportunity for all of us to spend more rewarding years at work and in retirement” (14). As a particular variant of “positive aging,” productive aging discourses have become deeply embedded within and shaped through social policy reforms aimed at prolonging work involvement. Such discourses emphasize the possibility and positivity of continued productive contribution to society with aging, holding out work as an occupational solution with both national and individual benefits (Laliberte-Rudman and Molke 2009). Although it has been proposed that productive aging is presented as a solution to social and individual risks associated with aging, the particular ways that discourses of risk intersect with productive aging has thus far received little focused attention (Carmel, Hamblin, and Papadopoulos 2007). Within this chapter, I critically consider the ways in which risk is addressed and mobilized within discourses of productive aging. As developed further in the remaining sections of this chapter, this focus on risk enables an enhanced understanding of the embeddedness of productive aging discourses within neoliberal political rationality, in that discourses of risk are drawn upon to frame and communicate responsibilities to aging individuals to effectively manage financial, social, mental, and physical well-being through engagement in work. Methodology

Informed by governmentality theory and an occupational science perspective, a critical discourse analysis (CDA ) was conducted to examine how risk is taken up within productive aging discourses in Canadian

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newspaper texts. Newspaper texts were chosen because this form of media plays a pivotal role as a site of discursive production within contemporary Western society that interplays with scientific, academic, and other forms of texts and circulates discourses within peoples’ everyday lives. Moreover, like other forms of popular media, such as magazines (see, for example, Cayen, Polzer, and Knabe, chapter 3), as a discursive genre, newspaper articles are a particularly powerful means of persuasion that merge various forms of “subjectivist” authority, such as personal testimonies, with “objectivist” authority, such as research results (Fairclough 1998; Rose 1999; Smith 2007). Newspaper articles were drawn from the two largest circulating Canadian newspapers (the Toronto Star and the Globe and Mail) from 1 January 2005 to 31 December 2006, during which the repeal of mandatory retirement within Ontario, Canada’s most populated province, was debated and enacted. Articles were selected that addressed work, retirement, and aging during this period of policy change. In total, 108 Toronto Star (TS ) articles and 144 Globe and Mail (GM ) articles were identified and analyzed. Drawing upon a governmentality perspective (Dean 2010; Nasedan 2008), productive aging discourses were conceptualized as technologies through which the governance of everyday life is achieved. The governance of retirees was viewed as involving a plurality of authorities, such as health care professionals, career consultants, and financial managers, who contribute to the production and circulation of discourses. Such discourses mark out possibilities for how aging citizens can and should understand themselves and act in relation to aging, retirement, and work, as well as how policies, programs, and services can and should respond to aging citizens. The two key foci of the CDA were to examine how risk was drawn upon within discourses of productive aging to construct possibilities and boundaries for subjectivity and occupation. Adding to this focus on subjectivity (Polzer and Power, introduction), the CDA drew on an occupational science perspective to identify the types of activities, or occupations, outlined as ideal (and not ideal) means to manage risks and achieve “productive aging.” Within the discipline of occupational science, occupation refers to the range of activities in which people engage in everyday life to meet individual and societal needs and

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desires (Hocking 2000). Based on previous research that employed a governmentality perspective to examine occupation as a socio-political construct (Laliberte-Rudman 2006, 2010, 2013), another primary assumption guiding this analysis was that the governance of everyday life is intimately linked to the construction of occupational possibilities. The term occupational possibilities refers to the “ways and types of doing that come to be viewed as ideal and possible within a specific sociohistorical context and that come to be promoted and made available in that context” (Laliberte-Rudman 2010, 55). It is argued that the concept of occupational possibilities is particularly useful within contemporary Western contexts in which there has been a noted rise in the use of activation technologies which aim to remake passive welfare state citizens into active citizens who responsibly engage in a range of activities to ensure their continued selfreliance and productivity (Ilcan 2009; Walters 1997). This is akin to the entrepreneurial subject that is privileged by neoliberal modes of governance and noted by others (e.g., Rose 1999; also see the introduction to this volume). Attending closely to the forms of occupation that were offered as ideal, possible, and risk-reducing, and to those that were considered non-ideal, not possible, and risk-enhancing, provided a means to closely interrogate the ways that power operates discursively to shape everyday life through discourses of risk in relation to aging and retirement. Given that discourses, as technologies of government, are embedded within broader political rationalities (Rose 1999; also see Polzer and Power, introduction), analysis of the newspaper texts also involved considering how possibilities for subjectivity and occupation were constructed in ways that linked individual being and doing with neoliberal aims to redefine social issues into individual problems and risks and, in turn, activate subjects “at risk” of dependency on the state into proactive, responsible subjects (Parton 1999; Petersen 1997; also see Polzer and Power, introduction). Drawing upon guidelines put forth by Cheek (2004) and Potter and Wetherell (1994), questions derived from these theoretical underpinnings were used to develop an analysis sheet that was used to record analytic notes with corresponding excerpts from texts. Texts were read several times, with each reading focused on different aspects of form, function, and content (for example, what were presented as ideal

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and non-ideal occupations for retirees; what risks were highlighted as problematic). A final analysis phase involved rereading all texts to confirm emphases, check for disconfirming data, and elaborate discourse patterns. Findings

The findings of this CDA are organized into three main threads: the construction of retirement as an economic risk for societies and businesses; the construction of retirement as risky for individuals; and the individualizing of risks and responsibilities connected to retirement. In the texts, alarmist language is combined with expert advice and personal testimony to deconstruct “traditional” notions of retirement as a social right and time of freedom from the obligation of work, and to persuade aging individuals that continued paid work is both a social and individual necessity as well as an ideal occupational choice connected with an array of positive outcomes. Risks and responsibilities once conceptualized as at least partly within the mandate of states, and sometimes businesses, are shifted to the individual and encompassed with the individual “duty to age well.” Where potential points of resistance to these dominant threads of the discourse appeared, such as discussion of gender or ability-based barriers to continued work or the declining value and accessibility of public pensions, these were frequently countered in ways that offered up the promise that individual proactivity and rationality could overcome such socially produced barriers. Retirement as an Economic Risk at a Societal Level: Constructing the Duty to Work

Within the texts analyzed, the notion of retirement as a social right is deconstructed by framing retirement as an outdated and discriminatory practice. This dismantling is based on the assumption that aging individuals “are healthier and living longer, so it is unfair to insist they stop working simply because they turn 65” (Howlett 2005a). Alarmist demography is combined with notions of risk to persuade readers that retirement is not only unfair and discriminatory to individual citizens,

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but is also a risk to the economic and social security of Canada as a nation. Various authorities and sites of authority (e.g., economists, financial management specialists, international organizations) are drawn into the texts, often alongside “objective” survey results, to present retirement as a serious threat to Canada’s economy. For example, a paper from the Policy Research Institute (PRI ) of Canada is cited as providing numeric proof of this threat: “A 2004 discussion paper from PRI cited research predicting that the aging population combined with a retirement age of 61.2 – the 2001 median – is already holding back the economy. By 2030, per capita real gross domestic product is forecast to be about 6 per cent smaller than it would otherwise be, and 14 per cent smaller by 2050” (Theobald 2005). The OECD is cited as issuing a similar economic warning: “Canada … needs a major overhaul of its retirement practices if it wants to pre-empt weaker economic growth” (Scoffield 2005). In turn, this slowing of economic growth is depicted as threatening the standard of living for all citizens. For example, an author of a book titled The Economic Implications of Aging Societies is quoted as saying, “The real punchline is that in many of our societies, we’re simply going to run out of an adequate number of workers to continue to produce the level of goods and services that represent our standard of living” (Partridge 2005). Through these discursive techniques, retirement is framed as placing all Canadians at risk of losing their social safety net due to the increased “strain on social programs” resulting from the combination of “a low birth rate and an increasing percentage of older people” (Howlett 2005b). Consistent with many of the texts that stress the need for massive restructuring of retirement in order to avert economic and social crises, one financial expert offers the “obvious solution” of removing incentives for retirement at age sixty-five: “Since it is unlikely that Canadians will be willing to shorten their lifespan to solve the country’s pension problem, Mrs. Rousseau said the obvious solution is to reform the system so that it no longer rewards workers for leaving the job market before they turn 65” (Church 2006). While the suggestion of ending life prematurely might be interpreted as obviously facetious, it provides a powerful discursive support to the assertion that continued employment into retirement is both acceptable and self-evident.

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Retirement is also framed as presenting risks to the economic success of Canadian businesses, particularly those in knowledge and service sectors. These risks are framed as resulting from the loss of skills, knowledge, and “organizational memory” that businesses face with “the prospect of the mass exodus of productive employees as the baby boom generation moves into retirement range” (Galt 2005a). Similarly, an article focused on the accounting industry warns that “a crippling shortage of talent and experience could hit the industry” (Wong 2006). While a small number of articles counter the focus on individual responsibility, pointing to the need for business to pay “more attention to strategies that could encourage older employees to remain” (Galt 2005b), the main solution foregrounded in this media sample is for aging individuals to take up their citizenship duties to continue working and thereby contribute to, rather than weaken, the economic growth and social cohesiveness of their nation. Through this framing, aging citizens are understood to lessen their personal risk, as well as the risks posed by population aging. Compared to stereotypes of aging workers as outdated and non-productive, these texts emphasize that “any solution [to Canada’s productivity gap] should include measures to entice baby boomers to remain in the work force, even part-time” (Editorial 2005). The responsibility to continue to work into older age is reinforced through positive constructions of older workers and by invoking intergenerational dependencies. For example, in an article titled “Thumbs Up for Working Seniors,” the author, who positions himself as a member of a younger generation, stresses the social imperative for “older people” to continue working: “We younger people need you older people to stay productive, at least for a few more years. We can’t afford to support all of you” (Keller 2006). Retirement as Risky for Individuals: Engaging in Work as a Means to Enact the “Duty to Age Well”

In addition to emphasizing the economic risks of retirement for societies and businesses, the newspaper texts emphasize the risks that retirement presents to aging individuals. Indeed, retirement is framed as inciting fear, panic, and uncertainty about the future and financial insecurity. In one Globe and Mail article, a fifty-something female

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author, who describes a recent shift from full-time to contract work, starts her article by connecting retirement to feelings of panic: “Retirement: Nothing brings on the panic more than wondering what you will do with all that time on your hands and less money in your pocket.” This message is reinforced with observations of her friends who did not continue to work in later life: “In my close circle of friends, almost all of whom are 50-plus, I have watched as some of them struggled to add meaningful time to their days after retirement. Others were trying to cope with money shortages as they tried to downsize” (Wood 2005). Similarly, in another article, a psychiatrist emphasizes that “Many fiftysomethings are terrified. They see their parents aging, and at the same time, the reality of their aging is more apparent. Major companies are downsizing and outsourcing and they’re fearful about their futures” (Timson 2006b). Within the texts, financial, social, emotional, and physical risks of retirement and those of aging are intertwined, such that retreat from work is framed as enhancing risks typically associated with oldness (e.g., becoming unproductive, inactive, and isolated). A gerontologist is quoted as stressing the social risks of retirement: “‘A lot of people miss the challenge of stimulating and interacting with colleagues,’ he says. Going from full-time work to no work ‘is like a cliff, when you’re working one day, and then one day you’re not’” (Ebden 2005). A man who started a small business after the age of sixty-five indicates that continuing to work enables him to address his “fear of becoming out of date, a fear of becoming extinct” (Shimo 2006). In relation to financial security, retirement is framed as increasingly risky given increases in life expectancy and current economic conditions. For example, a financial adviser warns of a “Longevity risk: If you are retiring early, you could be looking at 30 years of retirement living and you don’t want to last longer than your savings do” (Marron 2005). This expert’s advice is mirrored in the personal testimony provided by a sixty-four-year-old man who shares concerns related to his future standard of living in retirement: “And then there’s concern about money. He and his wife, who also works, are comfortable – they own their own home, and he believes their retirement savings, Canada Pension Plan, and Old Age Security should be enough to live on, he

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said. But then again, it might not be. ‘When it comes to pensions, the real question is, who knows how much is enough?’” (Ebden 2006). Few articles question whether pension systems, either those publicly funded or those provided by private corporations, are adequate or raise the possibility of improvement or expansion. Rather, the pervasive taken-for-granted assumption is that pensions will decline in value and accessibility, given economic conditions and population aging. Ultimately, retirement is framed as a risk to health and as potentially leading to “oldness” and death. Personal stories and anecdotes about retirees, often men, figured prominently in this framing. For example, in one article supporting the repeal of mandatory retirement, a columnist shares her story of her father’s retirement and subsequent decline: “It wasn’t much after that [mandatory retirement] came to an end that my dad’s health took a nosedive, and he died. It was the way that death came to a not insignificant number of his friends, shortly after their retirement, and though you couldn’t prove there was a relationship there, I always thought there was” (Blatchford 2005). Similarly, a politician who is described as having chaired public hearings into mandatory retirement shares his story about his father’s decline after being “forced into early retirement.” He concludes, “‘He was a lost soul [after retirement]. And I am positive that shortened his life’” (Ferguson 2005b). Such anecdotes are supported by the inclusion of experts who provide scientific evidence of the negative mental health effects of work cessation, such as a psychiatrist who “says it’s common for people lacking a sense of purpose – such as a retired businessman or an unemployed adult living on a trust fund – to fall into a depression” (Hutsul 2005). By problematizing retirement as a risk to social, financial, physical, and mental well-being, work is thus presented as imperative for individuals to combat these risks and “age well.” However, not all occupations are constructed as equally beneficial in this regard. Rather, the needs and desires of individual aging citizens are aligned with the call for them to continue working in order to decrease threats to the nation-state. This imperative to continue to work is constructed through discursive techniques that negate the potential benefits of leisure activities; connect work with an array of benefits that counteract

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the risks of retirement and aging; and present work as a financial necessity for a broad range of citizens. While a life of leisure has long been upheld as an ideal for retirement, many traditional leisure retirement pursuits are presented within the texts as meaningless, boring, and outdated. For example, an economist states that “many Canadians who opt for retiring early quickly find themselves bored. ‘There is only so much time you can spend golfing’” (Galt 2006a). Modern aging workers are depicted as rejecting the option of leisure in order to continue working and as “bluntly re-evaluating their career choices and wondering what on earth comes next. It’s what I call ‘the problem of the rest of our lives.’ And, believe me, not everyone wants to go golfing” (Timson 2006a). Predominantly, working in later life is presented as the ideal occupational choice to make in order to achieve an array of positive personal outcomes, particularly social inclusion, health, and continued youthfulness. Thus, readers are told that researchers have found that many older workers have “returned to work by choice rather than necessity” and “did so because they felt that work would keep them healthier, more energetic and in top mental form” (Galt 2006b). It is through this occupational choice that one enacts one’s social and personal duties to “age well.” Examples of “successful” aging workers emphasize improved health and continued youthfulness as benefits achieved by continued involvement in paid work. A seventy-five-year-old business owner is quoted as saying that “working keeps you young” (Flavelle 2005), while a seventy-five-year-old department store greeter is described as feeling “much younger than his age” (Yelaja 2005). At the same time, working into one’s sixties and perhaps beyond is presented as a financial necessity given “the new reality of life” (Theobald 2005) for an increasing proportion of aging individuals, including those with low and high incomes. Thus, “Even living longer has a downside. Boomers, who are likely to remain retired 25 years or more, now have to worry about financing those golden years well into their 80s. As a result, more would-be retirees are taking part-time jobs or going to work for themselves” (Akkad 2006). In this sense, work is framed as a financial necessity for those who are relatively well-off but who may experience a lowered standard of living in retirement:

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“Thirty-eight percent of people with assets more than $1 million said they expect to work in retirement in order to earn enough money to live … A possible explanation is that they simply want to maintain a certain lifestyle” (Theobald 2005). As well, continued work is framed as a necessity for aging individuals at risk for poverty, who are described as a “growing part of the labour force” (Theobald and Prashad 2005). For example, in one article the Canadian Association of Retired Professionals is described as “pushing for an end to mandatory retirement. It complains that 35 per cent of people over 65 live in poverty and that many need to work to pay for food, housing, health and transportation” (Howlett 2005a). Individualizing the Social: Shifting from Social to Individual Risks and Responsibilities

In line with neoliberal rationality, risks once conceptualized as responsibilities of states (e.g., retirement income) and businesses (e.g., job training) are reconfigured as individual risks and responsibilities. In turn, an array of risk management techniques are outlined as ideal means for aging individuals to achieve productive aging and “age well.” This individualizing of the social was particularly prevalent in articles that focused on financial security in later life, the nature of jobs available for older workers, and ageism and its effects on work opportunities. The problem of inadequate retirement income is framed in the texts not as arising from state or business actions (or inactions), but rather as resulting from the irresponsible financial and lifestyle “choices” of individuals. Indeed, reductions in public and private pensions are framed as the “new reality” – that is, as unavoidable measures given contemporary economic conditions within which individuals (are charged with the responsibility to) continue to work and navigate their own financial well-being. A spokesperson for Canadian Association of Retired Professionals outlines this “new reality” as well as her own responsibility to deal with her precarious financial situation that resulted from her “choice” to care for her mother: “With living costs going up and public pensions not keeping pace, an increasing portion

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of Canadians must keep working, Cutler said. ‘I’d love to retire next year when I turn 65 but I know I can’t. I used up all my savings looking after my mother’” (Theobald 2005). Subgroups of aging individuals who may experience heightened financial insecurity resulting from the intersections of various forms of structural inequity are framed as benefitting the most from continued work. However, the structural reasons leading to their enhanced precariousness are rarely addressed, and when such reasons are pointed to they are framed as the “way things are” but also as surmountable through individual effort. For example, in the following quote, caregiving responsibilities and timing of immigration are framed as choices made by women and immigrants, respectively, to take time off: “many workers – including women who took time out of the workforce to raise families – and immigrants who arrived later in life also need to keep working to pay bills and accrue pension benefits” (Ferguson 2005a). Rarely highlighted in the texts are the impact of caregiving responsibilities and other forms of structural inequity on decreased retirement savings, and the ways the public pension system penalizes women, who are expected to take on caregiving responsibilities, and other structurally disadvantaged groups. For more economically privileged workers, the failure to have adequate resources to finance retirement is attributed to inadequate saving and planning, out-of-control consumerism, and unrealistic lifestyle expectations: “‘It’s not that the Freedom 55 wasn’t attainable for baby boomers’ … ‘The problem has been that boomers weren’t willing to do the necessary groundwork, namely to save 10 per cent of their earnings and start maximizing their RRSP s contributions at an early age, as well as keeping their expenditures and mortgage debts within their means’” (Marlin 2005). Overall, the financial risks and responsibilities of retirement are discursively shifted from the social to the individual: “The study found 56 per cent of Canadians say that they are preparing to bear most of the financial costs of their retirements, compared with an average 43 per cent in the rest of the world” (Immen 2006a). Somewhat contradictory to this emphasis on a financial imperative to work, some of the texts addressing labour market opportunities for aging workers de-emphasize financial risk and renumeration. Contin-

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gent and entrepreneurial forms of employment are celebrated as offering new opportunities for older workers, with little recognition of the drawbacks that often accompany such forms of employment: “There are emerging labour market trends that work in favour of older job candidates – particularly the surge in temporary and contract opportunities that may be less appealing to younger candidates with heavier family and financial commitments” (Galt 2005c). Contingent forms of employment are aligned with ideal aging workers’ needs and desires, related to flexibility and gradually slowing down: “Experts say today’s older workers tend to approach retirement as a gradual process, choosing to reduce their hours, work on a contract basis or start their own business” (Mahoney 2005). The financial risks of retirement are de-emphasized, and the aims of business to utilize aging workers as a low-paid, surplus workforce are linked with the desires of aging workers for flexibility and intellectual stimulation: “These older workers are less interested in the size of their pay cheque as a measure of their self-worth and more interested in flexibility and doing work that engages them emotionally and intellectually” (Steiner 2006). Although the financial risks of contingent employment are sometimes acknowledged, these are often quickly countered by emphasizing that aging workers are not focused on money: “I’ve been a financial planner for 15 years and the trend I certainly have seen over the last five or six years is a lot of retirees, or ‘seniorpreneurs,’ are looking for something to do, and they’re not necessarily looking for money” (Ebden 2006). The risks of contingent employment are also countered by advising aging individuals to enact various practices to optimize their own security, such as “upgrading your skills” (Immen 2006b) and continuing to “stay in touch with old contacts and make new ones” (Galt 2005c). A final example in which retirement is reconfigured from a social problem into an individual risk and responsibility is provided in articles that focus on ageism and age discrimination in the labour market. Ageism and the “added hurdle of discrimination” (Swartz 2005) are presented by experts as realities that older workers must individually fight against through engagement in risk management practices aimed at avoiding appearing and acting old. The importance of looking young is emphasized, with a remarkable conflation of age with weight; for example, older workers are given tips for “shedding a few

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years at interview time” (Swartz 2005), and a cosmetic surgeon shares that many older clients “want to turn back time – or at least look like they are – for the sake of their careers” (Johne 2006). The importance of “projecting youthfulness” is emphasized, as suggested in one article where a career consultant states, “there are certain behaviours that signal ‘older worker.’ Going to a business event, for example, and reminiscing about the past the whole time – not a good thing” (Timson 2006b). Discussion

This CDA displays the various ways that risk discourses are taken up within productive aging discourses to reframe retirement in ways consistent with neoliberal modes of governing aimed at decreasing dependency on the state, activating groups who are situated as “at risk” of state dependency and inactivity, and individualizing responsibility for a wide array of life areas. Retirement, once framed as a well-earned social right, is reframed as risky, for nation-states, societies, businesses, and individuals. Commensurate with the wider use of activation technologies with groups viewed as at risk of state dependency, work is celebrated as the ideal occupational possibility within productive aging discourses. Work is framed as both a necessity and opportunity, to be continued as long as possible to ensure one’s own financial security, health, and well-being, as well as the prosperity and social cohesion of the nation-state. The authority of various types of experts, such as financial consultants, spokespersons for retirement, governmental and international bodies, researchers, and “successful” aging workers, is invoked to provide information and advice that align the needs, desires, and occupations of aging workers with aims consistent with neoliberal rationality; the ideal, modern aging individual is one who assumes responsibility for ensuring financial security in later life through continued work and simultaneously “ages well” through this occupational engagement. Cardona (2008) has proposed that aging itself has become articulated as a risk category that is discursively utilized within various forms of texts to “call for middle age and older individuals to act ‘responsibly’ to reduce these risks by self intervention in the name of health. The ethical obligation to exercise responsibility to manage

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risks becomes an enactment of citizenship obligations – our moral duty to the community” (41). Aligned with other variants of “positive aging”, productive aging discourses hold out the promise that the risks of aging, and ultimately becoming old, can be avoided by individuals through occupational choices and engagement in risk management practices (Dillaway and Byrnes 2009; Laliberte-Rudman 2006; Mann 2007). For example, in the texts analyzed, physical and psychological problems, once framed as resulting from the process of aging itself, are reframed as problems resulting from incorrect occupational choices to be solved through continued work engagement. Productive aging not only establishes work in later life as a risk management practice to maintain health and evade oldness, but also expands the citizenship duties of aging individuals to include continued engagement in work, conveying that “older workers must work because it is good for everyone else, good for social protection systems and good for the economy” (Carmel, Hamblin, and Papadopoulos 2007, 294). Just as the possibility of “aging well” has been transformed into an ethical and moral responsibility (Dillaway and Brynes 2009; Mann 2007), the failure to “age well” – that is, to succumb to the risks of aging and retirement – is framed as resulting from a failure of individual will and irresponsibility. As Asquith (2009) puts it, “if you are incapable of meeting the benchmarks of a positive aging experience, then you have negatively (or unhealthily, unsuccessfully, or unproductively) aged, and, with it, you must bear the weight of failure” (266). In relation to discourses of productive aging, aging individuals who fail to continue working or ensure their own financial security are thus considered “failed” aging citizens undeserving of state support. As such, the individualization of the risks of retirement and aging within productive aging discourses aligns well with neoliberal efforts to retreat from pension, health, and other forms of social and structural support for aging populations (Cardona 2008; Dillaway and Byrnes 2009). In addition, the individualization of risks and responsibilities in productive aging discourses may further exacerbate inequalities between older and younger generations of workers, and amongst aging workers embedded within multiple relations of power and social inequity. This individualization effectively obscures collective problems faced by aging workers that stem from existing systems and structures, such as

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the reduced access of aging workers to training programs and the use of hiring practices shaped by institutional ageism (Gunderson 2003). The homogenization of aging workers with productive aging discourses also obscures structural inequalities that make later life work an opportunity for some, such as highly skilled professionals, and extremely difficult for others, such as aging individuals with disabilities or aging women with caregiving responsibilities (Carmel, Hamb­lin, and Papadopoulos 2007). Moreover, inequities created through policies and programs that disadvantage certain segments of the aging population, such as gender-based inequities in access to private pensions and limited portability of pensions upon immigration (Gunderson 2003; McMullin and Shuey 2006), are reconfigured into individual challenges demanding longer engagement in work. Due to the neglect of structural barriers and the differential abilities of various types of aging workers to take up the demands of productive aging, the occupational possibility of continued work offered through productive aging discourses may itself create new demands, risks, and vulnerabilities for aging workers marginalized by economic, class, gender, or other forms of structural inequality (Mann 2007). As proposed by Polzer and Power in the introduction to this volume, this analysis further supports the contention that discourses aligned with neoliberal rationality allocate risk along existing lines of marginalization and perpetuate social inequities. As with other variants of “positive aging” discourses, productive aging discourses hold out continued health and the evasion of oldness as ultimate ideals to be attained through engagement in the right occupations and risk management practices (Dillaway and Brynes 2009). While celebrating the opening up of the occupational possibility of continued work into later life, such discourses constrain other possibilities for occupations in later life, where occupation is understood broadly as the various activities and forms of “doing” in which people engage in everyday life. Ironically, in doing so, productive aging discourses may increase the “risks” faced by aging individuals. For example, such discourses celebrate the creation of work opportunities for contingent forms of employment in later life, forms of employment often associated with job insecurity, low pay, and few health or other benefits (Riach 2007). This celebration of contingent work, particu-

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larly in relation to notions of flexibility and freedom, resonate with the findings of MacEachen, Polzer, and Clarke in chapter 9, as well as those of Facey in chapter 10, perhaps signalling ways in which discursive constructions of work align across diverse contexts in ways that enable increasing dissolution of employer commitment to workers. At the same time, the potential drawbacks of contingent work discussed by Facey’s informants, in relation to powerlessness and exploitation, rarely surfaced in the newspaper texts, and when they did they were offered up as readily solvable through rational decision making and proactive planning by aging individuals. Ultimately, the framing of aging itself as a risk within productive aging discourses sets aging individuals up to engage in a “duty to age well” that involves relentless engagement in risk management practices. In turn, the duties required for neoliberal citizenship are extended into the later parts of the life course. In addition, despite the promise of opening up “positive” possibilities for occupation, health, and identity in later life, productive aging discourses fail to overcome ageism by holding out “oldness” as something to continually work against. Not only do they create few occupational possibilities for those who do become “old” and are unable to engage in work, they obscure the ways in which access to resources over a lifetime is tied to other identity markers and social conditions, such as gender and citizenship status, and legitimize an inequitable distribution of the possibilities for “productive aging.” Acknowledgments

This research was supported with funding from the Social Sciences and Humanities Research Council of Canada and the University of Western Ontario Academic Development Fund. References

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Ch a p t e r 5

The Political Is Personal: Breast Cancer Risk, Genetic(optim)ization, and the Proactive Subject as Neoliberal Biological Citizen Jessica Polzer

Introduction

On 15 February 2001 the journal Nature triumphantly published a fold-out “map” of the human genome, “unveiled in all its glory.” The page opposite this map presents the bold title “Mapping the Human Genome,” accompanied by an advertisement for New England Biolabs, a company that “provides researchers with the largest selection of recognition sequences for genome mapping projects.” The ad features the profile of a woman standing with her arms reaching overhead, looking proudly out into the distance, chin slightly raised. Superimposed on her profile is an old-fashioned globe, complete with lines of latitude and longitude, carefully labelled and coloured countries, and explorer sailing ships. This globe-like image envelops her body, pulling her silhouetted form nobly upright so that she resembles the figurehead of a ship. Taken together, this female form and the globe that wraps around her raise a number of questions about how the body – and, specifically, the female body – is imagined by genomic science as a territory for scientific discovery and knowledge production, and constructed as a

resource for genomic technology (Zitzelsberger 2004). The uprightness and constrained strength that is conveyed by the woman’s enveloped posture is further suggestive of how subjectivity is constituted and harnessed by such technology. Around the same time that the human genome map was published, the Ministry of Health and Long-Term Care of Ontario, Canada, included predictive genetic testing (PGT ) for hereditary breast, ovarian, and colon cancers as an insurable health service for patients whose family histories indicate a possible genetic predisposition.1 The policy decision to include BRCA 1/2 mutation testing as a publicly insured health service is indicative of a governmental imperative to (re)orient health services for particular “at-risk” populations towards biotechnical and pharmaceutical options that aim to help women manage their risks for breast and ovarian cancer. As of July 2011, Ontario women aged thirty to sixty-nine years who have a family or medical history that puts them at high risk for breast cancer are eligible for specialized screening services, including genetic assessment, and annual mammography and magnetic resonance imaging (MRI ) screening. In this chapter, I explore how these predictive technologies effectively construct the gene as a biopolitical territory for the convergence of discourses on health, risk, and citizenship, drawing on insights from interviews conducted with women undergoing PGT for breast cancer, and informed by theoretical insights provided by the literature on governmentality (Gordon 1991; Foucault 1991), Foucauldian ethics (Rabinow 1994), and biological citizenship (Rose and Novas 2003; Petryna 2002). Specifically, I explore how the practice of PGT , and associated neoliberal constructions of genetic risk, shapes how a woman’s ethical work is conducted in order to constitute herself as a “proactive” citizen who manages her risks for future disease. Based on my critical, interpretive analysis of women’s experiences of BRCA 1/2 mutation testing, I suggest that the practice of PGT inspires a particular form of neoliberal biological citizen, a proactive subject who actively pursues information about her genetic risk for future disease, and attempts to secure access to health care resources presymptomatically, both for her and her biologically related family members, on the basis of this knowledge. Drawing on notions of

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biological citizenship and feminist insights regarding the biomedicalization of cancer risk, I further suggest that this proactive manager of genetic risk and the “choices” about risk management that she is invited to make in light of her family history of disease are constructed in the space where discourses on genetic risk converge with women’s personal cancer biographies and broader discursive constructions of Canada’s health and cancer care systems as resource-constrained and in “crisis.” Before presenting the themes that led me to these analytic insights, I begin by situating PGT theoretically as a neoliberal technology of governance and as a form of biological citizenship that engenders and idealizes particular ethical relations and practices of the self. Predictive Genetic Testing As a Neoliberal Technology of (Self-)Governance

Predictive genetic testing, or genetic susceptibility testing, generally refers to testing for the presence of genetic mutations in healthy adults whose family history puts them at increased risk of developing a disease in the future. In 1994 and 1995, scientists identified “BRCA 1” and “BRCA 2,” two genes located on chromosomes 17 and 13 that, when mutated, increase the probability that a woman will develop an inherited form of breast cancer at some point during her lifetime (Miki et al. 1994; Wooster et al. 1995). Although inherited forms of breast cancer account for only about 5 percent of all breast cancers (Heisey et al. 1999), mutations in either the BRCA 1/2 genes have been found to significantly increase susceptibility to breast and ovarian cancer, though estimates vary widely across research studies (Heisey et al 1999; Antoniou et al. 2003). By May 2000, mutation testing on these genes had become listed as a provincially insured health service in Ontario for women whose family histories of breast cancer indicated a possible hereditary component. In the public media, this move was hailed as a “victory” by some women with family histories of breast cancer who at the time were demanding their rights to genetic testing services (Abraham 1999). The establishment of PGT as a provincially funded health service for women at high risk for breast cancer emerged at a time when

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public confidence in the ability of the state to provide timely cancer care services for its citizens was framed in popular media as seriously eroding. During this time, major controversies were reported in the news press regarding lengthy waiting times to receive cancer screening and treatment (Kirkey 2001; Mackie 2001a; Smith 2001), the use of privatized cancer screening centres in order to reduce waiting times (Cherney 2001; Harding and Lu 2001), and the provincial government’s attempt to eliminate the agency overseeing the coordination of cancer care and treatment in Ontario (Lu 2001; Mackie 2001b; Mallan and Brennan 2001). At the end of 2001, a retrospective piece in the Toronto Star declared that “crumbling confidence in health care and services and the ability and commitment of the political/medical complex to supply them” was the prevailing theme underlying most of that year’s top health stories (Gerstel 2001). This media reporting on the erosion of public confidence has taken shape in the context of, and contributed to, multiple public discourses on “crisis” in relation to health care in Canada, including ongoing concerns about its financial sustainability and timely access to health care providers and services (see, for example, Romanow 2002). By 2006, the Canadian Strategy for Cancer Control (CSCC ) describes Canada as facing a “cancer crisis” (CSCC 2006, 2), which is constructed as both a demographic and economic problem. In their strategic planning, the “aging population” is blamed for increases in cancer incidence, with the resulting increases in sickness leave from work and demands for health care, coupled with projected decreases in tax revenue, leading to decreases in funding available for the health care system: The numbers [of cancer diagnoses] are rising because our population is aging, placing increasing demands on our health care system. As the baby boom population moves into age groups linked to higher cancer risk, there will be an unprecedented demand for health care services. Cancer patients are also surviving longer and needing longer intervention and care. The burden cancer puts on our health care system is growing. At the same time, cancer will increasingly have a negative impact on tax revenue, corporate profits and wage-based productivity, causing

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less money to be available to fund our health care system. (CSCC 2006, 3) The establishment of PGT as a provincially funded health service in Ontario can be viewed as marking a shift in the focus of health care priorities towards a specific, socially constructed segment of the population: the healthy yet genetically “at-risk” for future disease. This is evidenced by a report of the Provincial Advisory Committee on New Predictive Genetic Technologies in 2001, which clearly states its mandate as developing a policy framework so that new PGT services can be introduced into Ontario’s health care system, as a guide to help Ontario “navigate the new frontier of human genetic medicine and science” (Ministry of Health 2001, 1). This policy framework, the report states, will “help ensure that the provincial health system promotes wellness and improves health outcomes in advance of the appearance of disease” (Ministry of Health 2001, 1, emphasis added). As I have described elsewhere, PGT can be viewed as a neoliberal technology of governance that is implicated in a broader shift in responsibility for health from the state to individuals and their families (Polzer 2005; Polzer, Mercer, and Goel 2002). As a formula of rule that seeks to responsibilize individuals through their exercise of freedom and choice, neoliberal practices of governance rely on technologies of the self – that is, on the various practices that individuals carry out in their everyday lives to improve themselves and attain a certain state of being, such as health. These “technologies of the self” were seen by Foucault (1994c) to “permit individuals to effect by their own means, or with the help of others, a certain number of operations on their own bodies and souls, thoughts, conduct, and ways of being, so as to transform themselves in order to attain a certain state of happiness, purity, wisdom, perfection, or immortality” (225). Discourses on health risk, as we suggest in the introduction to this volume, both rely on and reproduce enterprising subjects who are invited to “freely” govern themselves through practices of self-monitoring and bodily vigilance. It is through such practices that individuals take up the duties associated with entrepreneurial subjecthood and prove themselves as moral and responsible citizens – citizens who perform their freedom in ways to protect their health and minimize the chance of developing disease

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(Petersen and Lupton 1996). In contrast, individuals who do not take up this entrepreneurial attitude, and its accompanying duties of risk reduction, are viewed as moral failures, unable to master their bodies through rational calculation and risk management (Lupton 1995). As a neoliberal technology of governance, the case of PGT for hereditary breast cancer risk provides a paradigmatic case of how asymptomatic individuals are constituted as “at-risk” subjects and recruited as free agents of self-regulation (Klawiter 2008; Fosket 2010; Dubriwny 2013). By inviting an awareness of the body prior to symptom onset, individuals constituted as genetically “at risk” are invited to take up surveillance strategies to inspect their bodies for signs of potential disease (e.g., misshapen moles, breast lumps) according to clinical norms (Polzer, Mercer, and Goel 2002). Obtaining knowledge of genetic risk for breast cancer invites women to objectify their bodies and to view them as untrustworthy and thus as in need of regular self-monitoring and medical surveillance in order to detect the earliest possible sign of disease (Polzer 2000; Robertson 1998). By situating women’s breasts as potentially dangerous body parts (Hallowell 1998, 1999), discourses on genetic risk reiterate the tendency in Western biomedicine to frame women’s bodies as “naturally pathological” (Morgan 1998) and have implications for how women relate to themselves and experience their bodies in everyday life. As Ann Robertson argues, women at high risk of breast cancer literally embody neoliberal risk rationality and the enterprising subjectivity it inspires as they “manage their uncertainty and anxiety about breast cancer by negotiating an uneasy pact with their ‘treacherous bodies’” (Robertson 2001, 300). PGT as Ethical Practice and Biological Citizenship

The way in which PGT and genetic risk discourse invites bodily awareness, reflection, and regulation prior to symptom onset resonates with Foucault’s work on ethics, which focuses on the ways in which individuals actively constitute themselves as ethical subjects through their engagement with various techniques of the self. Such techniques include the practical means by which individuals come to “reflect on modes of living, on choices of existence, on the way to regulate one’s

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behavior, to attach oneself to ends and means” (Foucault 1994b, 89). Foucault asserted that freedom was a precondition of ethics (Rabinow 1994) and was careful to point out that these practices of the self – or the ways in which the subject freely engages and constitutes itself – did not originate from within the subject but rather are historically contingent and constituted: “if I am now interested in how the subject constitutes itself in an active fashion through practices of the self, these practices are nevertheless not something invented by the individual himself. They are models that he finds in his culture and are proposed, suggested, imposed upon him by his culture, his society, and his social group” (Foucault 1994a, 291). This approach to ethical analysis is not concerned with elucidating the extent to which one’s behaviour is or is not aligned with moral laws or codes of conduct. Rather, it is concerned with articulating the means by which an individual constitutes a particular part of herself as the prime material of her moral conduct (what is the ethical substance?); the ways in which an individual establishes her relation to moral codes and recognizes her obligation to put this relation into practice (what is the mode of subjection?); the work that she performs on herself in order to transform herself into the ethical subject of her behaviour (what is the ethical work or askesis?); the ends sought through the ethical work and towards which one’s ethical work is performed (what is the telos or final cause?). For example, in his later writings on sexuality, Foucault focused on how it was that the self came to be the object of conscious attention and reflection, and how the “care of the self” was related to the production of knowledge or truth about the self (Foucault 1986, 1994c; Rabinow 1994). Foucault conceived of the care of the self as a practice, an activity in which one, by paying attention to oneself, produces one’s self as an object and lifelong project. Foucault specifically suggested that, during antiquity, the care of the self required one to “know oneself,” to equip oneself with the truth about one’s self (Foucault 1994c). It was through this linking of the care of the self with truth that Foucault connects his later work on ethics with his earlier work on power/knowledge: “I am not saying that ethics is synonymous with the care of the self, but that, in antiquity, ethics as the conscious practice of freedom has revolved around this fundamental imperative: ‘Take care of yourself’ … Taking care of oneself requires knowing one-

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self … To take care of the self is to equip oneself with these truths: this is where ethics is linked to the game of truth” (Foucault 1994c, 285). Just as sexuality became a way to “know oneself” in the nineteenth century, the explosion of knowledge about the human genome has brought with it an increasing emphasis on knowing oneself genetically (e.g., Church 2006), and the language of genetics has become common currency for knowing and speaking about oneself and one’s health in the twenty-first century (Nelkin 1992, 1994). Within an era of biopower, sex came to be an effect of discourse and mode of selfidentification (Foucault 1978); similarly, discourses on genetic risk for future disease (such as breast cancer) provide a biopolitical hinge between macro-level governmental imperatives to manage population health and micro-level desires of individuals who (are expected to) exercise their will to knowledge about their biological propensity for disease in order to take responsibility for their health. In this respect, in Canada and elsewhere (such as the United Kingdom), genetic research and technologies have been identified in policy documents as key to both the improvement and “development” of health for individuals and families (Department of Health 2003; Government of Canada 1998, 2003; Ministry of Health 2001) and to the economic prosperity of nations (Government of Canada 2003). It is within this “spirit of biocapital” that a new somatic ethics has taken shape, according to Nikolas Rose (2007), in which individuals increasingly experience their individuality as “grounded within our fleshly, corporeal existence, and who experience, articulate, judge and act upon ourselves in part in the language of biomedicine” (13). The centrality of healthism as a dominant ethical discourse in the West (Crawford 1980) provides multiple opportunities for processes of biocapitalization (Rose 2007) that proliferate a range of “technologies of life.” This includes genetic susceptibility testing, which extends biomedical expertise into the everyday, produces novel “forms of life” (e.g., the asymptomatically ill), and entails new possibilities to optimize one’s future through the uptake of additional responsibilities and interventions to manage risk: Technologies of life not only seek to reveal these invisible pathologies, but in a culture of prevention and precaution they embody

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a moral or professional obligation – to intervene to optimize the life chances of the susceptible individual. Given we will all sicken and die, all of us, even if existentially healthy are actually pre-symptomatically ill – we are all either actual patients or “pre-patients.” We can already see the proliferation of presymptomatic testing, and the ethos of responsibility, foresight and prudence that it embodies. Hence new forms of life are taking shape in the age of susceptibility, new individual and collective subjectifications of those “at risk,” and the extension of the powers of expertise potentially to all. (Rose 2007, 9) The interventions that become possible within this molecular ontology of life are no longer “constrained by the vital norms of a natural body” (Rose 2007, 7), but rather include techniques of ethical selfformation that aim for optimization and enhancement. Thus, contemporary discourses on genetic risk and susceptibility, rather than stifle one’s commitment to health by prognosticating one’s genetic fate, reinforce individual responsibility for health by creating “an obligation to act in the present in relation to the potential futures that now come into view” (Novas and Rose 2000, 486). It is in this sense that genetic mutations detected by PGT can be seen as constituting the basis of the work one conducts on oneself in order to form oneself as an ethical, healthy subject. Rose and Novas (2003) argue that contemporary biological citizenship gives rise to ethical practices that are shaped by a “political economy of hope,” which ties together personal biographies with broader political contexts. The ethical practices engendered by such a political economy of hope include adopting an active stance towards the future, and aspiring and lobbying for better treatments or services based on scientific knowledge. Within this political economy of hope “citizenship is enacted through ethical self-formation, through personal economizing, and through activism. It thus tries to constitute a public arena in which responsibility for the cure is not merely attributed to scientists and doctors, but is embraced by those who have a stake in the suffering wrought by [a] disease” (Rose and Novas 2003, 26). However, it is important to note that this political economy of hope, and the responsibility to optimize one’s future based on genetic

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self-knowledge, is shaped by conditions of “suffering, privation and inequity” (Rose and Novas 2003, 25) in which social security systems are eroding and in which individuals must bear the cost of having to care for themselves and loved ones with reduced or little social assistance. Within such conditions, individuals’ “choices” to seek out and use biological information about themselves can be seen as attempts to gain leverage in a struggle for social membership and as demonstrating the need to become savvy navigators in a terrain (of health care) where competition for scarce state resources is fierce. Adriana Petryna (2002), who coined the term biological citizenship, illustrates this in her ethnographic study of life in Ukraine after the Chernobyl nuclear disaster, where she details how citizens worked to mobilize their damaged biologies and status as “sufferers” in order to legitimize their claims against the state. The notion of biological citizenship popularized by Rose and Novas is not without its critics who claim, in various ways, that this view runs the risk of reinforcing reductionist accounts of health, undermining other forms of citizenship, and displacing critical analysis of how such citizenship projects and struggles are structured by biotechnology along existing lines of privilege and oppression (e.g., gender, race, class, sexuality) (Charles 2013; Orsini 2008; Plows and Boddington 2006; Raman and Tutton 2010). Alexandra Plows and Paula Boddington (2006) suggest that Rose and Novas’s view of biocitizenship tends to present biotechnological knowledge in a favourable light, and that labelling individual and collective formations in relation to biotechnology as biological citizenship may obscure discussion of the “power flows that help to make up categories as biological or otherwise, and hence help to influence strategies for action” (121). In the context of genetics specifically, Alan Petersen (2003) acknowledges that the language of rights (e.g., to genetic information) might be useful for groups to advance their health-related claims, but that this emphasis on individual rights masks the subtle operations of power that rely on and operate through the cultivation of “self-aware” subjects who learn to relate to themselves and others in particular ways. The notion of “informed choice” that characterizes modern forms of genetic testing, and distinguishes them from negative eugenics (e.g., forced sterilization), assumes that genetic information will enhance an individual’s

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autonomy and decision-making ability (Petersen 1998). However, such assumptions have gone largely unquestioned and, as Petersen points out, there is a need to examine the dispositions and practices that are implied by the choices that are “supposedly facilitated by the provision of genetic information” (2003, 4). In the context of biotechnologies that purport to enhance women’s health, a focus on biological citizenship obscures the ways in which some women’s lives and bodies (in particular, those of white, economically privileged women) have historically been subject to processes of medicalization (Brubaker 2007; Clarke et al. 2010, Ehrenreich and English 1990; Morgan 1998; Riessman 2003). It also obscures the ways in which neoliberal practices of governance that claim to help women reduce their risks for future disease through pharmaceutical products and biotechnologies co-opt feminist language of “choice,” capitalize on women’s desires for autonomy over their bodies and health, and create markets out of healthy populations (Batt and Lippman 2010; Lippman 1999, 2000). In this context, Abby Lippman (2000) suggests how the notion of “choice,” originally introduced with the feminist objective of enhancing the well-being of women, is increasingly filtered through the lens of risk and co-opted by neoliberal policies that aim to marketize women’s health and stimulate the economy: With health and economic policies merging in the politics of neoliberalism, and with health (care) seen as a source of economic development, increasing the choices women have is becoming a major way to stimulate the economy. As a consequence, feminist objectives for health, and the principle of choice that women introduced into the health care arena as essential for our well-being, are being appropriated by politicians and industry and turned into an array of biomedical options for us to use or undergo … Industry is encouraged (even subsidized with public funds) to develop, market and sell us choices in the form of new drugs, new technologies and new programs which, among other things, can not only identify our health risks, but also provide ways to manage them. And, with risk increasingly the lens thorough which choice is filtered – “you are at risk for,

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you can choose to do/undergo … to manage it” – a dangerous synergy between a “tyranny of risk” (Lupton 1995) and a “tyranny of choice” is catalyzed. (33) The individualized conceptualization of choice fuelled by neoliberal framings of risk forecloses a consideration of the various contextual influences that enable and constrain women’s choices and wrongly assumes that women are equally willing and able to exercise choices in relation to these technologies. Discourses of “choice” in relation to new technologies, drugs, and devices thus require scrutiny and further problematization to consider how they might contribute to and potentially exacerbate existing social and health inequities, and what new inequities and stratifications might be created through the marketing and public provision of new technologies, a point I return to later in the Discussion. In the following section, I turn to a study I conducted shortly after the introduction of provincially insured BRCA 1/2 mutation testing in Ontario for women with suggestive family histories of breast cancer. The study was conducted at a familial breast cancer clinic/research unit that was part of Ontario’s provincial network of genetic services. The purpose of the study was to explore how women’s experiences of their susceptibility to breast cancer were shaped by their involvement in PGT for BRCA1/2 mutations. In total, twenty-four in-depth interviews were conducted with nine women (aged thirty to forty-five) at three points in time during the genetic testing process: before genetic counselling, after genetic counselling, and after test results about BRCA 1/2 mutations were received.2 The study sample was ethnically diverse and included women from Chinese, Portuguese, Middle Eastern, Polish, and Ashkenazi Jewish backgrounds, reflecting the ethnic diversity that characterizes the urban centre where the study was conducted. Informed by the theoretical notions discussed above, I explore in the following section three themes that illustrate how the women in this study oriented themselves towards PGT and constituted themselves as ethical, proactive managers of genetic risk. The first theme examines how the women in this study viewed PGT as an opportunity for self-knowledge and a vehicle to take (better) care of themselves.

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The second theme examines how PGT was understood to expand the range of options open to the women for heightened surveillance and risk management prior to the onset of symptoms of disease. In the third theme, I consider how the proactive manager of genetic risk for breast cancer can be considered a neoliberal biological citizen for whom genetic vulnerability to disease itself is framed as both a liability and an opportunity for optimization. This neoliberal biological citizen optimizes her future by using her knowledge of her genetic risk as an opportunity to navigate among an expanded range of technologically driven risk-reduction and surveillance “options” and exert a calculated self-mastery and self-control over her body’s predisposition to disease. The Ethical Configuration of the Proactive Manager of Genetic Risk The Will to Genetic Self-Knowledge and Taking (Better) Care of the Self

As I have elaborated elsewhere (Polzer 2006; Polzer and Robertson 2007), the findings of this study suggest that women who participate in PGT for hereditary breast cancer risk experience a transformation in subjectivity, from active participants in health to proactive managers of genetic risk. As active participants in their health, most of the women in this study engaged in intense risk management regimes prior to their involvement in predictive genetic testing, which included multiple forms of breast screening (self-exams, clinical exams, mammography, ultrasound) as well as modifications to diet, exercise, and other aspects of their “lifestyle.” As proactive managers of genetic risk, the women in this study actively sought out information about their biologically inherited risks in order to reaffirm their vigilance to manage their risks for breast cancer, and to channel and fine-tune their preventive efforts among an expanded range of risk management options in the future, in particular chemoprevention, prophylactic surgery, and MRI screening. At the time of the study, these interventions were typically presented to women with genetic mutations as additional options that would enable them to (further) manage their risks for breast cancer.

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The women in this study viewed the “opportunity” for genetic self-knowledge as one more thing they could do to take charge of their health in order to bring their vulnerability to breast cancer within their rational control. This will to genetic self-knowledge became an integral part of the ethical work (askesis) they engaged in to transform themselves into proactive managers of their risks for breast cancer, and to take (better) care of themselves and their families, above and beyond what they were already doing. This proactive stance, and the importance of “taking care of oneself,” was firmly rooted in the women’s past personal experiences of suffering from breast cancer in their families. For example, Kyra noted how her mother’s recent death reinforced for her and her sister the need to “take care” of themselves. As well, this quote suggestively illustrates how a particular care of the self (medical surveillance) is cultivated through an intricate web of relationships with family members (father), experts (doctor), and other authorities (minister): When I watched my mum die I knew about my other aunts and … […] that’s when it really hit. And people would say to us – like the doctors or the minister or whatever would say “take care of yourself,” you know, “make sure that you look after yourself” and people would repeatedly say that to my sister and I and that’s when it all really started to sink in. […] And my Dad too. You know, he’ll often say to me “make sure that you’re going and getting screened and … look after yourself.” (Kyra)3 This intimate intertwining of care and surveillance was also noted by Annie, who had already been diagnosed with and treated for breast cancer. For her, a positive test result for a BRCA 2 mutation kept her acutely aware that breast cancer was a threat to her health and intensified her commitment to take greater “care” of herself through a closer “watch” over her body and eating habits: “I’ll be more careful about things. I’ll be more observant … it’s [positive test result] a constant reminder that I really have to watch out for things. I shouldn’t forget my vitamins. I shouldn’t forget eating properly … it just makes me more careful …” (Annie). On the other end of the spectrum, Erin, who did

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not engage in lifestyle modifications as much as she would have liked, purposefully became involved in genetic testing as a way of increasing her motivation to exercise greater care of herself through behavioural change. Despite a negative test result, she felt that her involvement in genetic testing made her more conscious of health-related decisions in her day-to-day life: [Genetic testing is] a wake up call … instead of talking about getting better with health, like exercising, eating properly, you know… […] So it’s like I’m thinking about it every day now. “I gotta’ get right. I gotta’ exercise regularly like I used to.” […] I find myself more conscious every day … “what should I be eating?” … “is this right or not?” […] I’m thinking more… “how can I help myself now?” I started eating more dairy products and yogurt, you know? Whereas before I didn’t care too much … so I started that but it’s every day a conscious decision. (Erin) One particularly interesting finding was that some of the participants felt that participating in genetic testing, and reaffirming their motivations to engage in risk reduction, was a way to prioritize care of their own health over that of their partners and children. This was the case for both Larissa and Erin: “I’m saying ‘Larissa … listen to your body. Do something good for yourself.’ Like I’m always the type that I worried about others. I care about how others feel. And the comfort of others. And I forget about me! Honestly I do! And that’s with my husband and my kids! … Everything! And the house and this and then I turn around I go ‘My God I haven’t even eaten!’” (Larissa). On the other hand, two of the women in this study expressed ambivalence towards the acquisition of genetic risk information. These women rejected mutation testing because they anticipated that a positive test result might make the threat of breast cancer too much of a reality; it might make them “feel sick.” This was the case for Elaine, who assumed the role of primary caregiver in her family at the age of seventeen when her mother died of breast cancer, and who described how she and her husband live with the assumption that she will get breast cancer and “that it’s just a matter of catching it early.” As suggested by the following quote,

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Elaine’s ambivalence can be read as resistance to the ways that genetic risk discourse translates the scientific possibility of future disease into the experience of disease: “I mean, the truth is I think I wouldn’t like to know if I had the breast cancer gene because then I would kind of feel like there was something wrong with my body [laughs]. I mean, there would be something wrong but … I guess I don’t like to think that way. Um … so yeah I can see that side of things that genetic testing and finding out that you have a gene … could make you feel sick, right?” (Elaine) Navigating New “Options” and Securing Resources Presymptomatically

In this study, participation in genetic testing was framed by the women as a unique opportunity that would enable them to take even more control over their health, above and beyond what they were already doing to manage their risks for breast cancer. By providing the women with more “options” for risk management, genetic testing acted upon the women’s already present desires to take charge of their health and expanded the ways in which they could perform the ethical work necessary to constitute themselves as active participants. As the women learned about new options for risk management, they came to understand their susceptibility as malleable, as something that could be subjected to their personal control and reduced through their own “choices” and actions, such as taking Tamoxifen or having one’s breasts or ovaries removed: “So I’m doing [oophorectomy] as a preventive measure while for ovarian cancer it would definitely – it takes the worry off my mind like ‘okay. It’s done.’ Over and done with. And also for breast cancer it’s just I’m trying to do the best I can to decrease my risk factor …” (Annie). Similarly, Kyra said, “if I take Tamoxifen then I’m reducing my chance … by 50%. So that’s huge! Like that’s huge. To me.” Furthermore, the women likened PGT to a “door opener” to quality health care professionals and restricted screening services, some of which were being offered on a research basis (e.g., MRI screening) at the time this study was conducted. This is suggestive of how the proactive manager of genetic risk is governed by harnessing her energies

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towards particular kinds of interventions (and thus steered away from other risk management options). The language the study participants used to describe how genetic testing would enable them to choose different “routes” of action was telling in this regard: If we were to be in a BRCA 1 or 2 positive [group] one option would be we could go on Tamoxifen and then also go into more of a serious screening group where they do the MRI ? […] And I think you’re screened … even maybe more than 6 months. […] So you could be followed that way. […] So [we] talked about that, we talked about radical mastectomy […] which is to me extremely drastic. […] I couldn’t do that. It was funny because afterwards when I spoke to my sister … she would be more inclined to go that route. (Kyra) Because they were provided with a number of different routes for breast cancer risk management, the women did not describe genetic testing as limiting what they could do. Similarly, the clinicians and doctors involved were not seen as paternalistically prescribing one course of action (thus limiting what the women should do), but were described as “guides” who could help them navigate among multiple potential courses of action depending on the outcome of their test result: [The doctor] did mention at the first meeting that if it does come back positive we’re taking [a] different route right? […] if it was positive, obviously I would have taken a different route. He would suggest me to go to probably a specialist. Or maybe put me on some sort of medication […] I think that’s what this whole thing is probably. If they find a patient that has this type of BRCA 1 or BRCA 2 gene in their system they obviously would guide them to some sort of a medication that’s out there for that. (Larissa) In this way, and in comparison to the active participant in health, the future of the proactive subject becomes less bound to her past experiences of disease in the family, as the present becomes reconceived as

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a map of a maneuverable options and choices through which she can actively navigate. Similar to Crawford’s (2004) idea of how risk profiles provide a “map of the self,” and reminiscent of the image that opens this chapter, genetic testing was described by the women in this study as a kind of genetic roadmap upon which they could begin to chart revised courses of risk management for themselves, and which would help them begin to navigate the health and cancer care system prior to a diagnosis of breast cancer. Scott et al. (2005), who found similar results in their study of a cancer genetics clinic in the United Kingdom, refer to their study participants as “patient-clients” who, like the women in the present study, are not worried about their risk per se, but are more concerned with securing access to health care resources. In the present study, gaining access to MRI screening had the effect of making the women feel as though they, together with health professionals, could “keep a closer look” over their potentially dangerous bodies. Similarly, Scott et al. (2005) state that such “references to being monitored, cared for, looked out for, and being supervised … signify a desire for surveillance and engagement with a health care system that will constantly check and ‘keep an eye on’ the patient-client. In that sense, patient-clients are … seeking ways of organizing health care resources around their specific and particular needs and lifeworlds” (1876). Taken together, the present findings and those of Scott et al.’s (2005) study suggest that predictive genetic technologies incite individuals to learn how to navigate or “work” the health care system in order to secure health care resources for themselves and their families while they are still well. For women who live with a constant awareness of breast cancer, the need to secure access to health care resources presymptomatically might be particularly pressing, as they may already see themselves as future cancer patients. Indeed, the ability to navigate the health care system has been identified in the Canadian breast cancer literature as a critical concern for women newly diagnosed with breast cancer. Penelope Williams quotes a participant in the Third World Conference on Breast Cancer who describes the overwhelming confusion typically experienced by a woman newly diagnosed with breast cancer, who “goes into this whirl, and all the issues

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are raging around her – she is bombarded on all sides. She needs to make decisions, she needs to get information, she needs to be able to navigate the whole system” (Williams 2004, xii). Genetic(optim)ization and Preparing for a Potentially Diseased Future

In contrast to this scenario of confusion and chaos that surrounds a woman diagnosed with breast cancer, the proactive subject of genetic risk need not wait for an actual diagnosis or even a breast lump to begin to navigate the cancer care system, for all that is required is a suggestive family history. By shifting the gaze of risk from the corporeal to the molecular, the process of PGT brings into the present a potential future with disease in a way that does not require the detection of an embodied abnormality (e.g., breast lump, precancerous cells). This bringing forth of a potential future with disease was experienced by some of the study participants as opening up a window of time during which they could heighten their vigilance in risk management and investigate possible treatment options without having to wait for a suspicious lump to present itself, and in order to “prepare” themselves for the possibility of breast cancer in the future. [My] reasons [for genetic testing] are number one … so I can get ready. So I can prepare myself for this. […] just to do the best I can with the circumstances … to get the best knowledge … hopefully by then [the time of breast cancer onset] I’ll even have a good doctor or maybe I’ll already know where I’m gonna’ go and who am I gonna’ see and I might even know the type of medicine I wanna’ take … If I wanna’ go whichever route. […] You’re just so … vulnerable. I don’t wanna’ be vulnerable. (Larissa) The proactive manager of genetic risk sees early detection through conventional screening strategies, such as breast self-examination and mammography, as already too late. As some of the study participants described, “waiting” to detect a breast lump (that may or may not lead to actual diagnosis) would limit their efforts to capitalize on the time they had while they were well to explore further risk management

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strategies and potential treatment options should they be diagnosed with breast cancer in the future. As the above quote suggests, vulnerability is framed by PGT not in corporeal terms, but rather as not knowing, being unprepared, and thus as limiting one’s abilities to mobilize time and maximize control over an uncertain future. As Larissa put it, taking the time to prepare for the possibility of breast cancer would make her feel less “vulnerable.” Similarly, Chantelle felt that waiting for early detection would put her in the “hands” of her doctor, which would make her feel dependent on her/his expert advice, which she saw as limiting the control she had to investigate choices for potential treatment and risk management beforehand: If all of a sudden you find out that you’re ill … you have no control. You’re totally in the hands of the doctors. If you find out that there are preventative steps you can take and you make those decisions … you’re in control. Um … if someone says to you, “You can do this or you can do this or you can do this,” you can research, you can ask questions, you can go for a second opinion but if you’re already sick and they say, “Well here you go. Here’s your chemo. Have a nice time” … what are you gonna’ do? Are you gonna’ say, “Well I don’t think I want this”… So yeah if you’re already sick what are your options? You’re in the hands of the doctor … (Chantelle) The centrality of the experience of self-control in this regard was also expressed by Annie, who had already been diagnosed with breast cancer and undergone a single mastectomy, and who later tested positive for a BRCA 1 mutation. In this passage, Annie eloquently expresses how genetic testing provides a way for her to adopt a “proactive” stance in preventing a recurrence of breast disease, experience a sense of control over her present, and attach hope to her future: [Genetic testing] just gives me a sense of accomplishment that I am doing everything I can. […] That I am being proactive in preventing it [breast cancer] from coming back. And plus it’s a good feeling … maybe I’m not in control but I feel like I do have control to a certain degree or that I’m doing the best I can … and

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it makes me very hopeful. You know? […] because of all the other things I went through and the negative prognosis that I got from doctors […] Like I don’t have to take their word … whatever it is … things can be different. (Annie) Discussion

The proactive subject of genetic risk for breast cancer can be considered a form of biological citizenship (Petersen 2003; Rose and Novas 2003) that emerges in the discursive space where knowledge of genetic predisposition to breast cancer becomes articulated with respect to a neoliberal politics of health risk. As a technology of governance (Polzer 2005), PGT relies on the capacities of active subjects who demonstrate their moral competence as biological citizens by exercising their “duty to know” their genetic risks (Polzer 2005) and optimizing their futures in light of this knowledge. As I have illustrated here, these proactive, biological citizens seek out genetic self-knowledge in order to further demonstrate and cultivate themselves as women who take charge of their health, and expand the ways in which they can be active risk managers in order to optimize their health outcomes and secure access to health resources prior to the onset of any corporeal signal of future disease. Informed by a neoliberal politics of health risk, which emphasizes personal responsibility for individual and family health, practices of PGT construct the duties required for healthy citizenship in terms of women’s desires for “choice,” self-knowledge, and self-control. In this regard, the present findings further illustrate how neoliberal modes of genetic governance are ethopolitical (Rose 2001) – that is, how they operate through the capacities of individuals (women, in this case) to establish particular kinds of relations with themselves and others to whom they are biologically connected. It is of interest to note that Foucault’s theoretical elaborations on sexual ethics were explicitly based on masculine conduct. In The Use of Pleasure, Foucault (1985) describes this as an “ethics for men: an ethics thought, written, and taught by men, and addressed to men” and in which “women figure as objects or, at most as partners that one had best train, educate, and watch over” (22–3). In contrast, the present analysis suggests that discourses on

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genetic risk for breast cancer constitute a set of ethical responsibilities for women that capitalizes on their desires to take matters of health into their own hands and creates opportunities for them to participate in a specified range of risk-based practices of the self, practices that entice them to watch over their own bodies, insert their bodies into new forms of technological surveillance and intervention, and educate themselves and their family members about their genetic risks for breast cancer. Because the study upon which this analysis is based only included women who sought genetic counselling, the results presented here should not be interpreted to mean that all women with family histories of breast cancer necessarily strive to become active participants in their health or proactive managers of genetic risk. It is possible that women with family histories of cancer who do not pursue PGT experience the threat of breast cancer as being “too close” to them personally, as suggested by the finding that there was a greater sense of ambivalence toward genetic testing among some of the women (e.g., Elaine) who had not been diagnosed with breast cancer, yet for whom breast cancer was experienced as a proximal threat based on their past experiences of witnessing disease in their relatives. The study of why women do not follow through with referrals to genetic diagnostic services would enable a greater understanding of how and why women resist the imperatives of genetic testing (to know and manage genetic risk) by declining technologies that foster self-control and accepting their uncertain futures. As well, this research would facilitate exploration of how not following up on referrals might also indicate lack of access to genetic services and how this intersects with other aspects of women’s lives and social positioning (e.g., difficulties accessing transport, lack of time and money to accommodate appointments). The analytic insights developed here, when considered alongside those presented in chapter 3 on human papillomavirus (HPV ) vaccination, are illustrative of the ways in which biotechnologies in health have constructed a permanent “risk role” for women (Klawiter 2008), positioning their lives and bodies – from the time that they enter sexual maturity onward – as requiring medical surveillance and technological intervention. Both chapters illustrate how women’s choices and autonomy with regard to health-related decision making are shaped by

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discourses on risk and regulated within highly biomedicalized cultural contexts. As two case studies in the biomedicalization of cancer risk, in which risk for cancer is viewed as a treatable health problem in and of itself (Fosket 2010), HPV vaccination and genetic testing for breast cancer are exemplars of how women’s “choices” are shaped and legitimized in relation to pathologized framings of female embodiment to form what Tasha Dubriwny (2013) calls the “vulnerable empowered woman.” Infused with the imperatives of postfeminism and neoliberalism, the agency over health that the “vulnerable empowered” subject proudly claims as her own, through, for example, her participation in risk management technologies, is recognized as such only when it is authorized by highly biomedicalized framings and technologies. In exercising this medicalized agency (Morgan 1998), the vulnerable empowered woman, as Dubriwny (2013) argues, acts in ways that inadvertently reinforce (hetero)normative biomedical norms and reproduce gender inequities. This is consistent with the notion of stratified biomedicalization, which refers to “the selectivity and strategic nature of biomedicalization, its unequal (and sometimes unintended) effects across populations, and how these may exacerbate rather than ameliorate social inequalities along many different dimensions” (Clarke et al. 2010). Often, such inequities tend to be viewed – importantly yet narrowly – in relation to who has and who does not have access to health care services and thus who has and who does not have the opportunity to engage in various forms of prophylactic intervention (e.g., mastectomy, Tamoxifen). However, this problematization leaves intact and unquestioned the ways in which risk biotechnologies reproduce individualized notions of health risk, construct new obligations for individuals to manage risk, and shape women’s subjectivities, including their expectations and hopes for their futures. The findings of this research suggest that these predictive technologies construct new hierarchies of responsible risk managers. Specifically, the ways in which the women in this study saw genetic testing as a “door opener” to access health care resources prior to the detection of a physical abnormality suggests that predictive genetic technologies have the effect of acting as a resource distribution mechanism within a health care system that is increasingly oriented (and marketed) to a highly motivated group of genetically-at-risk individuals who enter-

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prise themselves to navigate their “options” for risk management and treatment prior to symptom onset. These proactive managers of genetic risk can be thought of as elite risk managers who do all they can to manage their hereditary risks, not only through lifestyle modifications and screening surveillance, but also by presymptomatically seeking out ways of expanding their risk management options in the present (e.g., through pharmaceutical or surgical intervention) in order to optimize and secure the best possible futures for themselves and their families. Although PGT is a publicly insured health service available to all women in Ontario with suggestive family histories of breast cancer, women who desire and gain access to the role of elite risk manager are likely those who are already active participants in their health, and who thus occupy a certain amount of privilege in terms of their ability to mobilize their personal resources (time, money) in order to manage their risks for cancer. The ways in which the freedoms of (some) women are channelled by such predictive technologies thus intersects with economic and other forms of privilege in subtle and interesting ways, as a particular class of “at risk” women come to be governed, and govern themselves, along genetic lines. For women with strong family histories of breast cancer, the politically infused imperative to obtain knowledge about genetic risk capitalizes on, and is influenced significantly by, their personal experiences of breast dis-ease and their past experiences of having witnessed their own mothers, aunts, and other relatives suffer with cancer when women had fewer options available to them for screening and treatment. Within such biographical contexts, how, as some of the study participants clearly pointed out, can today’s woman, with the scope of information that is available to her – in newspapers, magazines, doctors’ offices, the Internet, and elsewhere – justify denying an opportunity for knowledge about how she herself might act in her present in order to avoid a future with breast cancer, or optimize her chances for survival? In the context of personal suffering and familial loss, such technologies incite desire for self-control and the need to “prepare” for (or pre-empt) a possible diagnosis of breast cancer in the future. Read alongside Sanford’s analysis of “preparedness” discourse in pandemic influenza planning (chapter 6), the findings of these chapters illustrate the versatility of biological risk discourses in traversing and

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connecting the global and molecular poles of contemporary forms of biopower, and how these discourses on risk responsibilize individuals, families, and entire nation-states to engage in a perpetual exercise of hypervigilance in order to mitigate future uncertain events. I further suggest that the ways in which the proactive subject assumes responsibility for her risk through an expanded range of surveillance (MRI screening), pharmaceutical (Tamoxifen), and surgical (mastectomy) options must also be considered in the context of the prevailing view of Canada’s public health care system as economically burdened and in a perpetual state of “crisis,” which includes specific controversies about the organization of cancer screening and treatment services and waiting times for treatment. Such views do little to instill public confidence in the state’s ability to provide quality health care for the sick, let alone reassure women who have witnessed suffering and death in their own families and who live with the threat of breast cancer in the back of their minds. The ways in which individuals take up personal responsibility for health in the context of state failure to provide adequate health care services for its citizens, whether real or imagined, is captured in this passage from a letter to the editor written by a cancer survivor on the topic of the privatization of cancer care in Ontario around the time that this study was conducted: “When your life is at stake, you need to take responsibility into your own hands if the state is not equipped to handle it” (Fleischmann 2002). Reinforced by neoliberal directives to reduce public resources, increase privatization, and for “austerity” measures generally, discourses about health care “crisis” constitute a terrain within which individuals must struggle for finite resources and make decisions about predictive genetic services and other forms of risk management. Within this discursive terrain, and buttressed by women’s experiences with familial breast cancer, molecularized constructions of genetic risk flourish, specifying new “options” or forms of regulated freedom through which women are governed and construct themselves as responsible, biological citizens. Thus, I suggest that the elite risk manager seeks out predictive technologies to optimize her life chances in her projected future not only in response to (the neoliberal political imperatives embedded in) predictive risk technologies and her own personal biography of cancer,

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but also to compensate for the confusion, shortages, and/or failures that have come to characterize the health care system, generally, and the cancer care system, specifically. By gaining knowledge and organizing care/surveillance presymptomatically, the proactive manager of genetic risk preemptively mobilizes the resources available to her for fear that care/treatment may not be available to her if/when she is diagnosed with breast cancer in the future. The proactive subject is thus charged with the dual tasks of managing not only her biological risk, but also the anticipated risk that the state may not be equipped to respond to her needs in the future when she may be ill and in need of care when time is of the essence. By focusing on BRCA 1/2 mutation testing, this chapter contributes to contemporary theoretical discussions of biological citizenship by considering the ethical work and responsibilities that are incited as requirements for this kind of citizenship, and highlights the potentially enabling and disabling effects of such risk-based technologies. The present analysis suggests that the proactive manager of genetic risk uses PGT as a way to take matters of her health into her own hands. In this sense, PGT governs women by inciting them to adopt an “active stance” towards their potential futures with disease prior to the development of symptoms. Thus, PGT can be seen as operating within a “political economy of hope” (Rose and Novas 2003) – that is, as a technology that holds promise for what women with family histories of breast cancer can hope for their futures, and for the futures of their children and other family members. While this attitude of hopefulness was articulated by a number of women in this study who took part in genetic testing, it is important to remember, as Nicole Charles points out in her critique of Rose and Novas’s (2003) “idealistically optimistic” view of biological citizenship, that “These technologies should not merely be taken as emanating hope, but instead, as holding the potential to engender a multiplicity of emotions and responses – some of which may be less than emancipatory. Understanding how these technologies work together with the state and industry … to drive particular modes of citizenship and neoliberal governance is … important in order to facilitate and sustain vigilant critique of these new biomedical advances which are growing at extraordinary rates, and bringing with them equally as unprecedented risks and obligations for us as citizens”

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(782). As part of this vigilant critique, we might question the implication of such models of biological citizenship for the ways in which individuals’ deservingness of access to publicly funded health services will be judged (by friends, family, health practitioners, and policy makers) on the basis of their demonstrating that they have presymptomatically exercised their personal responsibility for managing their health risks, genetic or otherwise, and through a variety of means. At the very least, it is important to acknowledge that, while participation in PGT may be experienced as enabling for some women, as pointed out by some of the quotations presented earlier in this chapter, this proactive stance entails new forms of genetic responsibility, self-identification, and social relations of obligation: Genetic risk does not imply resignation in the face of an implacable biological destiny: it induces new and active relations to oneself and one’s future. In particular, it generates new forms of “genetic responsibility,” locating actually and potentially affected individuals within new communities of obligation and identification. Far from generating fatalism, the rewriting of personhood at a genetic level and its visualization through a “molecular optic” transforms the relations between patient and expert in unexpected ways, and is linked to the development of novel “life strategies,” involving practices of choice, enterprise, self-actualization, and prudence in relation to one’s genetic make-up. (Novas and Rose 2000, 485) It is important to note that the critique offered here is by no means an attempt to evaluate women’s actions as they are confronted with the possibility of learning about their genetic risks for breast cancer. As well, although it is not the focus of this analysis, it is reasonable to assume that the heightened vigilance and prophylactic interventions promoted by practices of PGT may have life-extending effects for some women. I am in no way suggesting that the women who participated in my study were merely dupes of a generalized, top-down process of geneticization. Rather, the analysis I develop here aims to expose the politically contingent nature of ethical relations (self-self, self-

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other) by illustrating how women’s “choices,” and the forms of ethical conduct that become available and desirable to them, are shaped by particular political rationalities that prevail at specific historical moments and materialize in concrete health-related practices. Within the ethical and political configuration of “genetic risk” that characterizes our present, one cannot reasonably accept one’s genetics as fate, but must rather seek out ways of curbing and controlling risk. Far from being passive recipients of genetic risk information, this analysis draws attention to how women’s participation in genetic testing enables them to rescript their understandings of their family histories of breast cancer, and their own feelings of vulnerability to breast cancer, in order to “hold out the possibility of a different future for themselves and their family” (Gibbon 2002, 448). However, not all of the study participants who were eligible for mutation testing chose to learn about their genetic risks. Such decisions to decline testing were vociferously contested by some of the other study participants; because knowledge about genetic risk was viewed by most of the women in this study as desirable for its ability to optimize early detection and expand future risk management “options,” it was incomprehensible to them why anyone would refuse such an opportunity for self-knowledge. For one participant, the decision not to know one’s genetic risk was described as “willful blindness” (see Polzer and Robertson 2007, 46), an expression that succinctly articulates the ways in which women come to evaluate their own actions, and judge the actions of others, in relation to expectations that are constructed by the practice of predictive genetic testing. This puts into clear perspective the moral imperatives that structure women’s choices in relation to the practice of PGT , and the extent to which resistance to obtain knowledge about one’s genetic risk – even in the form of ambivalence – is contained and potentially stifled. In such biomedicalized contexts, as Thomas Lemke points out, demonstrating one’s will to biological knowledge reflects new standards for evaluating moral competence such that declining the opportunity to gain genetic information might be interpreted as morally negligent or inept (Lemke 2005, 100). Similarly, in her analysis of popular representations of prophylactic mastectomy, Dubriwny illustrates the moralization of

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women’s “choices” to manage their risks for cancer through surgical means, choices that are often experienced as compulsory. Similar to the study findings presented in this chapter, the moral dimensions of choice in relation to preventive technologies come into sharp relief when a woman must weigh her risks for future cancer in relation to her personal experiences of witnessing suffering: For the many women who have watched a family member struggle with cancer, cancer is understandably not a risk to be entertained. What the prophylactic mastectomy narrative makes clear is the very power of risk calculations. Although I argue that we should question the presentation of risk regarding health issues, from the emphasis on some risk factors over others to the very complex nature of statistical measures, the vulnerable empowered women of this narrative do not have the space to question risk. Once vulnerability to cancer is framed as unacceptable, the vulnerable empowered woman’s choices are placed in a highly moralized context with a focus on the possibilities for a better self, a context that offers prophylactic mastectomies as a compulsory choice for women with BRCA mutations. (Dubriwny 2013, 62) In closing, and in light of the critical interpretations offered in this chapter, the oft assumed claim that PGT enhances choice and facilitates individual autonomy over decision making might be more aptly described as capitalizing on and (re)directing individuals’ desires to take charge of their health in relation to a changing spectrum of surveillance, pharmaceutical, and surgical options for risk management. As suggested by the image described at the beginning of this chapter, women’s subjectivities and desires for personal control are channelled by predictive genetic technologies, such as BRCA 1/2 mutation testing, which encourage them to learn about and navigate their options for health, and recognize their duties to manage their treacherous bodies and biologies, increasingly through the logic, language, and evershifting terrain of risk.

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Acknowledgments

The study upon which this chapter is based was supported by a Social Sciences and Humanities Research Council (SSHRC ) doctoral fellowship and a National Cancer Institute of Canada (NCIC ) studentship. The author thanks Elaine Power, Sarah Sanford, and Nicole Charles for their very helpful comments.

N ot e s

1 In July 2011, Ontario’s Ministry of Health and Long-Term Care expanded its breast cancer screening program with an investment of $15 million over three years. This included the establishment of high-risk screening centres at select sites across Ontario (see http://www.health.gov.on.ca/ en/public/programs/breastcancer/about.aspx). 2 In this study, interviews were conducted at this third time point only with women who were judged to be eligible for BRCA 1/2 mutation testing and who consented to testing. Eligibility for testing under Ontario’s health insurance plan (OHIP ) is determined through the completion of a family history questionnaire and the construction of a “pedigree,” which is typically presented to the patient/client during the genetic counselling session. 3 In the presented quotations, ellipses are used to indicate pauses in speech (…) and ellipsis within square parentheses are used to indicate where passages of speech were removed to facilitate reading ([…]).

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Ch a p t e r 6

Global Biopolitics and Pandemic Influenza Preparedness: Securitization and the Regulation of Viral Uncertainty and Mutual Vulnerability Sarah Sanford

Introduction

Since the late 1990s, there has been considerable concern regarding a potential pandemic influenza outbreak that may result in extremely high mortality rates worldwide. The H 5N 1 influenza strain, a variant of avian influenza endemic in domestic and wild fowl populations in Asia, was, until the 2009 H 1N 1 pandemic, considered to be the likely source of such a pandemic. The H 5N 1 virus is highly pathogenic within the fowl population and has been spread through migration from its origin in parts of Asia to other countries such as Russia, Turkey, and Egypt. While the number of cases of H 5N 1 infection in humans has, to date, been limited, the concern among scientists and policy makers is that the virus will mutate to enable efficient human-to-human transmission and consequently result in the rapid spread of infection that characterizes a global pandemic. The potentially dire effects of a future pandemic have been predicted to be extensive, typified by projected worldwide mortality rates of between two and twelve million (Davies 2008). Much of the early

planning material on pandemic influenza refers to the mortality rates of previous pandemics, such as the 1918 “Spanish flu” that resulted in approximately fifty million deaths worldwide over eighteen months (Mackellar 2007; Monahan 2006). These precedents are widely cited as the foundation for perspectives that predict a future pandemic with potentially high mortality rates and support the general consensus among policy makers and the scientific community that the pandemic would occur despite the considerable uncertainty surrounding the event (Mackellar 2007; Williams 2008). In addition, there has been widespread concern, especially in policy circles, that such an event would potentially result in significant social and economic instability, due to projected effects such as the overburdening of health care systems, high rates of worker absenteeism, and the disruption of flows of goods and bodies across national borders (Sakaguchi 2005; WHO 1999, 2005, 2009a). In response to these projections, significant investments have been made in the development of pandemic influenza plans by Western nations. The World Health Organization (WHO ) has spearheaded this planning with the production of general guidelines for national health bodies and regional organizations or affiliations to achieve “preparedness” as a means of dealing with what has been framed as an uncertain but imminent event. Much of the social science, medico-scientific, and public health research on pandemic influenza highlights the scientific uncertainty and unpredictability inherent in this event (Williams 2008; Garoon and Duggan 2008). In this regard, it is generally acknowledged that there is a clear lack of consensus among scientific and medical experts engaged in pandemic influenza research and policy making (Garoon and Duggan 2008). My interest in this chapter lies in critically examining the preemptive approach to global health governance that emphasizes “preparedness” as a response to the uncertainty of the (re)emergence of pandemic influenza. The governance of emerging infectious disease involves a unique approach to the regulation of infectious disease that seeks to pre-emptively control a phenomenon that has yet to occur. Such pre-emptive responses require critical analysis that interrogates the underlying assumptions and values guiding global preparedness endeavours, in order to more fully grasp their potential effects. In this

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chapter, I engage in such an analysis by first briefly outlining the discourse of (re)emergence that frames contemporary understandings of pandemic influenza. I then introduce the theoretical framework of global biopolitics as a means to further understand the governance of (re)emerging infectious disease through techniques of securitization. Drawing on a critical reading of selected global pandemic planning documents and relevant literature, I use this theoretical framework to highlight the discursive structuring of pandemic preparedness in relation to the recent focus on the securitization of disease, and the interrelated theme of the regulation of uncertainty associated with borders in global(ized) contexts. I also point out how constructions of the influenza virus as unpredictable help to mobilize pre-emptive approaches by necessitating preparedness mechanisms that address the ongoing potential of the emergence of a pandemic virus. I argue that the objective of pre-emption involves establishing global norms about “preparedness” that responsibilize nation-states to engage and invest in a range of techniques (e.g., surveillance, vaccine production, and stockpiling) in order to monitor and manage pandemic risk. In this context, the representation of emerging infectious disease as a growing social threat coincides with the framing of disease in terms of security, a discursive practice that raises important questions with respect to how “uncertainty” and “security” are implicated in broader processes of differentiation and relations of inequality. The (Re)emergence and Governance of Infectious Disease in the Western World

By the mid-1900s, the Western world was thought to have experienced an epidemiological transition where the burden of disease shifted from infectious disease towards those chronic diseases resulting from lifestyle changes and longer life expectancies (McMichael 2004; Waters 2001; Epstein 1992). However, the emergence of new infectious diseases, such as the West Nile virus and Severe Acute Respiratory Syndrome (SARS ), and the re-emergence of existing infectious diseases such as tuberculosis,1 have led to a general re-evaluation of the pervasive sentiment that developed countries should minimize their focus

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on the control of infectious diseases. This re-evaluation of the threat of infectious disease to Western countries not only challenges the prevailing views of scientific and medical communities that infectious diseases are of little concern to the management of health in Western nations, it also exposes the limitations of the assumptions of technological and scientific progress that inform these views. In many respects, the SARS outbreak in 2003 represented a key event for the governance of emerging infectious disease. The rapid global spread of the disease, the severity of illness associated with infection, and the great initial uncertainty surrounding its specific clinical characteristics (e.g., the structure of the virus and transmission routes) presented unprecedented dilemmas with respect to the global governance of disease. While SARS was eventually contained – in fact, pandemic planning documents present the response to SARS as a remarkable success in terms of global disease management – the event provided substantial legitimacy and political will for investment in infectious disease planning at a time when momentum for such planning had already begun, and during a period in which the economic viability of publicly funded health initiatives had become a contentious topic. In 2005, following SARS , the WHO approved the International Health Regulations revisions (IHR ), a legally binding instrument requiring all WHO member states to report the outbreak of certain infectious diseases in addition to other public health events. Along with broadening the scope of notifiable diseases from the previous 1969 regulations, the IHR revisions require the strengthening of surveillance and response systems and are presented as a necessary update to international law in the contemporary context of trade, travel, and migration patterns associated with globalization. These developments were largely implicated in the pre-emptive initiatives that occurred prior to the SARS event, and solidified the legitimacy of preparedness mechanisms through the legal requirements outlined in the revisions. A dominant theme reflected in much of the scientific research on emerging infectious disease is that the increased interconnectedness associated with globalization has led to a heightened vulnerability to emergent viruses that circulate rapidly through the increased movement of bodies across borders. In response to the problem of (re)emergence of infectious disease, international and national health

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surveillance organizations such as the WHO and Centers for Disease Control and Prevention (CDC ) in the United States have developed mandates and strategies to prepare for potential infectious disease outbreaks, which aim to contain the spread of disease globally. As suggested by the following quote from a 2008 article in the journal Nature, support for such surveillance has been mobilized by the epidemiological identification of “risky” geographical areas and emphasis on containing the threat that is posed by these disease “hotspots” to the general global population in an era of globalization: “The [epidemiological] maps suggest that there are potential ‘hotspots’ of disease emergence – particularly in central America, tropical Africa and south Asia – that warrant greater surveillance. These findings support calls for investment in the capacity to detect, identify and monitor infectious diseases, targeted at regions of the world where the need is greatest … in an era of increasing globalization, emerging infectious diseases are everybody’s problem” (Woolhouse 2008, 899). Such epidemiological perspectives fail to consider the global politics of disease, including the structural factors that produce inequalities in morbidity and mortality between economically rich and poor nations, where rates of death and illness from infectious diseases such as tuberculosis, diarrheal disease, and malaria are disproportionately high. For example, Paul Farmer (1999) challenges the very conceptualization of “re-emergence” by acknowledging the experiences of extremely vulnerable populations in geographical areas that, due to specific historical, economic, and social circumstances, failed to undergo the epidemiological transition to chronic diseases. The framing of a common global vulnerability to disease reinforces the prevailing Western viewpoint that infectious disease originates from “elsewhere.” Calls by wealthy nations (and international institutions representing the interests of these nations) to address the emergence of infectious diseases, such as pandemic influenza, are founded on deep and culturally embedded understandings of difference. These understandings, and the assertions to which they give rise, not only oversimplify the political and economic dynamics that contribute to the global epidemiology of infectious disease, they also frame the priorities and activities of global health governance. Global health policies and priorities thus require critical interrogation to elucidate

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how they inform the regulation of (re)emerging infectious disease and the potential effects of these regulatory strategies on social and health inequities. Global Biopolitics and (Re)emerging Infectious Disease

This chapter is informed by Foucault’s conceptualization of biopolitics, where biopower represents the generalized configuration of modern power that focuses on the administration of life (Foucault 2010). Biopower joins two constitutive axes in the conceptualization and organization of power over life: the first axis refers to the focus on the individual body as the target of disciplinary control, while the second focuses on the population as the object and target of regulatory control. In contrast to the first pole, biopolitics addresses and constructs the vital, biological characteristics of the population as a political problem and as the object of political strategy (Foucault 2003). The main objective of the biopolitical state is the security of the population, which is achieved through intervention into its vital characteristics (Inda 2002). As noted by Foucault (2003), the vital characteristics of the population – fertility, birth, and mortality rates, for example – are “aleatory and unpredictable when taken in themselves or individually,” but “at the collective level, display constants that are easy, or at least possible, to establish” (246). As Thomas Lemke (2011) conveys, systems of knowledge focused on the biological features of life “make the reality of life conceivable and calculable in such a way that it can be shaped and transformed” (119). Thus, at its core, the regulation of population-level phenomena manages uncertainty by making the unpredictable predictable through the production of statistics and implementation of corresponding interventions that target these regular patterns (Foucault 2003). These interventions are enacted with the goal of securing an optimal state of health and life in populations, and it is largely this objective – the extension and enhancement of health and life – that lends biopower its authority and legitimacy. Within this biopolitical governance framework, “risk” is a key technology in securing the health of populations. In this respect, risk is both a form of reasoning that functions to control the future based on

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calculations of probability in the present (Rose 2001) and a means of operationalizing this rationality to regulate populations (Weir 2006). The projection of risk into a future probability through calculus transcends the binary of sick/healthy (since bodies at risk are neither sick nor healthy), and uncovers multiple targets and possibilities for intervention (Weir 2006). As Nikolas Rose (2001) suggests, contemporary biopolitics involves “a variety of strategies that try to identify, treat, manage or administer those individuals, groups or localities where risk is seen to be high. The binary distinctions of normal and pathological which were central to earlier biopolitical analyses, are now organized within these strategies for the government of risk” (7). Thus, risk governance no longer requires an actual instance of illness as deviance; instead, “it is enough to display whatever the characteristics the specialists responsible for the definition of preventive policy have constituted as risk factors” (Castel 1991, 288). In public health, risk governance is operationalized by systems of surveillance that use epidemiological techniques to categorize groups and places through scientific criteria aimed at “pre-detection” and based upon “abstract factors” that indicate the probability of future abnormality or disease (Castel 1991; Petersen and Lupton 1996). In locating the threat of disease beyond the individual body, risk governance pathologizes entire populations as “risky,” as well as their behaviours and the spaces they inhabit (Foucault 1978; Harris 1999). In the regulation of emerging infectious disease, risk discourse locates animals, objects, behaviours, people, and places that are thought to threaten population security, and justifies the use of a range of social technologies (e.g., surveillance systems, airport screening, health promotion strategies) to manage these risks. As a theoretical framework, biopolitics has much to contribute to critical analyses of (re)emerging infectious disease, especially in relation to risk techniques that attempt to forecast and pre-empt the future occurrence of disease in the context of globalization. There is a marked need to reconceptualize traditional accounts of infectious disease regulation in terms of a global biopolitics, given the stark inequalities in the distribution of infectious disease at the global level. As discussed above, the distribution of disease by social causes (e.g., poverty, gender inequity) illustrates that global disease transmission and prevalence rates cannot be understood outside of the relations

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of inequality and dependency that result from intersecting forces of colonialism and globalization and that constitute certain populations, in both rich and poor countries, as particularly vulnerable to disease. In this sense, while the biopolitical state takes as its objective the enhancement and securitization of health and life, the regulation of disease can function as a means of differentiation between lives deemed worthy of saving and those that are not. The biopolitical conceptualization of race offers one approach through which to explore how global relations of inequality and difference are produced and exacerbated through the regulation of emerging infectious disease. Foucault addresses the concept of race in population management by asserting that it is state racism that justifies the act of “killing” in its biopolitical form (Foucault 2003). In this sense, the right of the biopolitical state to “make live” or “let die” replaces the idea of power in the classical theory of sovereignty concerning the king’s right “to kill” or “let live.” This form of state racism places race struggles within the boundaries of the modern biopolitical state, the activities of which function to distinguish between lives that are deemed valuable and those that are not, and to mark and effectively exclude the lives and bodies of those who are viewed as unworthy of political and economic investment. Within this form of state racism, the marginalization and expulsion of particular bodies tends to occur indirectly, and often involves implicit and indirect decisions about the worth of life. This marginalization occurs, for example, by exposing some lives to risk by denying health and social services that aim to enhance and extend life (e.g., prenatal care) to particular groups (e.g., immigrant women) that are construed as a threat to the reproduction of the nation state (Inda 2002). In the remainder of this chapter, I use the theoretical frame of global biopolitics to examine contemporary discourses on emerging infectious disease, with a specific focus on pandemic influenza preparedness. I begin with a brief discussion of the securitization of global health, drawing from national and global policy documents that explicitly address the issue of security. I then analyze pandemic preparedness discourse as it has taken shape in global health governance agendas, drawing on relevant social science research and focusing on four WHO policy documents produced from 1999 to 2009 (WHO 1999,

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2005, 2009a, 2009b). These policy documents provide guidance and recommendations to national bodies for their own pandemic preparedness planning. The first document was produced in 1999, before most states had created official national plans. As such, the visioning outlined by WHO in these documents is key to understanding the problematization and legitimation of pandemic preparedness, which at conception was uniquely global in scale and jurisdiction. Drawing on the theoretical framework of global biopolitics explored above, I examine these texts in order to shed light on the responsibilities of the nation-state that are constructed in relation to the broader problematization of preparedness. I specifically focus on the themes of securitization and constructions of viral uncertainty and mutual vulnerability within preparedness planning. I discuss how nation-states are called upon to prepare against pandemic emergence, and consider the implications of these discursive constructions for understandings of inequality. The Securitization of Global Health

The discourse of securitization has become increasingly prevalent in the framing of global health, and particularly infectious disease. It has been suggested that health as an issue of national security has become the “most dominant discourse” to have emerged in recent years, and “is consistent with nation-states’ often explicit duties to protect their citizens from foreign risk by guarding their borders, whether the ‘invaders’ are pathogens or people” (Labonte 2008, 468). The rising awareness by Western states that infectious disease could pose a substantial threat to the health of citizens and to political and economic stability has led to the development of responses to such security threats. Sara Davies (2008) proposes that the WHO has a vested interest in the framing of infectious disease in security terms, as the management of this health issue through internationally coordinated surveillance measures legitimizes the organization’s authority in global health governance. As well, substantial legitimacy is granted to those health issues that are framed in terms of state security. For example, some suggest that the framing of infectious diseases, such as HIV /AIDS , in terms of security results from the well-intentioned motivation to increase political

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action and investment in eradicating or preventing these diseases (Elbe 2005). At the same time, others suggest that the WHO prioritizes the interests of Western states through their emphasis on maintaining security against infectious disease, with “developing” states largely excluded from this process (Davies 2008). Recent explorations of the governance of emerging infectious disease in Western nations have examined how uncertainty and danger operate in relation to discourses on securitization (Cooper 2006; Elbe 2005; Ingram 2008a, 2008b; King 2002, 2003). This work points to the increasingly blurred boundaries between military security practices (e.g., intelligence surveillance) and global health functions (e.g., infectious disease surveillance), resulting in what Alan Ingram describes as the “discursive slippage between the pathogen of terrorism and the terror of pathogens” (Ingram 2008b, 77). In this sense, the existing preoccupation with (in)security and the uncertain yet imminent materialization of novel infectious diseases is aligned with an increased focus of governance on the issue of bioterrorism, another source of considerable uncertainty following the events of 11 September 2001 and the subsequent anthrax “terrorist attacks” in the United States. While the connection of security and infectious disease regulation historically predates the events of 9/11, such acts of terrorism against the state have further legitimized the technologization and militarization of public health practices in the management of (re)emerging infectious diseases (Monahan 2006; Cooper 2006; Ingram 2008a, 2008b). In the Canadian context, the connection between health governance and security issues is evident in policy documents such as the federal government’s 2004 Securing an Open Society: Canada’s National Security Policy, produced by the Privy Council Office, which presents the first “integrated” approach to current and future security threats and dedicates an entire chapter to the management of public health emergencies. Within this document, 2001 terrorist attacks in the United States and the 2003 SARS outbreak are both cited as key events that illustrate the need to strengthen national capacity to deal with the “dangerous threat environment” by addressing significant security gaps (Government of Canada 2004, iii). The framing of global health concerns, and particularly pandemic influenza, in terms of securitization in many ways justifies an antici-

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patory or “pre-emptive” approach to the regulation of infectious disease. The 2007 World Health Report titled A Safer Future: Global Public Health Security in the 21st Century focuses on key themes designated as threats to global security and labels pandemic influenza as “the most feared security threat” (WHO 2007, 45). As I explore below, security as an objective of governance lends itself well to the current techniques of regulation that are evident in pre-emptive strategies to manage the health of populations in the event of an infectious disease outbreak. Viral Uncertainty and Pre-emptive Regulation

Constructions of the influenza virus within WHO policy documents as inherently unpredictable assist in mobilizing a pre-emptive approach to the regulation of (re)emerging infectious disease that involves interventions that take population security as their objective. Within global pandemic planning documents, discussions of the influenza virus depict it as an entity that is inherently unpredictable and uncertain. As I discuss in depth elsewhere (Sanford 2013), while most cases of emergence are described in the WHO pandemic planning documents as not actually leading to a pandemic event, the documents portray even benign influenza viruses (e.g., seasonal influenza strains) as possessing an innate capacity to transform into a harmful strain: “Many animal influenza viruses naturally infect and circulate among a variety of avian and mammalian species. Most of these animal influenza viruses do not normally infect humans. However, on occasion, certain animal viruses do infect humans … An influenza pandemic occurs when an animal influenza virus to which most humans have no immunity acquires the ability to cause sustained chains of human-to-human transmission leading to community-wide outbreaks. Such a virus has the potential to spread worldwide, causing a pandemic” (WHO 2009a, 14). The construction of the influenza virus as unpredictable and endowed with potential for pandemic has significant implications for understanding pre-emptive approaches to pandemic planning and response. The uncertainty associated with this construction of the virus informs planning activities and public health responses that entail ongoing surveillance and up-to-date preparedness and intervention in

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order to mitigate the potentially harmful effects of viral change. Thus, the construction of the influenza virus as inherently uncertain and ever-evolving legitimizes an approach to global health governance that aligns with a range of techniques of security, including constant global surveillance of emerging viruses, the ongoing production and accumulation of knowledge about viral strains for developing vaccine prototypes, and the stockpiling of antivirals (Davis 2005; Fidler 2007; PHAC 2007). The United States has been especially active in this stockpiling, and the Public Health Agency of Canada’s (PHAC ) Canadian Pandemic Influenza Plan for the Health Sector (CPIP ) has been modified to incorporate vaccine stockpiling into their “multifaceted” pandemic preparedness efforts, once the vaccine is developed (PHAC 2007). Other means of preparing for a future pandemic include an increased focus on global surveillance and contact tracing, the imposition of travel restrictions, and increased emphasis on border screening and quarantine measures should an outbreak occur (Garoon and Duggan 2008). In their emphasis on both economic and social security as objectives of preparedness, global pandemic planning documents propose securitization techniques that extend beyond the health sector. This is particularly evident in the approach to preparedness articulated in the WHO ’s 2009 “Whole-of-Society Pandemic Readiness” framework, which incorporates a number of recognized non-health social sectors into pre-emptive strategies. Where earlier planning documents largely target the health sector and public health policy makers, documents published in 2009 (WHO 2009a, 2009b) emphasize the importance of including what they describe as “all sectors” of society in preparedness exercises: local levels of government, the private sector, communitybased organizations, essential service providers (transport, telecommu­ nications, energy, water, pharmaceuticals, and finance), and families/ individuals. The general idea conveyed in these more recent planning documents is that the interconnectedness of these sectors creates “critical interdependencies [that] constitute complex vulnerabilities” (WHO 2009b, 10). This quote exemplifies the sentiment that inadequate preparedness by one party or organization will lead to the increased vulnerability of others; as a result, preparedness planning is constituted as necessary for all sectors of society.

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For example, the “Whole-of-Society” approach promotes what is called “The Readiness Framework,” where the overall objective is the increasing integration of pandemic planning into general “emergency preparedness” frameworks. One effect of this approach is that the distinction between pandemic and non- and inter-pandemic periods becomes increasingly blurred as non-pandemic circumstances are incorporated into conceptualizations of pandemic through ongoing preparedness activities. For example, the private sector is called upon to adjust their existing “Business Continuity” plans in order to make allowances for possible disruptions incurred by a future pandemic (WHO 2009a, 15). Through this blurring of distinctions between pandemic and non-pandemic phases, the governance of pandemic becomes presented as requiring a continual, ongoing process that is never complete. Ongoing preparedness is justified by the representation of the uncertainty inherent in the event of pandemic as requiring a response, and of complacency as a risk: “The precise timing and impact of a future influenza pandemic remains unknown. Developing and sustaining a country’s preparedness is challenging, and carries a risk of complacency” (WHO 2009a, 13). Boundary Transgression and Mutual Vulnerability

The construction of the influenza virus as uncertain and highly unpredictable, as discussed above, is connected to its tendency to circulate in both human and animal populations and to transgress both corporeal and territorial boundaries. The portrayal in planning documents of the influenza viral strains as having the capacity to “mix” with other strains through the transgression of national and corporeal (animal–human, human–human) boundaries reinforces the requirement to regulate infectious disease through minimizing spread and containing the virus within a particular territory. For example, the 1999 WHO planning document identifies China as a particular site of risk and frames the transgression of viral boundaries as more likely due to the co-infection of animals and reliance on local, traditional agricultural practices (i.e., as opposed to mass, commercial farming

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popular in the West): “It is possible that the agricultural practices and ecological circumstances in this area [China] provide continual opportunities for the co-infection of animals to occur with human, avian and swine influenza viruses. Such co-infections would enable reassortants to arise, from which those with human epidemic properties could then be selected through a series of transmissions between animals or humans over an extended period of time” (WHO 1999, 44). The increased risk associated with the transgression of boundaries between animal and human bodies that is attributed to China is further linked to concerns regarding the transgression of national boundaries. In this regard, countries with trade- and travel-associated links with places designated as “risky,” such as China, are described as having heightened insecurity. In addressing the varying levels of risk of emergence of a pandemic virus, countries other than China are rarely identified within the WHO planning documents; however, the mutual vulnerability of nation-states that arises from close trade and travel links is a recurring concern. The connection between border transgression and the regulation of viral uncertainty resonates with Ingram’s (2008b) argument that the shift towards governance through securitization is intimately connected to the erosion of seemingly discrete and stable boundaries, such as corporeal and national borders, through processes associated with globalization. In this regard, the issue of mobility is a key concern identified in the pandemic planning documents, most obviously through its conflict with viral/disease containment operations. The preoccupation with mobility and permeable borders becomes more explicit following the 2005 IHR revisions imposed by WHO, where a new distinction is made in planning and response recommendations for countries that are “affected” versus those that are “not affected” (WHO 2005). Furthermore, the designation of a risk locale that we characterize as risky by association is introduced in WHO (2005) through the inclusion of a category for planning and response activities specifically targeting “countries with extensive travel/ trade-related links with affected countries” (16). The establishment of these categories for planning and response purposes, by indicating whether a country is “affected,” “unaffected,” or “risky by association,” constructs a global hierarchy of risk based on the mutual vulnerability

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of states based on economic trade patterns and links between national boundaries and borders. Coinciding with this establishment of mutual vulnerability is the intensified circulation of goods and bodies associated with globalization. Thus, national borders are specified in the planning documents as sites of concentrated risk, and as in need of regulation to contain the spread of infectious disease. This is evident in the documents, which recommend that nations share pandemic plans with bordering countries and consider “cross-border” issues when developing their respective plans. For example, WHO (1999) states, “In regional areas where countries are contiguous, exchange of regional plans is recommended” (22), and WHO (2009b) directs, “National plans should be shared with neighbouring countries. Particular attention should be paid to plans in neighbouring border areas” (9). Similarly, nation-states are directed to “consider implementing entry screening at international borders” during a global pandemic (WHO 2009a, 43). At the same time, the WHO avoids encouraging border closure measures, and leaves such decisions to the authority of individual nation-states. Thus, while the border is a considerable object of contemplation throughout the planning documents, specific directions about border measures are avoided. This need for selective border control is consistent with Alison Bashford’s (2002) assertion that international biopolitics “governs the movement, transitions, settlement and repatriation of various populations – including refugees, migrants, guest workers, tourists and students” and, through such regulation, health concerns are commonly interlinked with those of immigration and citizenship (348–9). Furthermore, William Walters (2006) points to a central tension of preparedness within neoliberal globalization, which requires heightened border surveillance while maintaining open borders for economic trade. This tension reinforces distinctions between undesirable mobilities, suggested by the goal of Western governments to “intercept refugees before they have an opportunity to activate human rights claims within the territory” and desirable mobilities, which are marked by the “concern to decongest border crossings in the interests of further liberalizing and accelerating circuits of transnational tourism, trade and production” (Walters 2006, 195).

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Responsibilizing Nation-States to Respond

The constitution of mutual vulnerability to pandemic in the WHO planning documents reinforces the duty of nation-states to adequately prepare as part of their responsibility to other nations within global economic systems. In addition to the differentiation made between nation-states based on the global hierarchy of pandemic risk, as described above, the WHO planning documents designate a country’s capacity to respond in relation to specified pandemic phases.2 In the WHO (2009a) document, a distinction is made, for example, between those countries with “adequate surveillance” and those without. Such distinctions have implications for the integration of nation-states into global surveillance networks and systems. In this context, the IHR legally requires nation-states to report disease and engage in border regulation as part of their responsibility to participate in global public health surveillance: “The IHR (2005) also obligates State Parties to develop national public health capacities to detect, assess and respond to events, and to report to WHO as necessary, as well as capacities to address risks of international spread of disease at designated ports and airports (and potentially, at designated ground crossings). If a potential pandemic or related public health risk should arise, the IHR also provides extensive options for national authorities to obtain information from incoming aircraft, ships, and other vehicles and travellers” (WHO 2009a, 20). Along with emphasizing the risk attributed to cross-border mobility, this excerpt illustrates the considerable effort undertaken by international regulatory bodies, such as WHO , to incorporate nation-states into the global surveillance network of detection, assessment, reporting, and response in the event of suspected international health emergencies. At the same time, the demands placed on countries to develop their capacities to respond through vigilant and intensified border surveillance is disassociated from issues that influence their actual capacity and willingness to integrate into this globalized surveillance system. Thus, this responsibilization of national states obscures inequities in the degree of decision making different countries have in terms of their capacity to purchase, “stockpile,” and consume vaccines and develop public health infrastructure. Indeed, the accumulation

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of antivirals by some nations for use during a pandemic has been a key aspect of preparedness planning. Significantly, the accumulation of antivirals and vaccines by wealthy nations has evoked dissension among leaders in developing nations that do not have the resources to participate in this key preparedness activity. Another aspect of the responsibilization of states is the requirement of national officials to regulate food production techniques (and by extension, animal–human relations) to ensure that they are compliant with global norms outlined by key organizations such as the Food and Agriculture Organization of the United Nations (FAO ) and WHO . Again, the specification and implementation of measures to control the risk of pandemic emergence through the regulation of food production techniques frequently elide a consideration of the political and economic contexts within which such “risky” practices emerge and flourish. For example, Steven Hinchcliffe and Nick Bingham (2008) illustrate that economic processes such as market reform and privatization, and the food insecurities that resulted from these processes for many Egyptians, were in fact deeply implicated in the rise of subsistence animal husbandry that Egypt’s health officials attempted to prohibit in 2006, in response to avian influenza infections in the country. Similarly, where the WHO documents identify the proximity of animals and humans as a source of pandemic influenza risk, they neglect the roles that transnational corporations and large-scale agribusiness play in the production of risk and the possible emergence of a pandemic. For example, the 2009 “Swine flu” pandemic originated in La Gloria, a small community in Mexico, the location of a subsidiary of the US company Smithfield Foods, the largest producer of pork in the world and owner of many poultry farms globally. More than 60 percent of the approximately three thousand local residents became sick with a respiratory illness prior to the pandemic, and many attribute the outbreak to the poor environmental waste practices of the company (Grain 2009). Furthermore, the particular implications of trade agreements, such as NAFTA , for environmental and health regulations in medium- and low-income states are absent from the problematizations of emergence and preparedness in the WHO planning documents.

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The inequity central to the global response to infectious diseases has been voiced in a number of different ways. French infectious disease expert Marc Gentilini, for example, made news headlines when he described the response to the 2009 outbreak as a “pandemic of indecency.” His characterization highlighted the glaring disparity between the investment into pandemic preparedness and investment into treatable infectious diseases such as tuberculosis and malaria that disproportionately affect the inhabitants of “poor” nations (Martinache 2009). Inequalities between the global North and South intersect in complex ways with other dimensions of inequality, such as race and gender (Gandy and Zumla 2003). Discourses of preparedness that call on nation-states to invest in resources to mitigate a future pandemic, for the benefit of the “global good,” not only neglect to consider these inequalities; they also obscure the political and economic contexts that implicate all nation-states in these interrelationships. This framing reinforces histories of colonialism by responsibilizing individual states to engage in preparedness readiness and, thereby, blaming those nation-states that are judged as inadequately prepared. Discussion

This critical examination of discourses on pandemic preparedness illustrates how constructions of viral uncertainty and boundary transgression are linked to the responsibilization of states to develop preemptive “preparedness” plans and measures. As well, it illuminates a number of tensions in preparedness discourse. Specifically, my analysis suggests that those places, conditions, and practices identified and labelled as “risky” and in need of regulation (or disallowed) on the grounds of securing “global public health” are made possible and encouraged by the neoliberal economic and political contexts that contribute to global health inequities. Within the WHO policy documents examined here, representations of the nature of the influenza virus as inherently unpredictable function as key mechanisms in enabling pre-emptive and ongoing approaches to infectious disease regulation. This construction is but one of the many uncertainties inherent in the problematization of “pandemic” that frame the conditions of possibility for the generalized objective

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of “preparedness.” The discursive feature of viral uncertainty within global preparedness planning discourse is a contemporary exemplar of Foucault’s (1978) theoretical insight regarding biopower and the intersection between the biological and the political. As Lemke (2011) conveys, systems of knowledge focused on the biological features of life “make the reality of life conceivable and calculable in such a way that it can be shaped and transformed” (119). Similar to the analyses of risk related to human papillomavirus (HPV ) and genetic mutations presented in chapters 3 and 5 in this volume, assigning risk status to certain “in-between” states opens up sites for governance through technological means (e.g., heightened surveillance in bordering nations or the vaccination of groups against emerging viral strains). Whereas these chapters examine how risk discourse situates individual bodies in temporally liminal states “in-between” health and disease, my analysis of pandemic preparedness shows how entire populations are regulated through a kind of geographic or spatial liminality, where the spaces between national bodies are constructed as sites for increased pandemic risk through the discursive deployment of infection scenarios and requirements for increased surveillance and border monitoring. The constitution of all influenza viruses as potentially pandemic resonates with the contemporary construction of sexually transmitted HPV as normal yet potentially fatal given the association of some high-risk strains with cervical cancer (Polzer and Knabe 2012). Similar to Jessica Polzer and Susan Knabe’s (2012) analysis of constructions of HPV in popular media, this emphasis on uncertainty, whereby normal viral events are discursively linked to potentially dire health outcomes, justifies a response that pre-empts risk through technological intervention (vaccination). In the case of HPV , the linking of increased risk for cancer with normal viral circulation not only requires heightened vigilance (on a personal and familial level), but also has the effect of medicalizing nascent female sexuality (Polzer and Knabe 2012). This is elaborated in chapter 3 by Cayen, Polzer, and Knabe, who illustrate how the vaccine is presented in popular magazines as a way to resolve the “ambiguous boundaries of maturity and sexuality that characterize tweendom” (102). While these case studies of HPV and pandemic influenza operate at distinct levels of analysis, they similarly illustrate the biopolitics of

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contemporary imaginings of infectious disease, which mobilize constructions of viral uncertainty to simultaneously induce anxiety and support public health responses that responsibilize individuals and nation-states to pre-empt risk through vaccination. As a key discursive technique that enables the forms and logic of pre-emption that characterize contemporary infectious disease governance, the construction of viral uncertainty as a “natural” biological feature of the influenza virus resonates with Lorna Weir and Eric Mykhalovskiy’s (2010) insights about risk and vigilance. Their work on global infectious disease control as a “global emergency vigilance apparatus” distinguishes between “risk” and “vigilance” as “separate techniques of foresight” (9); while risk technologies operate through a “predictive calculation of probabilities,” vigilance apparatuses “are not intrinsically calculative … as they aim to identify the specific, suspicious event that is distinguished from a background of prior data. Vigilance apparatuses operate through exhaustive sensitivity, whereas risk systems act by estimating the likelihood of unwanted future harms based on the calculation of probabilities” (Weir and Mykhalovskiy 2010, 9, emphasis added). In this regard, global emergency vigilance is marked by its emphasis on early detection of numerous “events” that “extends to species other than humans, to environmental disasters, to nuclear explosions, and to the deliberate spread of pathogens” (Weir and Mykhalovskiy 2010, 6). This objective of global health governance to identify a variety of events that may have pandemic consequences through a generalized emergency framework is articulated over a decade of WHO planning and culminates in 2009 in the “Whole-ofSociety” approach and “Readiness Framework,” discussed earlier in this chapter. My analysis suggests that the temporal repositioning of response to infectious disease, in this case influenza, towards one of ongoing “sensitivity” is a key technique in managing the uncertainty and unpredictability of the virus. The idea that all flu viruses could “naturally” transform into the next pandemic necessitates continual surveillance and data collection and that both nation-states and international bodies be attuned to any atypical features of viral emergence. Importantly, this approach of a generalized preparedness is no longer organized around the aim of prevention, but is characterized by the continual engagement with the possibility of emerging threats.

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As discussed earlier, a key theme in the conceptualization of emerging infectious disease is the role of the so-called “borderless world” (Walters 2006) in contributing to the rapidity and ease with which diseases of globalization, such as SARS , are transmitted. The requirement to maintain open borders for uninterrupted trade within neoliberal globalization is an underlying force in (unequal) disease transmission worldwide. An implication of my analysis is that regulation through the discourse of preparedness involves ongoing distinction between desirable and undesirable circulation. This distinction occurs at the liminal, in-between site of the border where undesirable circulation (e.g., of bodies that are suspected to host and transmit viruses) is intensely monitored and regulated with the intention of maintaining or increasing more desirable circulation (e.g., of goods that maintain global economic relations). Mobility (of bodies, goods) in this sense is symbolically and materially attached to representations of certain types of political and economic (in)security, and the policing of borders associated with a heightened need for security functions as a “shoring up” of space in order to allow for the circulation required for the continued economic functioning of society. The tensions between the desire to maintain neoliberal free trade and market control (under regional trade agreements such as NAFTA ) and the need to reduce security threats (e.g., pandemic viral strains) that cross borders – or, expressed another way, the need to distinguish between and regulate desirable and undesirable border crossings – are also evident in much of the planning and political discussion involving pandemic influenza. In this light, the objective of maintaining or increasing circulation within networks through which knowledge, products, services, and people flow within global capitalism conflicts with the aim to control or contain unpredictable entities (e.g., humans, viruses, biological weapons) that threaten the global order. In the case of global health security, some acknowledge the co-option of uncertainty and anxiety surrounding the H 1N 1 pandemic by specific conservative political agendas in the United States. As Merrill Singer (2009) emphasizes, these positions target national border control, legitimizing “a platform to attack ‘illegal aliens’ for being responsible for carrying the disease across the Mexican border and infecting innocent Americans” (203). This location of global health risk in “other”

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bodies and territories is reflected in the present analysis of pandemic planning documents where China is identified as a source of pandemic risk – and as a threat to global health and economic security – through reference to the increased chance of animal–human viral transmission associated with reliance on traditional farming practices. Such cases are suggestive of a global biopolitical racism where the “infected” bodies and practices of alien others are expelled – literally and symbolically – to secure global public health. The framing of pandemic preparedness in terms of security (especially economic, but also national/military and social) is thus implicated in differentiating between infected and uninfected bodies (individual, national) and potentially reinforcing systems of global health inequality discussed earlier in this chapter. As Ingram (2008a) states, security discourses relating to disease function according to “a preconceived and stereotyped array of subjectivities: the entitled and unentitled; good citizens and the enemy within; innocent victims (whom we unfortunately cannot accommodate) and wilful and predatory deceivers (whom we must exclude). Security is to be achieved via the assignation of people thus defined to proper locations in space” (889). While the propagation of these values and ideas are rarely explicit, the framing of infectious disease in security terms – and its subsequent threat to nation and other imagined unities – represents deeply embedded cultural judgments about difference and its external origin. In this chapter, I have considered how the discourse of “preparedness” responsibilizes nation-states to prepare for the uncertain yet imminent health event of pandemic influenza through its emphasis on global health security. A key element of preparedness is the concern with boundary transgression accentuated by the potential emergence of an influenza pandemic virus and the recourse to the idea of a global mutual vulnerability arising from increased mobility and interconnectedness. As I have suggested above, these discursive components are mobilized in WHO planning documents to invoke nationstates to prepare as part of their responsibility to maintain global health and the global economic order. In the context of pandemic influenza planning, the interconnection between the securitization of global health risks and neoliberal economic agendas can be seen in the labelling of border restrictions as trade protectionist measures and

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in the activities associated with market speculation, production, and circulation of biotechnologies. At the national level, increased focus on vaccines and pharmaceuticals that purport to manage global health risks represent the enhancement and extension of life characteristic of the biopolitical state. A global biopolitics perspective further questions how global regimes of drug production and distribution shape, and potentially exacerbate, global health inequities, including access to such vital resources. A key strategy in the governance of pandemic influenza and regulation of insecurity at the national level has been investment into the stockpiling of vaccines and antivirals by Western states. At the same time, there has been criticism regarding unequal access to resources prior to the H 1N 1 pandemic (Davis 2005), where low-income countries were required to depend on the “benevolence” of rich nations through the donation of vaccines and pharmaceuticals in the form of aid. This reliance on charitable aid reproduces economic and social disparities among nations and stimulates important questions concerning the role of drug regulations in protecting pharmaceutical patents over the health needs of populations who are marginalized – economically, politically, and otherwise – through processes of economic globalization. Furthermore, this highlights the tensions between the stated motive of a common “global good” driving global infectious disease surveillance and the unequal distribution of vaccines that are actually developed from the flu samples gathered through this surveillance system. An example of resistance to this global health inequity was illustrated by the refusal of Indonesian officials to share flu samples with the Centers for Disease Control (CDC ) due to the unequal distribution of vaccines worldwide (Fidler 2008; Normile 2007). As David Fidler (2008) notes, Indonesia’s cooperation in the sharing of viral strains was crucial to the operation of global influenza surveillance given its relatively high rates of avian influenza, and this has motivated the WHO to seek a solution to the problem of unequal access highlighted by this act of resistance. The process of negotiation between WHO , nation-states, and pharmaceutical companies regarding the obligation to share flu samples was extensive, and resolved in 2011 when companies agreed to provide developing countries with a percentage of the global supply of influenza vaccine produced, at lower cost (Knox 2011). While this

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is no doubt a victory for developing countries in the case of increasing equitable access to influenza vaccines, it could also be interpreted as an instance of adaptation to resistant discourse (discussed in the introduction to this volume) and a prevention of broader change that targets the production of pharmaceuticals more generally (e.g., with respect to patents or the prioritization of some health problems over others). In responsibilizing nation-states through discourses of mutual vulnerability that frame infectious disease as global security threats, preparedness discourse privileges the question of “who is prepared?” over considerations of the political, economic, and historical forces and conditions that render some groups as more vulnerable to disease and some states as less capable of responding to the possibility of pandemic through pre-emptive planning. Such a framing obscures the interconnection between the objectives of preparedness and broader political and economic relations. The global biopolitics perspective elaborated in this chapter brings this connection into focus by critically examining how “preparedness” is implicated in a particular kind of biopolitical regulation, one that naturalizes pandemic though constructions of viral uncertainty and unpredictability, secures the risk posed by this uncertainty through increased surveillance of borders and sites marked by mutual vulnerability, and responsibilizes states to prepare for the uncertain yet imminent event of pandemic influenza. Acknowledgments

This research was supported by a Canada Graduate Scholarship from the Social Sciences and Humanities Research Council of Canada.

N ot e s

1 Although concern over the re-emergence of existing infectious disease, such as tuberculosis, has grown – particularly in relation to its threat to the “general population” – it is important to acknowledge that such diseases have been an ongoing and real concern for a number of marginalized populations in Canada. See, for example, Sara Tedford’s discussion in this volume of tuberculosis among the Inuit in the context of settling the

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North. See also Kelm (1998), who provides a detailed analysis of the effects of colonization on tuberculosis among First Nations peoples in British Columbia. 2 See Sanford (2013) for a more detailed explanation of the pandemic phases and their relation to the regulation of uncertainty. References

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Government of Canada, Privy Council Office. 2004. Securing an Open Society: Canada’s National Security Policy. Ottawa: National Library of Canada. http://publications.gc.ca/collections/Collection/CP22-77-2004E.pdf. Grain. 2009. “A Food System That Kills: Swine Flu Is Meat Industry’s Latest Plague.” Against the Grain, 28 April. http://www.grain.org/article/entries/ 189-a-food-system-that-kills-swine-flu-is-meat-industry-s-latest-plague. Harris, Patricia. 1999. “Public Welfare and Liberal Governance.” In Poststructuralism, Citizenship and Social Policy, edited by Alan Petersen, Ian Barns, Janice Dudley, and Patricia Harris, 25–64. London: Routledge. Hinchcliffe, Steve, and Nick Bingham. 2008. “Securing Life: The Emerging Practices of Biosecurity.” Environment and Planning A 40 (7): 1534–51. Inda, Jonathan X. 2002. “Biopower, Reproduction and the Migrant Woman’s Body.” In Decolonial Voices: Chicano and Chicana Colonial Studies in the 21st Century, edited by Arturo J. Aldama and Naomi Quinonez, 98–112. Bloomington: Indiana University. Ingram, Alan. 2008a. “Domopolitics and Disease: HIV /AIDS , Immigration, and Asylum in the UK .” Environment and Planning D: Society and Space 26: 875–94. – 2008b. “Pandemic Anxiety and Global Health Security.” In Fear: Critical Geopolitics and Everyday Life, edited by Rachel Pain and Susan J. Smith, 75–85. Aldershot, UK : Ashgate. Kelm, Mary-Ellen. 1998. Colonizing Bodies: Aboriginal Health and Healing in British Columbia, 1900–1950. Vancouver: UBC Press. King, Nicholas B. 2002. “Security, Disease, Commerce: Ideologies of Postcolonial Global Health.” Social Studies of Science 32:763–89. – 2003. “The Influence of Anxiety: September 11, Bioterrorism, and American Public Health.” Journal of the History of Medicine 58:433–41. Knox, Richard. 2011. “WHO Resolves Impasse over Sharing of Flu Viruses, Access to Vaccines.” Shots: Health News from NPR . http://www.npr.org/ blogs/health/2011/04/18/135519592/who-resolves-impasse-over-sharing-offlu-viruses-access-to-vaccines. Labonte, Ronald. 2008. “Global Health in Public Policy: Finding the Right Frame?” Critical Public Health 18:467–82. Lavin, Chad, and Chris Russill. 2010. “The Ideology of the Epidemic.” New Political Science 32:65–82. Lemke, Thomas. 2011. Biopolitics: An Advanced Introduction. New York: New York University Press. MacKellar, Landis. 2007. “Pandemic Influenza: A Review.” Population and Development Review 33:429–51. Martinache, Veronique. 2009. “Swine Flu: Rich Nations’ Spending Spurs Ethics Row.” Associated Free Press, 1 August. http://www.google.com/hostednews/ afp/article/ALeqM5jy8Rf383vod.

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McMichael, Anthony J. 2004. “Environmental and Social Influences on Emerging Infectious Diseases: Past, Present and Future.” Philosophical Transactions of the Royal Society of London. Series B : Biological Sciences 359: 1049–58. Monahan, Torin. 2006. “Securing the Homeland: Torture, Preparedness, and the Right to Let Die.” Social Justice 33:95–105. Normile, Dennis. 2007. “Indonesia to Share Flu Samples under New Terms.” Science 316:37. Petersen, Alan, and Deborah Lupton. 1996. The New Public Health: Health and Self in the Age of Risk. Thousand Oaks, CA : Sage. Polzer, Jessica, and Susan Knabe. 2012. “From Desire to Disease: Human Papillomavirus (HPV ) and the Medicalization of Nascent Female Sexuality.” Journal of Sex Research 49 (4): 344–52. Public Health Agency of Canada (PHAC ). 2007. New Component Added to Canada’s Pandemic Preparedness Plan. Ottawa: Public Health Agency of Canada. http://www.phac-aspc.gc.ca/influenza/vac_antiv/newcomponent_ nouvelelement-pandemic-eng.php. Rattansi, Ali. 1997. “Postcolonialism and Its Discontents.” Economy and Society 26:480–500. Rose, Nikolas. 2001. “The Politics of Life Itself.” Theory, Culture and Society 18: 1–30. Sakaguchi, Ann M. 2005. “Review Essay: Emerging and Reemerging Diseases and Globalization.” Journal of Health Politics, Policy and Law 30:1163–77. Sanford, Sarah. 2013. “Integrating Pandemic through Preparedness: Global Security and the Utility of Threat.” PhD diss., Dalla Lana School of Public Health, University of Toronto, Toronto. Singer, Merrill. 2009. “Pathogens Gone Wild? Medical Anthropology and the ‘Swine Flu’ Pandemic.” Medical Anthropology 28:199–206. Walters, William. 2006. “Border/Control.” European Journal of Social Theory 9: 187–203. Waters, William. 2001. “Globalization, Socioeconomic Restructuring, and Community Health.” Journal of Community Health 26:79–92. Weir, Lorna. 2006. Pregnancy, Risk and Biopolitics: On the Threshold of the Liv­ ing Subject. London: Routledge. Weir, Lorna, and Eric Mykhalovskiy. 2010. Global Public Health Vigilance: Creating a World on Alert. New York: Taylor and Francis. Williams, Simon N. 2008. “‘Plausible Uncertainty’: The Negotiated Indeterminacy of Pandemic Influenza in the UK .” Critical Public Health 18:77–85. Woolhouse, Mark E.J. 2008. “Epidemiology: Emerging Diseases Go Global.” Nature 451:898–9. World Health Organization (WHO ). 1999. Influenza Pandemic Plan. The Role of WHO and Guidelines for National and Regional Planning. Geneva: WHO Department of Communicable Disease Surveillance and Response.

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– 2005. WHO Global Influenza Preparedness Plan: The Role of WHO and Recommendations for National Measures Before and During Pandemics. Geneva: Department of Communicable Disease Surveillance and Response, Global Influenza Programme. – 2007. The World Health Report 2007 – A Safer Future: Global Public Health Security in the 21st Century. Geneva: Publications of the World Health Organization. – 2009a. Pandemic Influenza Preparedness and Response: A WHO Guidance Document. Geneva: WHO Global Influenza Programme. – 2009b. Whole-of-Society Pandemic Readiness: WHO Guidelines for Pandemic Preparedness and Response in the Non-Health Sector. Geneva: WHO Global Influenza Programme.

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Ch a p t e r 7

Risk and Resistance: Citizenship and Self-Determination through Health Governance in Nunavut, Canada Sara Tedford

Introduction

In April 1999, the establishment of the new Canadian territory1 of Nunavut2 marked an important moment in both the history of Indigenous3 governance in Canada and the Inuit struggle for selfdetermination. Comprising an area of one-fifth of Canada’s landmass, Nunavut’s creation as Canada’s third and largest territory promised to bring decision-making power to a largely (85 percent) Inuit population through a democratically elected territorial government and the Nunavut Land Claims Agreement. In separating Nunavut from the Northwest Territories, with a governing system developed according to their own traditions, the Inuit have framed self-determination within a context of common belonging and coexistence with a settler society (Cairns 2001; Scott 2001). Within a postcolonial context, the establishment of Nunavut with an Inuit-informed and -guided governing system is part of a struggle for citizenship. Similar to popular imaginings of Canada and Canadian citizenship, particular notions of “health” and “health care” became central pillars of the construction of Nunavut as a new political territory, and of citizenship in that territory.4 Establishing priorities for

the new territory, the Bathurst Mandate Pinasuaqtavut stated that “the health of Nunavut” depends on the health of its physical, social, economic, and cultural communities (Government of Nunavut 1999a). In this chapter, I examine discourses on health governance in the context of the establishment of Nunavut, and consider the implications of these discourses for the shaping of this territory and Inuit citizenship within Canada. I treat citizenship as governmental, drawing on ideas that recognize the ways in which citizenship is negotiated and unstable, constructed through participation in and engagement with discourses of nation and nation-building (Citizenship Studies Media Lab 2005; Isin 2002; Stasiulis and Bakan 1997; Tully 2000). In this way, citizenship in Nunavut is not a determinate, fixed result of the establishment of the territory, but an ongoing process of engagement with existing political authorities, governing systems, and discourses (Christie 2003; Turner 1993; Wood 2003). This examination of discourses on health governance during the formation of a territory ostensibly developed and governed using Inuit values and principles exposes tensions in the efforts to realize selfdetermination as a people within the Canadian nation-state, and in a historical context of colonialism and a contemporary ideological context of neoliberalism. These contexts bring into sharp relief the question, how do Inuit Nunavummiut (the people of Nunavut) work toward collective self-determination within and alongside discourses on risk and neoliberal political rationalities that medicalize life and frame health and disease as individual problems and responsibilities? In this chapter, I focus in particular on how risk problematization emerges as a central organizing feature of Nunavut’s health discourse, and how such problematizations shape Nunavummiut’s experiences of health and health care. I begin with a look at the historical context of health governance in Nunavut followed by consideration of notions of citizenship, governmentality, and risk, and the relevance of these concepts for the current shaping of health governance in Nunavut. Through a qualitative exploration of the unfolding of health governance in this new territory, I examine how Nunavummiut took up and challenged notions of health and governance, and being Canadian, Inuit, and Nunavummiut in the early years of establishing Nunavut. I consider how health care

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practices, programming, and planning were sites for the exercise and reproduction of colonial relations, including the medicalization of life (as Browne and Fiske 2001 and Kaufert and O’Neil 1993 suggest), and how risk problematization emerged as central in citizenship practices. The Historical Context of Health Governance in Nunavut

During the late 1800s and early 1900s, the Far North of Canada (generally considered to be the Arctic, north of the 60th parallel) was largely a place of myth for the South. Early contact between Inuit (historically, the sole Indigenous group of the Central and Eastern Canadian Arctic) and non-Inuit intensified through the early twentieth century as missionaries, traders, explorers, the Royal Canadian Mounted Police (RCMP ), and Canadian and American military personnel (during the Second World War) began “settling” the North. By the 1940s, large Inuit family groups began to settle around trading posts. Soon thereafter, reports of “alarming rates” of tuberculosis and other illnesses fuelled a growing sentiment among southern policy makers that the Inuit should be considered “wards of the state” and that the federal government “must exercise a ‘protective’ responsibility” towards them (Tester and Kulchyski 1994, 36). To do so, it staffed semi-icebreakers with physicians (and occasionally other specialists such as dentists) and equipped them with x -ray machines, darkrooms for chest x -rays, and beds for patients (Grygier 1997; Hankins 2000). These excursions to the North effectively transformed the North into a laboratory for studying the Inuit after exposure to southern diseases. Inuit were brought on board these semi-icebreakers where they came face to face with medical practitioners who subjected them to tests and sometimes kept them on board to bring back to the South for medical care with little explanation and regard for implications for individual, family, and community. Through the 1960s and 1970s, the Inuit across the North of Canada organized politically by developing a new national Inuit organization, Inuit Tapirisat of Canada (ITC ) (now Inuit Tapiriit Kanatami or ITK ), and settled the first Inuit comprehensive land claims agreement, which brought increased local autonomy. During this time, health services in

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northern Canada continued to be colonial in character, and there was increasing dependence on the non-Aboriginal professional nurses and doctors who worked for the federal government (O’Neil 1990). By the mid-1970s the Canadian government began to devolve administrative authority to regional and territorial governments, facilitating Inuit efforts to shape their own territory and citizenship within the nation. In 1976, the ITC made a formal call in a presentation to the Government of Canada for the creation of a new territory to be known as Nunavut. By 1999, this proposal had become the Nunavut Land Claims Agreement, the largest Aboriginal land claim in Canadian history, which formally established the Nunavut Territory. The Government of Nunavut (GN ) is a representative public service that distinguishes itself from other territorial and provincial governments through its incorporation of Inuit values and beliefs into its system of government. Efforts to overcome significant gaps in health care across the territory have given rise to new health centres and support for the local development of health care worker training. These new developments take place within a field of power relations characterized by a tension between the desire to “‘Canadianize’ Nunavut health care” (Government of Nunavut 2002a) and attempts to prioritize northern and Inuit approaches to governance and life. This tension exposes the contested nature of citizenship, with health governance and health care providing sites for the exercise and reproduction of colonial relations. Citizenship, Governmentality, and Risk

Self-determination, the term that many Inuit Nunavummiut use when speaking of building Nunavut, is about shaping a particular kind of collective identity, one that is constantly shaped in relation to others.5 Exposing a deep connection between identity and citizenship (Isin and Turner 2007), struggles for collective self-determination engage people in practices of citizenship, and are responses to, and reflections of, relations between Inuit and non-Inuit, South and North. This concept of self-determination is distinct from the forms of self-government and empowerment advocated by practices of liberal governance, which aim to maximize the freedom of citizens while gov-

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erning “from a distance.” Liberal governance is reserved for those who are considered capable of exercising the rights and responsibilities associated with a form of regulated freedom, and historically excludes some categories of people from full citizenship. These have included women, children, the poor, the unemployed, the criminal, the dangerous, and Indigenous peoples (Hindess 2001; O’Malley 1996; Valverde 1996). Under colonialism, Indigenous peoples were considered “impossible” to govern through liberal forms of rule, and subject to extermination, enslavement, and assimilation (Hindess 2001). As Polzer and Power point out in their introduction, recent policies that promote self-empowerment may be considered an advance in liberal governance, but marginalized groups, including Indigenous peoples, are still subject to governance through the imposition of “unfreedom.” Expert knowledge, including discourses of risk, is a key feature of liberal governance (Rose 1996). Risk discourses invite the neoliberal citizen to exercise his or her freedom responsibly, a sign that one is “deserving” of full citizenship (Crawford 2004). As Treena Orchard explains in chapter 8, institutional power relations, including those involving community and health-related agencies, help shape the neoliberal governance of marginalized populations. Health governance is a particularly robust example of governance through expertise and risk management. As a contemporary counterpart to medicalization, healthism elevates health to a metaphor for all that is good in life, and depoliticizes it by making individuals solely responsible for their own health and that of their families (Crawford 1980), consistent with neoliberal governance. As Crawford (2004) explains, “to be assessed at risk is to become an object of surveillance and a site of intervention” (514, original emphasis), broadening and deepening the medicalization of life. However, while risk discourses seek to individualize responsibility for health, Lupton and Tulloch (2002) found that such individualization only goes so far. This study suggested that Australians do individualize risk, but they also consider their risks in relation to those of other Australians, thus politicizing risk and emphasizing the production of social inequity via deliberate government strategy or neglect. Eide and Knight (1999) refer to this collective, re-problematization of risk as grievance-based politicization, where grievances are “a form of complaint,” which re-place blame on the actions or inactions of others

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(529–30). Similarly, O’Malley (1996) found that the neoliberal project of governing Indigenous people in Australia through self-determination has created contradictions, tensions and instabilities as “key liberal technologies of rule are reshaped or abandoned” (316) in the face of Indigenous traditions and structures of governance. Foucault’s analysis of governmentality provides a way to explore the ways in which constraint and resistance emerge simultaneously, and opens analysis to consider the elements that limit and encourage possibilities for engagement as a self-determining people. While Foucault may have been skeptical about the prospects for full emancipation, his analysis of governmentality suggests the possibility of altering particular normalizing practices (Dean 1996; Foucault 1988, 1991; Sawicki 1996). Thus, emphasis placed by Indigenous peoples on self-determination, rather than self-government, demands that greater attention be given to the re-colonizing effects of “citizenship,” which is typically formulated in terms of a nationally bound subjectivity and which may impose particular ways of “being political” onto Indigenous resistance and engagement (Denis 1997; Ong 1999; Tully 2000). In the following sections, I explore the risk problematizations that emerge in health governance discourse in Nunavut. In so doing, I consider health governance and health care as sites for the exercise of, and resistance to, colonial relations. In creating Nunavut through their self-determination efforts, Inuit Nunavummiut contest the “ward of the state” relationship with the South, which posits Inuit as a people that need to be taken care of, as well as the northernization, medicalization, and individualization of health “problems” that result from risk discourse. Methodology

From 2001 to 2003 I used ethnographic methods to consider Nuna­ vummiut health and health governance within the context of this new territory. Fieldwork involved several trips to three Nunavut communities – Iqaluit, Igloolik, and Rankin Inlet – between March 2001 and March 2002.6 Inuit have always referred to the Central and Eastern Arctic as Nunavut – “our land” in Inuktitut. Iqaluit (population 6,184), just south of the Arctic Circle on Baffin Island, is the capital and largest

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settlement in Nunavut. It grew around what had been an American Air Force base and a Hudson Bay Company trading post. Rankin Inlet (population 2,358) is on the northwest shore of the Hudson Bay and was developed in the 1960s at the site of a nickel mine and a tuberculosis rehabilitation centre. Igloolik (population 1,538), the geographic centre of Nunavut, is about 300 kilometres north of the Arctic Circle and has a long history as an Inuit meeting place (Nunavut Planning Commission 2016). I conducted forty-one in-depth, semi-structured interviews and three collective discussion sessions, one in each community. Interviews were conducted in English with interview participants translating some Inuktitut terms and phrases and translators assisting when required in collective discussions. Community participants were asked about their visions of Nunavut as an Inuit territory within Canada; health and health care; and their health- and health-care-related experiences in the newly established territory. Participants ranged from twenty to sixty years of age. They included teachers, health care providers (such as nurses and community health representatives [CHR s]), social workers, students, territorial decision makers, territorial planners and managers, artists, homemakers, and others.7 In keeping with ethnographic approaches, my analysis is also informed by many informal conversations throughout the fieldwork. I also examined print and visual media from 1999 to 2003, including public documents from government and non-governmental organizations, films (including early films that brought the North to southern Canadian viewers and current Inuit-made films), and other forms of visual art (carving, sculpture, printmaking, and others). As well, I explored interview transcripts produced for the Igloolik Elders Project, held in the archives of the Inullariit Society, Igloolik Research Centre, Igloolik, NWT , and at the Northwest Territories Archives, Prince of Wales Northern Heritage Centre, Yellowknife, NWT . Over the past decade, health and health governance in the territory have increasingly become topics of local, territorial, and national discussion and continue to be prominent in media at these locales. Through discourse analysis of these transcripts, field notes, and various other texts, I explore multiple and shifting meanings of health, health governance, and participation in territory building. I consider

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the discursive strategies employed by speakers and writers, what meaning-making practices they engaged in, where the text was located and how it was or became part of a broader discourse (Denzin 1994). Two predominant discourses emerged through this analysis. The first is a discourse of risk that incorporates a southern and Western idea of health as a goal or state to be achieved, constructs the North as a risky place to live, and holds the South as the source of “health care.” The second is a counter-discourse, rooted in an entirely different worldview that resists the first. It has no specific word for health or health care, and offers instead an Inuit approach to community, participation, and territory building, from which “well-being” arises. Risk

Several assumptions about health and health care emerged throughout this study. These assumptions were part of a discourse of Nunavut as a new and predominantly Inuit northern territory within Canada. They reflected dominant ideas about Canadian health care for remote, Aboriginal communities within Canada, framing Nunavummiut as currently lacking but deserving the kind of health care that Canadians see as their inherent right as citizens. Central in this discourse was a problematization of risk comprised of three interrelated themes. The first describes how health was framed within southern parameters, which had the effect of (re)colonizing everyday aspects of northern, Inuit life. This set the foundation for the second theme in which Nunavut was problematized as a risky place to live, and the Nunavummiut as having risky ways of living, and thus prone to health problems and in need of assistance. Related to these ideas, the third theme describes how this risk problematization had the effect of marginalizing northern knowledge and expertise. Health and the Colonization of Everyday Life

For many Inuit and non-Inuit Nunavummiut, health and health care are English terms that refer to a southern or Western idea, an idea that arrived in the North with the first European settlers and traders, and evolved with changes in southern health care. Health care has come

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to refer to the collection of professionalized services available to Canadians, both publicly and privately, in their pursuit of health. When asked what health means to them, several Inuit interview participants referred to hospitals, nurses, physicians, and Western medicines, and illness and injury prevention. They suggested that health and health care are Qallunaat or Kadluna terms,8 with no equivalent words in Inuktitut. When speaking of the pre-colonialist past, Inuit spoke very little of health as a state, a goal to be achieved, or of approaches to achieving such a state. While shamans addressed problems that we might now refer to as health problems, and midwives provided what we might call health care, their scope of practice was rooted in a different worldview and set of beliefs. In addition to bringing infectious diseases (such as tuberculosis) and new illness experiences to the North (Grygier 1997; Kaufert and O’Neil 1993; O’Neil 1988, 1990), colonialism brought a centralized, medicalized, and professionalized approach to addressing a broad spectrum of life-course events including childbirth, death and dying, injury and illness. This approach included evacuations to the South for childbirth (Kaufert and O’Neil 1993), and the establishment of nursing stations, health centres, hospitals, and hospital ships. As a result, health and health care are considered by many to be Qallunaat; they are southern, biomedically based ways of looking at life, life events, illness, sickness, healing, and recovery. An Inuit man working in local government who referred to health as a “government word,” explained that its introduction brought new ways of looking at individual bodies: “it used to be – we all woke up, got dressed, went outside, went hunting … You don’t know what you’re doing – but you’re exercising, eating well … They wouldn’t look at a person as unhealthy – a fat person or a skinny person” (Participant). Another older male Inuit participant explained Inuit exposure to the term health: When Inuit were exposed to the term health, when the government established their department sometimes it was difficult to translate some words. And health was one area where it was difficult. I think more confusing than difficult. Inuit, I’d say, were exposed to these services first in a hospital area. They received these services through a centre, like a hospital centre. So the

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hospital, for Inuit, is a place to go when you are sick. So the term health – Inuit have adapted the term to mean a place you go when you are sick. (Participant) For the Inuit, health care is synonymous with the hospital, a place to address sickness, which, ironically, is a reasonably accurate understanding of what southern, Western “health” care actually does. Nunavut and Nunavummiut Lives as “Risky”

A predominant message conveyed by discourses on health and health care in Canada is that northern Canadian, Aboriginal communities are among the sickest in the world and the North is a risky place to live. Nunavummiut and Inuit lives, in particular, were, and still are, constructed as risky and as needing help to avoid the risks apparently inherent in their northern and Aboriginal existence. An Inuk woman in Igloolik highlighted some of the perceived health risks of living in the North: “Everyone has cancer. People are dropping like flies. I was away for a year and a half and I came back and people have died. Is it the water? Is it the food?” (Participant). News media are particularly powerful in their ability to articulate and disseminate messages that tend to frame Aboriginal peoples both as having and creating problems (Fleras and Kunz 2001). From 1999 to 2002 both the Nunatsiaq News and News/North ran stories, editorials, and letters to the editor on the poor health of Nunavummiut and the risks of northern living. Articles described the “low health status of Nunavummiut,” including poor nutrition, alcohol abuse, suicide, tobacco use, diabetes, STD s, as well as injuries related to northern living and environmental contaminants. Related to the construction of Nunavut as a “risky” place to live, discourses on health and health care in the media, research, and government documents symbiotically worked to construct an image of Nunavummiut lives as risky. For example, a newspaper article on the Government of Nunavut’s Report on Comparable Health Indicators for Nunavut and Canada released in the fall of 2002 was titled “Nuna­ vummiut Get Sick More Often, Die Younger: Want to Live and Prosper? Don’t Live in Nunavut” (Bell 2002). Nunavut’s report was part

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of the Government of Canada’s National Health Indicators Report, the first time that all provinces and territories gathered information on the same set of health indicators. Nunavut’s report indicates that Nunavummiut experience lower life expectancy, lower birth weights, and high infant mortality rates than the Canadian population in general (Government of Nunavut 2002c). Such framings are aimed at making individuals more aware of the potential health risks associated with their daily activities, and reinforce the idea that health is a problem that requires intervention at an individual level. Health policy and programming materials targeted individuals and encouraged them to seek out health care to address their individual(ized) health “problems” such as smoking, diabetes, and poor nutrition. This focus on Nunavummiut ways of living as risky has been facilitated by a shift from medical treatment and crisis intervention to illness prevention and health promotion, put into effect in Nunavut from 1999 onward by the Nunavut Department of Health and Social Services (Government of Nunavut 2001). The health promotion emphasis on self-improvement and individual behaviour change is particularly evident in nutrition education. Problems with obesity, diabetes, tooth decay, and other nutrition-related health issues have been linked to the decline of country food consumption and increasing intakes of highly processed food available in co-ops and other grocery stores in northern communities. As a result, there has been increasing attention to northern nutritional behaviour. Health promotion strategies emphasize the benefits of country food over other foods and encourage a balanced diet comprising the four food groups. At the heart of these efforts is the development of a Nunavut Food Guide (Government of Nunavut 2002b). Like the Canada Food Guide, it divides foods into four types: “For Strong Muscles” – meat, fish, birds, eggs and beans; “For Strong Bones and Teeth” – milk, yogurt, cheese, and bones; “For Good Eyes, Skin and Less Infection” – berries, fruit, and vegetables; “For Energy” – bannock, bread, cereal, rice, and pasta. The guide incorporates images of the North by laying the four groups out over an ulu (an Inuit knife) and including images of local foods such as caribou, whale, and Arctic blueberries. Some of the first things a person sees when he or she walks into the public health office or nursing station are several information sheets in English, and often in Inuktitut, that

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emphasize country food. One sheet, for example, includes a recipe for “Caribou head stew.” While a health promotion tool such as the Nunavut Food Guide might remind people of what is nutritious, participants strongly connected access to country food with their ability to make good eating choices and their capacity for good health. Many participants referred to access to country food and the land as two related aspects of healthy living that distinguish Inuit and non-Inuit. When Inuit spoke about feeling good about themselves they often referred to their access to country food and spending time “out on the land.” For example, when discussing the land around Iqaluit, one Iqaluit woman explained the advantages of living in a smaller community: It’s [traditional food] very available in the small communities, people will come on the radio and say “I have some caribou meat or some char, if anyone wants to come and pick it up …” But here you can’t do that, everything is for sale. You know. Even if, I was listening to the CBC the other day and someone said they had walrus meat for sale. That’s not very traditional, from my own understanding. It’s very different. I was craving traditional food when I first moved. Everything was so available back home and when I moved here I was just craving it … Another thing, I don’t think you see people going out. Especially at this time of year and in May and June, you see so many people going out camping, hunting and fishing. They may go out at 1 or 2 in the morning. I think it’s so healthy. But you don’t see that here. (Participant) Thus, participants’ comments about access to country food must be understood in relation to their overall relationship with the land and the community they live in. For example, participants in Iqaluit stated more often than participants from the other study sites that it was hard to find country food. Some remarked that you have to pay for food, as opposed to the long-standing cultural tradition of food sharing, and suggested that this presents a barrier to their capacity to contribute to family health. There is a common perception across the territory that country food is healthful while southern, grocery store food is not. This was supported in an Aboriginal People’s Television

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Network (APTN ) advertisement in which an Elder woman stands in a grocery store aisle commenting on the poor quality of store-bought food compared to country or traditional food. Several participants related the trend to buy store food and junk food, to the effects of colonialism, which they also linked to “low self-esteem.” In this way, they politicized health problems by shifting the discussion away from the maintenance of individual behaviour and looking, instead, to historical colonial relations that have fostered dependency and resulted in environmental dispossession among Canada’s Aboriginal peoples (Richmond and Ross 2009). Similarly, most participants framed health problems in terms of a lack of access to the quality of health services and information available in the South. One Inuit participant explained his family’s experience of trying to access care for his mother: My mother has cancer. For a long time, she kept complaining about pain and the nurse would say “it’s nothing serious, it will go away,” over and over. Finally, my mother couldn’t take the pain anymore so the family chartered a plane from [the community] to here for her to see another nurse. It so happened that there was a doctor in town so the doctor spent the whole day with her. By evening he sent her down to Winnipeg because he knew there was something seriously wrong. So he sent her down. It’s a lack of concern on the part of certain nurses. And lack of availability of doctors up here. And lack of health care facilities. There are health care facilities but really no equipment up here. (Participant) This participant’s grievances politicize problems by identifying a lack of resources and health services (Eide and Knight 1999), and the difficulties encountered in travelling to the South for health care. Such grievances raise questions about the impacts of colonialism and how institutional structures inhibit or encourage possibilities for health and health care. Complaints about the lack of services, funding, and resources in Nunavut were often framed in terms of equality. In demanding equality among citizens of Nunavut, there was some erasure of difference

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between Inuit and non-Inuit northerners. Northern newspapers position themselves as northern newspapers and news coverage usually refers to Nunavummiut rather than Inuit or non-Inuit. When an article refers to the “low health status of Nunavummiut” it suggests that all residents experience this low status. This erases the influence of context, as Inuit and non-Inuit have very different histories with health and illness, and further erases the intersections of various dimensions of inequity such as racism, lack of economic privilege, and poor access to health services that Inuit continue to experience. While non-Inuit residents have the same services available to them locally, many of them have connections in southern Canada that facilitate access to services there. Furthermore, when travelling to the South for medical care, non-Inuit residents are likely to be more comfortable with the language than Inuit residents and may have family and/or friends in the southern community, whereas Inuit often will not. Marginalizing Northern Experience and Expertise

On 28 November 2002, The National, the daily news television program of the Canadian Broadcasting Corporation (CBC ), reported on the long waits that the residents of Clyde River, Nunavut, face in attempting to see a physician. The report suggested that a lack of providers in the North leads to significant health risk. This report was for a southern audience: CBC flew into this community with its camera to show the South what is happening in the far corners of the nation. By emphasizing the lack of physicians rather than any other health strategy, it strengthened a particular biomedical view of health expertise, health resources, and the solutions to health problems. Grievances about a lack of resources are often framed within a discussion of “primary health care,” which assumes the physician-centred model of primary care that is dominant in Canada. In this model, decision making is bounded by a particular kind of expertise that does not include consultation and collaboration with communities. The dominance of the biomedical model limits what is considered to be legitimate health knowledge and restricts legitimate health services to those provided by the medical profession or allied health professionals. The Clyde River story contributed to the notion that southern expertise is superior to

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northern and Inuit knowledge and expertise by eliding any consideration or discussion of northern and Inuit-defined strategies for solving northern and Inuit-defined problems. This omission, again, ignores the intersecting inequities that many Inuit face in their daily lives that result in insufficient and inappropriate health care and lack of recognition for care provision. This omission of northern, Inuit experience and expertise was reflected in an interview with a community health representative (CHR ) who voiced frustration about how nurses did not typically seek community expertise when addressing health problems: “I’d like to see nurses ask for my help. For example, if a mother has a kid who isn’t putting on weight, the nurse should ask me ‘this lady needs help, go talk to her’” (Participant). As a representative of the community in the health centre, the CHR could potentially contribute to more culturally appropriate and community-oriented health promotion work. Often, however, the CHR s in these communities found that they spent most of their time on interpretive work and providing administrative and other support to nursing staff. Thus, the simple inclusion of an Inukbased position like the CHR does not legitimize Inuit expertise. In fact, CHRs often found themselves caught between their own vision of their roles and others’ expectations of their work. This marginalization of Inuit expertise was also observed at the level of program and policy development. In this respect, one woman who worked with an Inuit-representative organization explained that Inuit non-governmental organizations are consulted very late in the process of program development: “the federal and territorial governments are coming to Inuit organizations later than they should …We get it at the end and have to adapt a lot of their programs which aren’t really helpful for Nunavut” (Participant). While there is recognition across the territory that Inuit tradition, knowledge, and experience must underlie all forms of governance, there is a largely uncontested assumption that southern expertise and approaches to health governance are better than northern or Inuit ones. Similarly, Inuit expertise in health care was almost invisible, and local-level health profession training was significantly lacking in Nunavut. Apart from a nursing program, which had seen few graduates, and a social work program, there were no local training programs

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for health professionals available during my fieldwork. The inclusion of Inuit in health care through CHR or maternity care worker roles is often framed as putting health care in the hands of Inuit and incorporating Inuit “tradition” into health care. This view of Inuit “traditional” practices as complementary additions to (southern) health care subjugates Inuit knowledge to biomedical perspectives that dominate (southern) health care, and positions Inuit roles in northern health care as subordinate in a hierarchy of (southern) health care professions that is left relatively undisturbed. While most agreed that these types of positions are crucial to health care and self-determination in Nunavut, many suggested that such efforts do not go far enough. Many participants suggested that there are various restrictions by government and bureaucracy placed on their capacities to serve the public. In this regard, nurses complained about the many levels of bureaucracy. CHR s were extremely limited by the national health promotion program, which they are directed to follow; limited access to resources; virtually no support; and their perceived role as assistants to health centres. The invisibility of Inuit in decision making and frontline health care positions pervades the discourse of health policy, planning, and delivery in Nunavut. Most participants emphasized the need for more Inuit health care professionals, planners, and decision makers. Nevertheless, participants maintained that health was key to territory building and Inuit struggles for self-determination. One nonInuit participant explained his perception of the link between health and self-determination: It’s just part of our thinking. To have self-government without influence and involvement in health services would be strange. However, there’s no doubt in Nunavut, with the federal government, in fact, being responsible for health care for the people, it shifts the focus a bit. Because there are still a lot of people who think of the feds, not the territorial government, as being responsible for health services. Another thing that’s interesting is that the land claims organizations in their mandates and in the legislation that set them up have never given them [the federal government] a role in managing health and social services. And

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yet they’re often looked upon as the source of self-government … It’s very confusing. (Participant) While “influence and involvement in health services” might be necessary to self-government, the territory’s relationship with the federal government complicates the potential for increased participation. As suggested by the participant above, relations between levels of government lead to much confusion concerning responsibility for health governance, which further complicates the struggle for selfdetermination and which may have the effect of rendering people inactive. For example, many of the study participants perceived the federal government as holding the purse strings with respect to Inuit health in Nunavut, a fairly accurate perception given that Health Canada continues to fund Inuit, First Nations, and Métis health separately from other Canadians. While monies are transferred directly from the federal government to First Nations communities, in the case of Nunavut health care, monies are transferred to the territorial (i.e., public) government, not an Inuit government, thus producing a confusing line of accountability when it comes to Inuit health. In turn, Canada’s provinces and territories are encouraged to “deny responsibility for Indigenous wellbeing, insisting that those people be separately provided for by the federal government in Ottawa” (Jull 1999, 5). Resistance

The discursive field of health and health care in Nunavut was not simply characterized by the dominance of one perspective or approach. Several discourses and practices for resisting a singular, dominant perspective emerged throughout this study. Many Nunavummiut, and Inuit Nunavummiut in particular, articulated an awareness of the dominance of one approach, but they identified it as an approach – one among many. This consciousness of multiple perspectives can perhaps be linked to several things: the recent history of colonization in the Arctic; the fact that many Inuit, even those in their forties, can remember living on the land; Inuit linkages with other Aboriginal struggles for self-determination and self-government; and their connection

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with a global postcolonial shift that calls into question the dominance of one way of understanding, living, and governing. This resistance is part of a construction of Nunavut as Inuit land, located in Inuit history, within a history of colonization and the development of Canada as a nation. It is about Inuit-Nunavummiut wanting to be part of Canada while being recognized and respected as Inuit. It frames Nunavut and Nunavummiut as being the locus of a particular way of looking at and understanding the world as historically situated. It is a discourse of rights and citizenship – as Nunavummiut, Inuit, and as Canadians. This discourse of resistance posits the success of Nunavut as an Inuit territory dependent on the strength of its communities. I consider here three themes or techniques of resistance whereby Nunavummiut articulated a connection between health governance and Inuit self-determination. The first is the attempt to shift the conversation away from “health” and “health care” and toward inuusiqattiarniq. The second is the collective effort and emphasis on shaping local governance through Inuit expertise and experience. The third technique is the promotion of collective self-reliance and selfdetermination. The discourse that these three themes contribute to is not one of blame or risk. It is one of collective struggle and participation, in which Nunavut is considered “our land,” rooted in Inuit history, part of Canada but not required to look like the rest of Canada. From “Health” and “Health Care” to Inuusiqattiarniq

During my many discussions with study participants about “health” and “health care,” several participants, both Inuit and non-Inuit, diverted the conversation to other issues by using terms that were not about health at all. Such attempts to shift the conversation were most clearly demonstrated when participants were asked how they would refer to health in Inuktitut. Several participants used inuusiqattiarniq (as written by one participant) to describe what health meant to them. One Inuit government worker suggested that this word refers to “living with yourself and others … It means trying to have a better life.” He explained, “It makes me think of health. It is important to have inuusiqattiarniq.” Unlike the dominant discourse about health, which dichotomizes Western and Inuit notions of health, this participant

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subverted discussion about health versus illness by speaking about life. While acknowledging that health and health care are terms that give rise to talk about specific individual problems, most interview participants suggested that what is really at stake is the ways in which they live in community with others, and their local capacity to provide for their families and communities. Like many other studies that address the health of Aboriginal populations in Canada (e.g., Richmond and Ross 2009; Browne and Fiske 2001), the participants in this study identified colonial relations as major contributing factors to the breakdown of this capacity. In the following quote, an Inuit woman demonstrated a different way of framing the discussion. Rather than placing blame on others, she describes health as a process of negotiation and cooperation that is necessary to facilitate change: “There’s a lot of hostility between Inuit and non-Inuit because of the control and the environment that we’ve had for many generations. So I think … pulling down our defences and saying, ‘okay, I’m willing to put my emotional well-being on the line if you can help deal with this.’ I think that’s really how I define health” (Participant). During the interviews, many participants directed attention away from topics of physical and mental health problems to focus on issues of individual and community self-reliance, community cohesiveness and participation, communication, resources, and self-confidence. This redirection, I contend, draws attention to the enduring effects of colonization and the role of medicalization within these colonial processes, and calls for the application of Inuit expertise in order to redress these effects. Shaping Local Governance through Inuit Expertise and Experience

Like other studies about Indigenous views of health and healing (e.g., Richmond and Ross 2009), the findings of this study illustrate how Inuit have their own ideas about how to improve their health. Innuqatigittarniq – the healthy interconnection of mind, body, spirit, and environment – is one of the lamps or qulliqs9 lighting the way for Inuit health reform. Qaujimajatuqangit – Inuit traditional knowledge – is

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another such qulliq (Qikiqtani Inuit Association cited in Romanow 2002). Across Nunavut, people have called for recognition of Innuqatigittarniq Qaujimajatuqangit (IQ ) – traditional Inuit knowledge, expertise, and experience, as well as Inuit participation, in planning, service provision, and decision making. The nature of IQ and its proposed role in territorial governance makes it a particularly salient point from which to examine the attempt to legitimate northern and Inuit expertise. The Bathurst Mandate identifies IQ as part of all aspects of territorial governance, thus setting the new territory apart from other provinces and territories. In simple terms, IQ is about traditional knowledge. The IQ Working Group10 defined IQ as a philosophy or a way of living and thinking that encompasses a range of elements, including the long-practised tradition of passing Inuit knowledge,11 values, and teachings from the Elders down to the younger generations; a system of laws, values, and consultations before making important decisions that affect the community; and an understanding of complex family relationships that is explained by Inuktitut kinship terminology. IQ is about “healthy, sustainable communities regaining their rights to a say in the governance of their lives using principles and values they regard as integral to who and what they are” (Arnakak 2001). It is not about static, traditional knowledge that can be integrated into health promotion programs to increase their cultural sensitivity. Rather, bringing IQ into territorial governance is about fostering a way of living that is flexible and adaptable and that incorporates Inuit values and understandings into strategies of health governance. IQ is not easily translated into English; its broad scope makes for an uneasy fit with government planning and practice that is shaped by the dominant southern perspective. It is even more difficult to put into practice in health care, partly because health care is commonly perceived as non-Inuit. When asked how IQ could be incorporated in health planning, most interview participants were stumped. It seemed much easier to consider how IQ could be incorporated in education, for example, with the introduction of Elders as teachers in schools, in planning curriculum, and in training teachers. In setting out the relationship between IQ and governance, the IQ Working Group pointed to an important link between IQ and Inuit well-being: “That confirming the value of Inuit Qaujimajatuqangit will

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restore Inuit pride and increase individual self-esteem. By increasing young Inuit self-esteem, some of today’s social problems such as substance and alcohol abuse and even suicide will be eliminated” (Government of Nunavut 2000). But governing through IQ within a framework that is not based on IQ is not a simple task. Despite the difficult fit between IQ and a Canadian framework for territorial and health governance, Nunavummiut remain strongly committed to the goal of making health governance more relevant and meaningful to Inuit and Nunavut. Promoting Collective Self-Reliance and Self-Determination

This third technique of resisting the colonizing tendencies of discourses on health was suggested when participants framed discussions of health governance in terms of self-reliance and self-determination. Many study participants spoke of collective self-reliance, decisionmaking power, and local participation in attempting to shift our conversations about health to issues of community strength and building Nunavut as a largely Inuit territory. Discussions of health governance from this perspective included a reclaiming of Inuit decision-making power as well as the interconnectedness of life, place, and community. Both Inuit and non-Inuit suggested that the implementation of Nunavut as a political and geographic space increased local capacity for self-determination. The establishment of Nunavut in and of itself gave rise to a new sense of empowerment among many Inuit, as one young Inuit man explained: “It has changed my life in some ways. It taught me to be more informed in terms of decisions that are made by our leaders and how it’s going to affect us as a public. It made me realize that we have a place in this world as an Inuit group. I feel more strongly about my culture, the changes that have affected culture, the responsibility that we have to make it better for our children, our grandchildren, great, grand children” (Participant). Many participants underlined the importance of building selfreliance, individually, as a territory, and as a people. Rather than being the objects of health promotion and other health-related services, participants stated that they needed to be involved in every stage of

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planning and delivery. In October 1999, the GN ’s Standing Committee on Culture, Education and Health (Government of Nunavut 1999b) released its Report on the Six-Month Departmental Progress Update. In this report, the committee applauded the Department of Health and Social Services’ overall goal of Inusikatiarniq but stated that it “is concerned that the approach envisioned seems to be one of hiring more professionals from the south, rather than one of community empowerment” (13). It questioned the wisdom of spending more on staff from the South given recruitment, retention, and housing difficulties, rather than investing more in the community itself. It recommended community-based decision making through a community health committee with consistent staff support and a community wellness worker for each community. Attempts at both territorial and community levels to address suicide, for example, highlighted the potential for community-driven strategies, as well as the distance between government and public perspectives on governance. In May 2001, in response to growing concern about high suicide rates and mental health concerns, the GN ’s health and education departments unveiled a campaign promoting Inuit values. The campaign consisted of a set of posters and advertisements bearing images conveying resilience, survival, strength, and perseverance. One non-Inuit health care provider suggested that the difficulties underlying suicide were not addressed through these strategies: In 1999 it was – “okay, it’s Nunavut now” – after one or two generations of developing dependency on government institutions. Some communities are very skilled at living off the land so they have some choice around dependency. But in Rankin Inlet, where a lot of people don’t have the skills, people don’t have choices around dependency. Young people don’t see themselves as agents … I saw a suicide poster – a health promotion poster – and someone had written on it “caught between two cultures.” There are a lot of real difficulties, a lot of challenges and I don’t know if they’re being talked about. (Participant) This vision of Inuit youth as “caught between two cultures” superimposed on a health promotion poster speaks volumes to the endur-

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ing effects of colonization on community and individual resilience and identity, and their effects on health. Many suggested that the administrative, regulative role of government in their lives can complicate family or community autonomy. They suggested that issues such as suicide need to be addressed by communities at a community level. Discussion

The risk problematization identified in this research shows how lived experiences are reduced to problems that should be managed and governed by a southern, non-Inuit health care approach, and in the medicalized language of the South. While health promotion tools and other approaches in Nunavut may be posited as contributing to the betterment of Inuit Nunavummiut lives, the risk problematization that underlies discourses of health governance in Nunavut individualizes health and social problems and decontextualizes them from their historical, colonial context in order to emphasize the risks both of the North itself and of northern, Inuit ways of living. In this sense, couching discussions of health governance in terms of risk has the potential to re-colonize Inuit knowledge and experience. However, the relations of governance privileged by this risk problematization are distinct from the “ward of the state” mentality, which characterized governmental relations with Aboriginal peoples in Canada during the first half of the twentieth century. Rather than bring Aboriginal peoples under the authority of the federal government for their own “protection,” the risk problematization discussed here situates Nunavummiut as a people who need help to help themselves and become full citizens. But, in helping them to help themselves, northern health services remain “one of the most powerful symbols of the colonial relationship between northern peoples and the nation-state, and the pervasiveness of this symbol in the intimacies of everyday life undermines further development in other institutional areas” (O’Neil 1988, 47). Thus, despite health being identified as an important pillar for territory building and avenue for citizenship in Nunavut, the potential for health policies and programming to marginalize Inuit experience and foster new relations of dependency should be taken seriously.

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Similarly, the incorporation of Inuit food practices into the official nutrition discourse is in sharp contrast to health promotion efforts in the mid-1900s when National Health and Welfare mounted a crusade about the benefits of milk for a people who had never consumed it. The new twenty-first-century food guide clearly incorporates Inuit knowledge and nutritional practice. At the same time, it focuses efforts on changing individual behaviours and does not address the social determinants of health (such as poverty, racism, and the history of colonialism) or self-determination and self-government (Adelson 2005). The relationship between the North and South has long been defined by dependency, and these North–South, Inuit–non-Inuit relations are further complicated in a postcolonial context. In this context there emerges the tension between a discourse that constructs Nunavummiut lives as risky and in need of help from experts from the South, and a discourse of placing responsibility on political authorities to redress the effects of colonization by supporting Inuit efforts toward self-determination. This tension breaks open a space for resistance as Inuit Nunavummiut find themselves slowly attaining access to decision-making and negotiating power and working toward collective self-determination. This collective self-determination opposes neoliberal prioritization of individual autonomy and efficiency. Within this space, Inuit Nunavummiut do not see themselves as totally dependent on southern systems and models of care. They define themselves as a people with rights, expertise, and experience. Moreover, the tension between the idea that health is key to territory building and the absence of a word for health in Inuktitut adds to health as a contested domain and a site for struggle over citizenship and governance. It seems plausible that, rather than “health,” the Bathurst Mandate is actually referring to strength when it states, “the health of Nunavut depends on the health of each of its physical, social, economic and cultural communities, and the ability of those communities to serve Nunavummiut in the spirit of Inuuqatigiittiarniq” (the first part of this word, Inuuqati, means neighbour or companion) (Government of Nunavut 1999a). Rather than individual health, priority is given to re-establishing community strength and capacity as the basis for policy discussions about governance at a broad level, including the governance of health and health care. While it may be a challenge to

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incorporate IQ into rethinking health in the territory, maintaining it as a priority ensures an Inuit-led approach and possibilities for the broader self-determination struggle. While several participants raised concerns about the imposition of southern systems and approaches in health, most suggested that undoing the relationship between North and South, Inuit and non-Inuit is impossible. They suggested, rather, that they would like to transform the relationship from one of dependency to one of cooperation. Rather than pitting Inuit against non-Inuit, many talked of building Nunavut on Nunavummiut terms. Despite the complex field of power relations that the Nunavummiut must make their way through on the way to self-determination, they persist. They continue to talk in terms of collective self-reliance and self-determination. Just as Inuit came together to establish Nunavut as a separate territory, Inuit may find the strength to craft their own model of self-determination in Nunavut through their local, national, and international mobilization. In providing the Inuit with a geopolitical space of collective identity and claims to territoriality, Nunavut also provides Inuit with a stronghold from which they may challenge and change embedded systems that have, in the past, repressed Inuit knowledge, experience, and expertise. Acknowledgments

The research process upon which this paper is based has transformed my vision of the North, Canada, Inuit and non-Inuit relations, as well as my own work as a sociologist. For all of this, I would like to thank everyone who participated in this project – thank you for sharing your stories with me, inviting me into your homes and lives, and providing me with further direction when you felt I needed it. I gratefully acknowledge the Social Sciences and Humanities Research Council and the Canadian Health Services Research Foundation for a joint doctoral fellowship, which made this research possible.

N ot e s

1 Canada has ten provinces and three territories. While provinces receive their powers and authority from the Constitution Act of 1867 (they are

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co-sovereign divisions), the territories are jurisdictions that receive powers from the federal government (they are not sovereign). 2 Nunavut comprises Canada’s Eastern and Central Arctic regions, 60 percent of what was the Northwest Territories. 3 I use the terms Indigenous and Indigenous peoples as are commonly used in Canada to include the Aboriginal or First Peoples of Canada and other countries. I employ the terms Aboriginal and Aboriginal peoples in this chapter as they are often used in Canada to refer, as Inuit Tapiriit Kanatami (ITK ) explains, “to the indigenous inhabitants of Canada when describing in a general manner the Inuit, and First Nations, and Métis people, without regard to their separate origins and identities” (ITK 2016). 4 I explore more specifically how health and health care are employed in constructing notions of citizenship and belonging in a separate article published in Citizenship Studies in 2007 titled “Techniques of Citizenship: Health and Subjectivity in a New and Predominantly Inuit Territory,” Citizenship Studies 11 (4): 349–65. 5 See Monture-Angus (1999) for a discussion of self-determination as rights and responsibilities. 6 Breaking up fieldwork in this way not only decentred the primacy of immersion (see Gupta and Ferguson [1997] for a discussion of rethinking the “field” in fieldwork), it also provided the opportunity to reflect on my experience, my own assumptions, and constructions of North and South in both northern and southern spaces. 7 To ensure anonymity of participants, I include very few characteristics alongside quotes and discussion. 8 These are terms that Inuit and some non-Inuit use to refer to nonAboriginal people. This word is sometimes spelled as Qabloonat. 9 A qulliq is a traditional Inuit oil lamp used to warm and light spaces as well as to cook. 10 In September 1999, the Government of Nunavut hosted the Inuit Qaujimajatuqangit Workshop, where territorial government employees from all levels sought “counsel” from Elders on ways to preserve, promote, and integrate IQ into all Government of Nunavut programs, services, and policies, to best meet the requirements of the majority of the population served by the new government (Government of Nunavut 2000, 3). 11 Inuit knowledge is said to include knowledge of wildlife, survival skills, traditional healing and counselling methods, and a system of dealing with fellow Inuit who need help that is based on trust and love (Government of Nunavut 2000, 14).

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Isin, Engin, and Bryan Turner. 2007. “Investigating Citizenship: An Agenda for Citizenship Studies.” Citizenship Studies 11 (1): 5–17. Jull, Peter. 1999. “Reconciliation & Northern Territories, Canadian-Style: The Nunavut Process and Product.” Indigenous Law Bulletin 30 (20). http://www.austlii.edu.au/au/journals/IL B/1999/30.html. Kaufert, Pat, and John O’Neil. 1993. “Analysis of a Dialogue on Risks in Childbirth: Clinicians, Epidemiologists, and Inuit Women.” In Knowledge, Power, and Practice: The Anthropology of Medicine and Everyday Life, edited by Shirley Lindenbaum and Margaret Lock, 32–54. Berkeley: University of California. Lupton, Deborah, and John Tulloch. 2002. “Risk is Part of Your Life: Risk Epistemologies Among a Group of Australians.” Sociology 36 (2): 317–34. Monture-Angus, Patricia. 1999. Journeying Forward: Dreaming First Nations Independence. Halifax: Fernwood Publishing. Nunavut Planning Commmsion. 2016. “Communities.” Accessed 21 January. http://www.nunavut.ca/en/communities/baffin/igloolik. O’Malley, P. 1996. “Indigenous Governance.” Economy and Society 25 (3): 310– 26. O’Neil, J.D. 1988. “Self-Determination, Medical Ideology and Health Services in Inuit Communities.” In Northern Communities: The Prospects for Empowerment, edited by Gurston Dacks and K. Coates, 33–50. Edmonton: Boreal Institute for Northern Studies, University of Alberta. – 1990. “The Impact of Devolution on Health Services in the Baffin Region, N.W.T.: A Case Study.” In Devolution and Constitutional Development in the Canadian North, edited by Gurston Dacks, 157–94. Ottawa: Carleton University Press. Ong, Aiwha. 1999. Flexible Citizenship: The Cultural Logics of Transnationality. Durham, NC : Duke University Press. Richmond, Chantelle, and Nancy Ross. 2009. “The Determinants of First Nation and Inuit Health: A Critical Population Health Approach.” Health & Place 15:403–11. Romanow, Roy. 2002. Building on Values: The Future of Health Care in Canada – Final Report. Ottawa: Commission on the Future of Health Care in Canada. http://publications.gc.ca/collections/Collection/CP32-85-2002E.pdf. Rose, Nikolas. 1996. “Governing ‘Advanced’ Liberal Democracies.” In Foucault and Political Reason: Liberalism, Neo-liberalism and Rationalities of Government, edited by Andrew Barry, Thomas Osbourne, and Nikolas Rose, 37–64. Chicago: Chicago University Press. Sawicki, Jana. 1996. “Feminism, Foucault, and ‘Subjects’ of Power and Freedom.” In Feminist Interpretations of Michel Foucault, edited by Susan Hek­ man, 159–79. University Park: Pennsylvania State University Press.

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Ch a p t e r 8

“So It’s Always a Dance”: The Politics of Gifts and Governance at a Drop-In Centre for Vulnerable Women in Southern Ontario Treena Orchard

Introduction

The city that is the focus of this chapter, which I will refer to here pseudonymously as Meadowvale, is located in the densely populated region of Southern Ontario. It is often described as a sleepy city, whose founding industries included oil refineries, industrial factories, insurance corporations, and development, and more recently manufacturing, food processing, information technology, and university and colleges. Like many North American cities, Meadowvale’s economic and social development has changed dramatically since the 1970s, and many business and civic organizations have moved from the original downtown core into more affluent suburban neighbourhoods. This shift has affected the various sections of the city differentially, but has had particularly negative impacts on poorer neighbourhoods. These neighbourhoods feature a disproportionate number of low-income rental properties and boarded-up buildings compared to other sections of the city, and are home to many people who depend on social assistance to survive.

One of these neighbourhoods is known locally as “North Central” (NC ), also a pseudonym. Once home to an array of thriving commercial and industrial businesses, these approximately twenty city blocks are now mainly residential, following the economic collapse of the neighbourhood in the late 1970s. A handful of businesses still exist, including convenience stores, pawn shops, second-hand furniture and appliance stores, ethnic restaurants, faith-based missions, tattoo shops, pharmacies, funeral homes, the odd curio, tea, and dog grooming places, and social and health services for residents on social assistance and disability programs. Some of the oldest taverns in the city are found in this neighbourhood and are patronized faithfully by locals. There has been a modest economic upswing in the neighbourhood in recent years driven by affordable rents and a commitment among shop owners and residential organizations to clean up the area – and its image. In the media and the popular imagination, this part of the city, and by extension the people who live, work, and spend time there, are often referred to using tropes of decay, social failure, crime, and stigma, and are commonly associated with the illicit drug and sex trade markets and the drug treatment centres (e.g., methadone clinics) that thrive there. Those who look beyond the disparaging picture painted of NC find a colourful, busy, and dynamic neighbourhood. The people who live there have meaningful and busy lives, even as some of them struggle with addiction, disabilities, and the pains of being poor. The popular social descriptions of the NC landscape as a highly marginalized terrain, though not a central focus of this chapter, is useful to understand the struggles with control and surveillance experienced by the agency that I refer to in this chapter as Women Welcome (WW ). This community-based, grassroots organization experienced fundamental challenges to its ways of working as a result of amalgamation with other community “partners,” an amalgamation that was required to ensure its survival. Critical to framing this analysis is a consideration of the impact of restructuring in the province of Ontario that began in the mid-1990s – specifically with the election of Conservative premier Mike Harris in 1995 – on the organizational culture and governance of local community agencies and their clients. Referred to as the “Common Sense Revolution,” Harris’s platform ushered in

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profound changes to socioeconomic, health, and institutional policies that were purported to decrease taxes, reduce the debt and deficit, streamline social services, cut “overspending,” and reduce the role of government in the lives of Ontarians (Bezanson 2006, 3). The implications of this neoliberal agenda, which was taking place not just in Ontario or Canada but also internationally with the expansion of the global economy, were especially devastating to the poor, who are often represented as undeserving and unwilling to work. The Harris government was particularly concerned with minimizing its responsibilities for the poorest and most marginalized citizens of the province, shifting those responsibilities to family members and community agencies. It mounted a campaign against welfare fraud, the rate of which was not increasing, despite the government’s repeated claims to the contrary (Little and Marks 2006). It established a series of complicated social assistance eligibility programs (e.g., Ontario Works) designed to discourage the poor from obtaining welfare and collecting benefits for longer than legally allowed (Little and Marks 2006, 32). The Harris government also slashed social assistance rates by an astounding 21.6 percent (Bezanson 2006; Little and Marks 2006; Ralph, Regimbald, and St-Amand 1997). The deep impact of this cut was devastating at the time, has not been reversed, and has grown with inflation. For example, in 2009, a single employable person on welfare in Ontario had an annual income of $7,500, 35 percent less than the amount welfare provided in 1992 (National Council of Welfare 2010). Coupled with corporate tax cuts, these neoliberal policies have had a real and lasting impact on growing income inequalities in Ontario, and on the depth of poverty and social exclusion experienced by the most marginalized individuals, families, and communities. The impacts of these increasing disparities extend to community-based, voluntary, and third-sector organizations that struggle to work within the confines of drastically reduced funding at provincial and federal levels (Bezanson 2006, 8) while serving an increasingly larger number of clients whose health and well-being have been deeply and negatively affected by the same neoliberal agenda. These policy changes are deeply paternalistic and stigmatizing, and their effects are especially painful for women living in poverty, particularly for single women with children who are generally required

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to provide more documentation than men to obtain welfare. For example, women with children must provide proof of the age and custody of the child/children, their status as single, and any payments received from the father of the child/children (Little and Marks 2006, 29). To locate and complete the array of forms required to claim social assistance, many women turn to local volunteer-based, charity, or non-profit organizations for help. This is especially the case for women battling mental illnesses or addictions and who are homeless. These particular issues were once the responsibility of provincial governments, who provided support and advice for women navigating the complicated process of obtaining financial assistance. However, since the Harris regime, these responsibilities now fall on the shoulders of a range of community agencies, whose increasing work load, more complicated client needs, and attendant intra-agency competition for funding leave many staff members overworked and frustrated to the point of burnout. It is within this political context that Women Welcome (WW ) amalgamated in 2006 with Supporting Social and Mental Health (SSMH ), under the direction of a civic initiative called Community Care (CC ) (also pseudonyms), to ensure its own survival. One year later, this amalgamated agency was the recipient of a generous private donation of just under two million dollars from a local family for the purchase and renovation of a new building to house the services it provides to vulnerable and homeless women. The conditions of this altruistic and desperately needed gift, however, complicated the picture as SSMH and CC became the official directors of WW. Drawing upon ethnographic data from a community-based research project with WW , this chapter examines the structural and institutional tensions that have emerged since the amalgamation. I am particularly interested in the ways that gift-giving takes on a life beyond “just” a private act of kindness and becomes a medium through which the socioeconomic inequalities inherent in neoliberal governance and practice are reproduced and impact poor women and the community-based agencies that strive to work with them. In exploring these tensions, I first provide an overview of the agencies and initiatives involved in the amalgamation process. This is followed by a discussion of the methodologies employed during the

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research project and the theoretical frameworks used to contextualize and interpret the findings that relate to the issues of gift-giving and governance. The next sections examine the specific conditions that informed the amalgamation and the problematic outcomes of the amalgamation for staff and clients at WW – namely, their experiences with increased forms of surveillance stemming from the merger. I also explore life at WW after the amalgamation, and how the staff worked to strike a balance between maintaining their philosophical integrity and adhering to these new forms of institutional control. In the conclusion I consider the implications of the findings for extending current understandings of the political dynamics of gifts, gift-giving relationships, and governance of vulnerable populations in the time of neoliberal rule. The Organizations and Initiatives: Women Welcome, Supporting Social and Mental Health, and Community Care

Women Welcome was established in 2004, by a coalition of women who had earlier created a project dedicated to understanding the impact of addictions and mental health issues on the lives of poor women living in Meadowvale. Alongside these two key issues, homelessness emerged as an equally important, yet inadequately addressed, concern for many of their clients, especially those who were already marginalized due to their precarious economic status, racialized identities, and involvement with the police. It became clear early in the development of this project that there were significant numbers of women in Meadowvale with addictions and mental health issues who experience violence in their everyday lives, were at risk for becoming homeless, and were additionally alienated and neglected by inadequate structural and institutional supports. As a loosely organized grassroots organization with virtually no financial support from municipal or provincial governments, the group found it challenging to address these issues and make real change in women’s lives. Upon learning of the project through informal social networks, a group of religious Sisters who were running a hospice for homeless women out of one of the local hospitals stepped in to offer moral and financial support to the

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coalition. The Sisters provided one year of funding and a space in their own residence to house the organization, which allowed WW to open its doors and function as a largely self-governing agency. Rooted in the philosophy that these women are not social “problems” but are rather marginalized individuals striving to find stability and realize their potential, WW is a transitional support house for women who have experienced multiple forms of exclusion and vulnerability, including addictions, participation in the sex trade, and dependence upon government social welfare programs to survive. Helping women acquire stable housing and a case worker to manage mental health issues are the first points of service for many WW clients, as they provide the baseline for the care and healing many of the women need to begin working on their immediate and long-term health issues. WW is funded by Community Care (described below), through the Corporation of the City of Meadowvale and the United Way. The funding received in 2012 enabled WW to extend their program to 9 p.m. on weekdays and offer the program on weekends from 11 a.m. to 2 p.m., which enabled WW to reach more women, many of whom depend on the services and support from staff, as well as other clients, to survive. The day program helps clients obtain a range of medical, social, and financial services and offers thoughtfully prepared and healthy meals. It is also highly valued as a safe place for women to gather, relax, and socialize. Weekly activities, like bingo, and women-centred events, holidays, and birthdays are marked and celebrated in fun and meaningful ways. Everyday interactions such as smoking together under the gazebo located outside the building are an especially fruitful time for women not only to exchange gossip and daily updates of goings-on in the neighbourhood but also to offer empathy and support regarding everything from family matters to legal advice. The number of women who drop in to WW has risen dramatically from fifteen per day when they first opened in 2004 to over one hundred per day in 2013. All women who come to WW are homeless or have experienced housing insecurity. The ages of the clientele range from late teens to mid-sixties, with many in their thirties to fifties. About half of the clientele have been involved in the sex trade and about 25 percent are Aboriginal (First Nations, Métis, Inuit). Given the histor-

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ically exploitative relations between Aboriginal peoples and EuroCanadian society and political systems, the staff at WW have made a strong commitment to recognize and support the unique experiences and needs of Aboriginal women. They have developed a number of initiatives, including the hiring of two full-time staff who identify as Aboriginal. WW also links with other Aboriginal organizations, operates Aboriginal outreach and awareness programs, and incorporates sensitivity to Aboriginal relations as part of their everyday practice. The staff are a diverse group of women (eight full-time, six parttime), some with long-standing roots in local and national feminist organizations, some with expertise in community-based harm reduction strategies, and some with experiential knowledge of being poor, homeless, and struggles with addictions. This diverse range of staff experience, and particularly the hiring of women with firsthand experiences of social exclusion and marginalization, is particularly important to establishing meaningful and trusting relationships with the women who come to WW . As well, there is a large and dedicated cadre of volunteers whose work is essential to the running of WW . Established in 1970, Supporting Social and Mental Health is a registered, non-profit corporation and charitable organization that is governed by an independent board of trustees and funded by the Government of Ontario. (The funds are administered through a health network that serves the Southern Ontario region.) SSMH ’s primary mandate is to offer services that promote wellness through partnerships, support, and self-determination for people living with mental illness, with the aim of reducing the socioeconomic impacts of mental illness on society. Its primary services include case management, community integration and life skills support, employment programs, treatment programs, clinical programs, and women’s mental health programs. They serve over one thousand adult clients annually, including men, unlike WW with its exclusive focus on women. Their approach to supporting and treating their clients with mental illness is guided by the principles of psychosocial rehabilitation, which focus on personal strengths, skill building, empowerment, hope, and recovery. Additional tenets of this approach include a focus on the establishment of “normal” roles in the community – namely, education and

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employment – and the reintegration of clients into community life throughout the rehabilitation process. When compared to the harm reduction philosophy employed at WW , which fosters support, encouragement, and safety through “meeting people where they are at,” the environment at SSMH is decidedly more formal and institutionally regulated; indeed, many of the clients at WW who also obtained services at SSMH described it as being more “top down” in its approach to clients. Community Care, an initiative spearheaded by the City of Meadowvale in 2009, is the body that provides the majority of the financial support for the ongoing running of WW . Unlike WW and SSMH , CC does not serve a specific population; it is a managing body that oversees a range of different programs, services, and funding related to homelessness. CC emerged from the concerns of neighbourhood residents, business associations, service providers, the police service, and the City, and was developed to improve health outcomes of the city’s homeless population and enhance public safety and order by increasing police presence in the NC neighbourhood and the viability of business in the downtown core. In 2009–10, CC allocated $140,639 to WW. In addition, CC has also provided financial and technical support for the expansion of street outreach services and intravenous needle collection programs. Methodology

The findings presented in this chapter are from an ethnographic, community-based project that I conducted with WW to examine the sex trade in Meadowvale and the structural and institutional forces that shape women’s experiences of their marginalization and involvement in the sex trade. I started volunteering at WW during the summer of 2009, which enabled me to establish respectful and effective relations with the staff and clientele as a researcher and member of the local community. Data collection began in the summer of 2010 and was completed in the winter of 2011. During this time I spent one day per week at WW and took part in its everyday activities, including lunch, which is served from noon until 1 p.m., in-house updates regarding

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neighbourhood news and organizational activities, and informal conversations with the women and staff members. On these research days, the project research assistant, who was also a relief worker at WW , and I conducted interviews with one to three women who were clients of WW and had been involved in the sex trade. In conjunction with the interviews with clients, we also conducted interviews with staff members, took part in staff meetings and community partner meetings, and attended monthly and special celebrations whenever possible, such as birthdays, special meals, and other social events that took place in the neighbourhood. In my field notes, I recorded observations related to my interactions with staff, the clients’ interactions with staff, the social climate within WW and the surrounding neighbourhood, and the women’s responses to the project and the interviews. These field notes were important to understanding the social and political context of WW and the lives of the women it serves. Although the primary interest of the study was the experiences of women in the sex trade who come to WW , it became readily apparent that the amalgamation and move to the new location loomed large in the minds of the staff and many of the women. Indeed, these issues were featured in many informal conversations we overheard or had with the clients and staff. In addition, the relationship between WW and SSMH and changes (positive and negative) that followed the move to the new location were raised in some of the interviews with the women, discussions with staff, and informal observations during a number of special events that I took part in, including the official opening of the new building on 4 July 2010 and a national conference on women and homelessness in May 2011. The monetary gift given by a local family to WW not only complicated the organizational structure of WW by instilling SSMH as the official administrative “boss” of WW , but also ensured a much-needed new building for WW and was connected to its survival. This survival, however, is contingent upon the control and management of the gift according to institutional policies and practices established by powers beyond WW – namely, SSMH and CC . Most problematically, adhering to “appropriate” rules of governance often depends on invasive techniques of self-surveillance on the part of WW staff and, to a certain

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extent, their clients. This calls into question not only the value and meaning of “gifts” in this context but also their role in neoliberal governance and practice. Gift-Giving and Neoliberal Practices of Governance

Gift-giving, in primarily non-Western societies, is a classic domain of ethnographic research within social and cultural anthropology. Giftgiving practices involve the circulation of material items, religious knowledge, animals, land, or people as different kinds of gifts in systems of exchange, instead of the use of a formalized currency. Traditional treatments of gift-giving between both individuals and social collectives have focused on how various systems of exchange engender cycles of obligatory relationships through the ongoing nature of gift-giving (Mauss 1954) and how gift-giving reflects the moral and political order of the societies in which these exchanges occur (Malinowski 1922). One of the foremost writers about “gifts” is Marcel Mauss (1954), whose comparative examination of gift exchange and ritualized economies in ancient and modern societies stands as the classic text within this domain of anthropological research. Mauss is interested in the different powers imbued within and transferred by gifts, as well as the ways in which gift exchange is as much about relationships between individuals and groups as about the objects themselves. Particularly useful for this discussion is his notion that gifts are never free and are part of larger systems of socioeconomic, cultural, and political systems of exchange, reciprocity, and shifting power dynamics. Bourdieu’s (1997) theorization of contemporary gift economies is also of importance here, because he extends Mauss’s (1954) observations about the sociality related to the exchange of gifts. Bourdieu argues that when gifts emerge out of the social divide that separates people, they often consolidate that divide and are likely to form and sediment relations of dependence. Central to these forms of dependence is the idea that certain gifts can never be reciprocated and instead become part of lasting systems of obligation – what he refers to as a “gentle, invisible violence” (cited in McGonegal 2007, 3). A foundational idea about the nature of gifts and gift-giving is that a gift is

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never given or received in isolation. Rather, there is a well-established sequence through which most gift exchanges operate: they are given, accepted, and reciprocated (Danby 2002, 20). Despite the benevolence that is almost always associated with gifts, in many instances, these exchanges between people, organizations, and societies follow existing socioeconomic, political, and gendered “fault lines” on both sides of the exchange. In this way, gifts are very much implicated in the persistence of power relations that are often unequal and are given new channels of influence through gift exchanges. The context in which the gift discussed in this chapter emerged aligns with and extends these classic tenets of gift exchange theories through reference to writings on charity and neoliberal governance. The monetary gift provided to WW by the family was intended to be a charitable act, and on the surface it follows the classic pattern of gift exchange in that was given, accepted, and reciprocated – that is, it ushered in a new set of relations between WW , SSMH , and CC that was directly related to and dependent upon the financial gift. However, in this instance the gift and the attendant amalgamation process do more than perpetuate existing relations of power and relationships, as is the focus in most traditional treatments of gift-giving and systems of exchange. In this case, they function to distribute and circulate new forms of dependence, obligation, and relations of power, instilling institutional conformity and self-surveillance in WW . As I will go on to illustrate, the gift and the attendant amalgamation function as techniques of governance, giving SSMH and CC disciplinary power over WW . Amalgamation As Regulation and Surveillance

When I first began volunteering at WW , the amalgamation with SSMH and CC , as well as the impending move to the new building that was purchased with the private donation, were frequent topics of conversation. Framed at the civic level as a resounding success in the survival of WW , these twin developments (private donation plus amalgamation) were often discussed by the staff and some clients in ambivalent and fearful terms. In many ways, these fears were very much linked

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to the diametrically oppositional ideologies and practices espoused by SSMH and WW. For example, one staff member contrasted the staff at SSMH , who she described as “corporate and in the ivory tower … They don’t have the compassion or empathy … They make policies and procedures, the culture that comes down from the CEO ,” with the approach adopted by staff at WW : “we care, work with the people, are the front lines.” This same staff member went on to describe some of the techniques of regulation and surveillance that emerged following the amalgamation. She spoke about institutional changes that SSMH wanted to mandate at the new building, including metal detectors, swipe cards, and cameras. The staff member explained that these intrusive and stigmatizing techniques of surveillance were not welcome by staff and clients, many of whom were afraid that WW would have to change a great deal to be in line with SSMH ’s mandate. At the time of writing, cameras were installed at WW but the metal detectors and swipe cards were not. Interestingly, the cameras have been interpreted by staff at WW as helping them to manage their clientele in the larger building and in the adjacent outside space. During another interview, the same staff member talked about other regulating practices that were imposed on WW by SSMH that involved the monitoring of “bad” client behaviour. She described this new requirement to monitor clients as making staff feel as though they too were being controlled and watched by SSMH , albeit in a hidden way. In addition to the power imbalance between SSMH and WW , this example illustrates how the techniques of unfreedom directed towards WW clients extended to WW staff (see the introduction to this volume for a discussion of unfreedom). By charging staff with the responsibility to report bad client behaviour to SSMH , WW staff were both subject to surveillance by SSMH and became implicated in the surveillance and governance of their clients, and themselves, and in ways that were opposed to their organizational philosophy. Interestingly, this staff member also talked about how staff members resisted exercising these techniques of unfreedom on their clients. For example, this research participant described how staff members downplayed or did not report certain incidents, such as fights between women, because they suspected that both they and the women involved would be treated in a punitive manner by SSMH . The

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concern in an incident like this was that the staff member would likely be reprimanded for not controlling the situation properly. Firsthand experiences of WW staff with such situations, as this participant confirmed, made many of those employed at WW wary of how and what they share with SSMH . Equally indicative of SSMH ’s institutional techniques of control is that WW has been renamed “SSMH -WW ,” a linguistic move that is deeply symbolic of WW ’s forced loss of organizational and ideological autonomy. When I concluded the conversation with this staff member, she reiterated her fears, shared by others at WW , about being managed and controlled by SSMH in powerful and intrusive ways that made them feel as though anything they said or did could be detected and deemed punishable. Amalgamation As Protection and Control

Staff also identified a tension between feeling controlled yet also protected by SSMH , in the sense that the financial gift and amalgamation ensured the survival of the organization. Furthermore, a number of WW staff described how they were deemed to be “a liability” and a “dogooder” kind of organization by SSMH . This was confirmed when I was going through volunteer orientation at SSMH in May of 2009, when the staff member referred to WW as a “do-good kind of thing that is now firmly under the protective wing of a more established organization.” This SSMH employee went on to say that, during the amalgamation, CC and the City “took some flack” when they supported WW because “[Meadowvale] is a very sleepy town … [and] people like to think we don’t have those kinds of problems” (e.g., homelessness, addictions, poverty). I spoke with a different staff member about these troubling, complicated issues, and she provided another example of how the tensions between protection and control under SSMH affected particular staff members’ employee status, especially those with extensive experience and influence in the local world of service provision for vulnerable populations. Before the amalgamation, a number of these staff members were demoted and assigned to positions that did not reflect the wealth of their work and personal experience, and the woman I

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interviewed expressed palpable fear of losing everything she and other staff had worked so hard for at WW . From her perspective, the profound differences between WW and SSMH are partially due to what she describes as SSMH ’s fear of the Other, primarily with respect to WW ’s feminist and women-centredness orientation. She went on to describe SSMH as the “dominant culture that relies on familiar forms and needs to contain and maintain.” This staff member summed up our discussion with powerful words that reflect the dangerous costs associated with the amalgamation: although amalgamation has ensured WW ’s survival, she equated joining with SSMH as akin to making a “deal with the devil” and as compromising their commitment to working with their clients in caring, respectful, and autonomous ways. Her concerns are echoed in the words of another participant, who said, “if we are on the margins, that’s where we will always be … we want the privilege without selling out.” This statement speaks to her desire for WW to maintain the feminist, grassroots philosophies that are at the core of their organizational integrity, and reflects her resistance to the forced adoption of ideologies and practices of SSMH , which are far removed from those of WW . The Effects of Amalgamation on Staff and Vulnerable Women

At the time of writing (January 2016), it has been eleven years since WW amalgamated with SSMH and CC and just over five years since they moved into the new building. This forced partnership continues to engender problematic experiences with regard to the running of the agency and also the lives of its staff and clients. In this section, two examples are provided of the ongoing challenges of maintaining institutional autonomy and self-governance that WW continues to experience since the amalgamation. The first example draws attention to the difficulties WW encountered when trying to maintain the integrity of their particular approach when working with clients under the gaze of SSMH . The second example provides insight into the clash between philosophies and approaches practised by SSMH and WW and its impact on the lives of some of their most vulnerable clients.

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An ongoing challenge for staff at WW is the tension they experience in relation to the competing philosophies of the two organizations and how these differences influence client–staff relations. This tension became evident when funding from the City for an outreach worker at WW was terminated. This position involved the delivery of outreach services (e.g., condoms, clean syringes, small food items, feminine hygiene products) to female sex workers in the NC and downtown areas and was the only funded position of this kind in the city. Despite the vital necessity of these services to the well-being of the women who received them, funding for this position was withdrawn by the City after only two years. The City and other local powerful stakeholders, including the police, provided a number of reasons for ending the outreach position – namely, the relative inexperience of the outreach worker in the realm of civic and intra-organizational relations and politics. A representative from one of the agencies who raised concerns about this employee contacted WW and indicated that there were instances where her professional conduct was questionable, which reduced the outreach worker’s credibility and the credibility of the position more generally. The following quotation from the director of WW captures the tension between being grateful for the funding they received for the outreach position and feeling the pressure to ensure that the gratitude is reciprocated through the appropriate management of the position and the conduct of the young woman who filled it: “It’s the only funded position in the entire city for sex workers from a community level besides the police and that’s different, and it’s the first funded position by the City, for this whole realm, so we’re conscious we’re careful, and we’re always coming up against issues, always, that the City is wanting to micromanage around that position and around the way we are doing our work, so it’s always a dance.” The second example illustrates some of the troubling outcomes stemming from the amalgamation in the life of one of WW ’s clients. A senior staff member at WW , Rebecca, often spoke about Dionne (both pseudonyms) as an example of how profoundly women’s lives can change for the better, with the “right” kind of support and services – from a life characterized by chaos, sickness, and isolation to one

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of relative stability, less reliance upon drugs, and significantly more confidence with which to obtain the services and supports they need. Rebecca described Dionne’s chaotic life, and her potential, beautifully: “Dionne was a mess, she lost her children, she lost all her teeth, she was doing sex work, she’s sort of outrageous but is one of the most loveable woman I’ve met in my life, but totally outrageous, violent, all over the map.” One of the most pressing things that Dionne needed was housing, which falls under SSMH ’s purview of services, and Rebecca, along with other staff at WW , was able to provide her with housing at a former group home run by SSMH . After securing housing, however, Dionne began using the space as a brothel, which, according to Rebecca, “didn’t go over too well with the neighbours and SSMH wasn’t exactly thrilled with us either.” In the ensuing discussion of the interinstitutional tensions between WW and SSMH and how they affected Dionne, Rebecca also spoke about how the compassion extended by one SSMH staff member who acted against the institutional grain was essential to securing housing for Dionne: “They’re [SSMH ] used to dealing with nice cooperative schizophrenics who are on medications, and try as I might to explain that Dionne was the new face of what someone looks like that does have a mental health issue, they weren’t buying it. They were set to throw her out on the street and convict her and Chris [pseudonym], who is the director of housing, took a shine to her too. So bless Chris’s heart.” After obtaining housing and connecting more closely with medical and social services, Dionne began to stabilize and things started to come together for her. Rebecca repeated numerous times that she could not believe Chris took what she describes as a very big risk with her for Dionne. It is noteworthy that if it were not for the efforts of this “wayward” SSMH employee, Dionne would have been denied the support and resources she so desperately needed. As Rebecca describes, these acts of risk-taking were essential to the “miraculous” changes she has witnessed in Dionne: So this has been about over two years, well anyways a few weeks ago I walked in and Dionne’s downstairs and she’s standing there, she’s a great big tall woman, with wild crazy hair, and a big smile on her face, with full teeth. I’m like, “Dionne you have

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teeth!” We got her some teeth through the university and she has her kids back and she’s taking college-level courses, she’s mostly clean, not entirely, she’s working [in the sex trade] occasionally but not that much, and it’s just miraculous so, you know we’re all hoping and praying she can hold onto it. Discussion

Ideas relating to gifts and neoliberal governance are particularly useful to contextualize these data regarding the complicated structural and interpersonal forces at play in the running of WW in the time of amalgamation and their impact on the agency’s autonomy and organizational culture. As suggested by these data, withdrawal from statedirected funding generated conditions that extended the exercise of government through increased surveillance and control, a dynamic that is characteristic of neoliberal governance (see introduction to this volume). Although the monetary gift donated to WW to help ensure its survival was motivated by the donor’s benevolence, it is clear that it inadvertently became part of a process of institutional restructuring and neoliberal strategy of governance, which involved shifts in power relations involving WW , SSMH , CC , and other City agencies. The above examples illustrate how this gift-giving helped to sediment unequal relations of power between SSMH and WW , and affected relations between WW staff and their clients, in ways that constrained and limited their self-governing capacities. The techniques of unfreedom that WW staff described as imposed on them by SSMH protocols (e.g., monitoring and reporting of “bad” client behaviour) aimed to firmly place WW clients under increased suspicion and surveillance. This is similar to Power’s (2005) analysis of how poor women on social assistance, who are deemed to be unproductive and unruly, are governed and disciplined through techniques of unfreedom and constructed as undeserving Others through contemporary forms of neoliberal rule and discourse. Such unfreedom is also demonstrated in chapter 7 in Sara Tedford’s analysis of how health discourse (re)constructs the Inuit Nunavummiut, their ways of living, and the northern spaces they inhabit as “risky” and in need of intervention from the (colonial) South. While the Inuit Nunavummiut featured in chapter 7

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by Tedford and the poor women of interest in this chapter have been subject to unique processes of marginalization, both populations have a long history of being constructed as lacking the capacity to selfgovern and of being subjected to illiberal practices of rule, such as intensified surveillance and monitoring, that constrain individual (and organizational) autonomy and collective self-determination. In this chapter, I have illustrated how the designation of being undeserving of autonomy and incapable of self-rule profoundly affected the ability of WW to maintain its ideological and organizational integrity as its staff had to find their way to govern themselves in accordance with SSMH’s rules. Furthermore, this chapter illustrates how the organizations and staff that serve marginalized women become implicated in these unequal power relations through “benevolent” acts of gift-giving and forced amalgamation. Within the unequal power relations sedimented by the gift, WW staff became uncomfortably positioned as agents of unfreedom who were expected to apply the rules and regulations of SSMH and extend its watchful gaze over their clients. The resistance that staff exercised in response to this expectation was evidenced in their accounts of how they suppressed reporting incidents at WW that might put their clients, and them, at risk for punishment by SSMH . In these ways, and much like Mauss (1954) and others argue, the monetary gift was not “free” in any sense, and because of the power relations WW was forced into, the original meaning and purpose of the gift was transformed from an assurance of survival to a tool to ensure surveillance and control of WW by SSMH and other civic partners that were involved in the amalgamation process. What is particularly interesting is the further extension of the life or uses of the gift within neoliberal modes of governance, which alter the bonds and valence of reciprocity such that charity is exchanged for greater surveillance and control. On the surface, the gift acted as a kind of saviour for WW . However, as more recent writers about gifts argue (Danby 2002; McGonegal 2007), this benevolence is an effective way to mask unequal power relations at play in these situations of gift-giving and receiving. The WW staff expressed their understanding of such unequal power relations in many of our discussions. I was surprised initially, but their observations began to make much more sense when I learned of the

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many strings that were intimately and fundamentally attached to the private donation, and when I learned how this gift was linked with institutional and political processes that were set into motion through the amalgamation process, serving to bring WW and its practices under the watchful and disciplining gaze of SSMH . Time and time again, WW staff expressed conflicted ideas and feelings about the gift and what it entailed for them and their clients – namely, the fear of institutional domination by agencies that are largely out of touch with the philosophy of WW , and how this would affect their clients and their desire to circumvent and quietly resist some of the more problematic aspects of the amalgamation. The reciprocal nature of gift-giving, which typically engenders cycles of obligation and dependence through various modalities of exchange, emerges as an interesting way through which to understand the circulation of power, competing ideologies, and divergent approaches to governance that are, in complicated and not always beneficial (to WW and their clients) ways, central to the deployment of neoliberal governance. The dichotomy that is often drawn between charity, which is often praised, and welfare, which is often despised (Loseke 1997, 426), is another useful lens through which to understand some of the tensions between increased individual/civic responsibility for the poor and the often unmentioned reliance of the government on charitable organizations in light of reduced economic support for such agencies under neoliberal rule. Central to neoliberalism is the retreat of government support for many facets of social welfare, especially for those deemed unworthy or morally suspect, and the increasing shift of responsibility for these sectors onto private citizens and volunteer/ charitable organizations, such as WW . The private gift from the family to WW is a perfect illustration of this downloading of responsibility and the attendant rise in surveillance and forms of control that WW was subject to in order to receive the full benefits of the gift. As revealed in interviews with staff members, the family was well aware of the difficulties the agency was experiencing as they struggled to survive during the amalgamation process. Thus, the family’s intentions behind the gift may have been a strategy for WW to resist the impending conformity with and rule of SSMH and CC over them and their subsequent loss of autonomy. WW has, in covert yet important ways,

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been able to maintain some of their traditional, grassroots practices and philosophies despite being governed through their (forced) relations with the other two agencies, thus demonstrating the potential for resistance and organizational integrity in the face of institutional control and governance. Despite having the potential for some forms of subtle resistance to techniques of rule and organizational philosophies that are not commensurate with those employed at WW , the agency continues to experience what Bourdieu (1997) describes as gentle, invisible violence. Their engagement with SSMH and CC remains rooted in, and operates in accordance with, the institutional inequity between WW and these other powerful bodies, which in some ways perpetuates relations of dependence and obligation. WW is very much caught in this web of dependence and obligation, as evidenced by WW staff feeling pressured to acquiesce to the particular procedures and policies employed at SSMH and other attendant agencies in order to remain compliant and demonstrate their appreciation for the support provided to/forced upon them by these organizations that ensured their survival. This was illustrated in the complex set of circumstances that led to the decision to terminate the outreach position for women in the sex trade. The police and the City argued that the outreach worker’s inappropriate conduct/fashion choices and inexperience in one meeting she attended discredited the position, and that this justified cancelling what was the only such position in the city. However, insights from one of the WW staff who was drawn into this complicated situation reveal this to be much more an outcome of state-related powers to withdraw support while also demanding institutional and ideological obedience under the new system of governance that controls the running and survival of WW , both of which are central tenets of neoliberal social and economic restructuring (Bashevkin 2006, 15). Also, the conduct/dress of the outreach worker transgressed the divisions between worker and client, divisions that Bourdieu (1997) argues must be perpetuated by a system of governance that is invested in maintaining relations of dependence. In her examination of how municipal restructuring in London and Toronto shapes women’s political engagement and modalities of citizenship in an age of state restructuring and economic globalization, Bashkevin (2006) discusses the concept of “working from the inside” 244  ■  T R E E N A O R C H A R D

to describe how many women use their activist, feminist-based experiences and ideologies in their pursuits to assist in the development of emerging civic bureaucracies and administration. In many ways WW is also engaged in a struggle to work from the inside as they navigate the complex terrain of both private gifts and state-related funding and contractual obligations (see also Cloke, Johnson, and May 2007, 1091). In this chapter, I have suggested that these gifts are part of larger cycles of obligation and governance that tend to reproduce relations of dominance within neoliberal systems of rule. However, it is important to acknowledge that, in many powerful ways, WW continues to serve its clients and most sister agencies in the same shared spirit that is devoted to making a difference for women whose lives have been rendered vulnerable through processes of sexism, economic marginalization, and social exclusion. While gifts are never free, and can be dangerous, it is hoped that this chapter has shed some light on the ways in which community-based organizations like WW find innovative ways to (re)circulate the value of such gifts in ways that circumvent the political, fiscal, and institutional powers that seek to govern them. In conclusion, I wish to draw attention to the fact that, although my primary interest has been the outcomes of the gift and the amalgamation for WW , SSMH and other agencies have also experienced significant changes in institutional culture and management stemming from the socioeconomic and political restructuring inherent to neoliberal practices of governance. When completing volunteer training at SSMH , the woman working with me discussed her perspectives on several administrative changes. She said that up until four or five years ago, SSMH kind of “flew under the radar,” and the provincial Ministry of Health (their primary funders) did not implement stringent regulations on the agency with respect to their ability to obtain financial support or develop and run their programs. However, now they must take part in a nationally mandated accreditation process that was instituted to avoid the duplication of services; from her perspective this meant that “now we [SSMH ] have to fight for money.” She likened the end goal of accreditation as being like “a factory” with all of the products resulting from the same process and being virtually identical, which, for SSMH , involves everything from the documentation of case files, training, and volunteer procedures to case management. Thus, although SSMH is in a position to exercise arguably more power and influence within Gifts and the Governance of Vulnerable Women  ■ 245

the local landscape of service provision in Meadowvale, they too are caught up in the same web of dependence and obligation upon which the deployment of neoliberal rule hinges and that has so profoundly affected the women and staff at Women Welcome. References

Bashevkin, Sylvia. 2006. Tales of Two Cities: Women and Municipal Restructuring in London and Toronto. Vancouver: UBC Press. Bezanson, Kate. 2006. Gender, the State, and Social Reproduction: Household Insecurity in Neoliberal Times. Toronto: University of Toronto Press. Bourdieu, Pierre. 1997. “Selections from the Logic of Practice.” In The Logic of the Gift: Toward an Ethic of Generosity, edited by Alan Schrift, 190–230. London: Routledge. Cloke, Paul, Sara Johnson, and Jon May. 2007. “Ethical Citizenship?: Volunteers and the Ethics of Providing Services for Homeless People.” Geoforum 38:1089–101. Danby, Colin. 2002. “The Curse of The Modern: A Post-Keynesian Critique of the Gift/Exchange Dichotomy.” Social Dimensions in the Economic Press 21:13–42. Little, Margaret, and Lynne Marks. 2006. “A Closer Look at the Neoliberal Petri Dish: Welfare Reform in British Columbia and Ontario.” Canadian Review of Social Policy 57:16–45. Loseke, Donileen. 1997. “‘The Whole Spirit of Modern Philanthropy’: The Construction of the Idea of Charity, 1912–1992.” Social Problems 44 (4): 425–44. Malinowski, Bronislaw. 1922. Argonauts of the Western Pacific. London: George Routledge and Sons. Mauss, Marcel. 1954. The Gift: The Form and Reason for Exchange in Archaic Societies. London: Routledge. McGonegal, Julie. 2007. “The Tyranny of Gift Giving: The Politics of Generosity in Sara Scott’s Millenium Hall and Sir George Ellison.” Eighteenth-Century Fiction 19 (3): 1–16. National Council of Welfare. 2010. Welfare Incomes, Ontario. Ottawa: Government of Canada. http://ywcacanada.ca/data/research_docs/00000179.pdf. Power, Elaine. 2005. “The Unfreedom of Being Other: Canadian Lone Mothers’ Experiences of Poverty and ‘Life on the Cheque.’” Sociology 39 (4): 643–60. Ralph, Diana, Andre Regimbald, and Neree St-Amand. 1997. Open for Business, Closed to People: Mike Harris’s Ontario. Halifax: Fernwood Publishing. Strathern, Marilyn. 1988. The Gender of the Gift: Problems with Women and Problems with Society in Melanesia. Berkeley: University of California Press.

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Ch a p t e r 9

“You Are Free to Set Your Own Hours”: Governing Worker Productivity and Health through Flexibility and Resilience Ellen MacEachen, Jessica Polzer, and Judy Clarke

Introduction

Flexible work is now endemic in modern economies. As information and communication technologies have developed and economies globalized, work norms have moved away from what has been characterized as the postwar standard of long-term, local, and steady employment (Edgell 2005; Lowe 2002) to employment that is not restricted to one particular place or steady work hours. In contrast to the Fordist model of standardized production, work, and employment (Edgell 2005), modern flexible work is characterized by flat organizational hierarchies that invite worker autonomy and decision-making responsibility (Frenkel et al. 1995; McKinlay and Starkey 1997) and by dimensions of precariousness (Vosko, Zukewich, and Cranford 2003),1 such as varied working hours and off-site workspaces including the home and “the road.” Today’s flexible employees are often knowledge workers such as consultants, software developers, and public relations specialists (Newell et al. 2002) who are “on call” (Baxter and KrollSmith 2005), engaged in networks, and mobile (Economist 2006; Shih

2004). They develop their skills and conduct their work amid the demands of external shareholders, client-mandated deadlines, and global competition. Much of the related literature deals with whether flexible working arrangements involve positive or negative changes for workers and businesses. For instance, when work flexibility is depicted in a positive light, it is touted as being able to accommodate diverse employee needs and as contributing to “organizational justice” (McGuire, Pitt-Catsouphes, and Kenney 2006; Swanberg, Pitt-Catsouphes, and Drescher-Burke 2005). This approach also emphasizes the home–work balance that can come with work flexibility (Golden 2001; Mauno, Kinnunen, and Ruokolainen 2006). When flexibility is cast negatively, it is portrayed as lacking many of the employment security and stability features of the postwar era (Sennett 1998). From this perspective, flexibility is understood to contribute to employment precariousness and job insecurity, with the associated negative health effects (Lewchuk et al. 2006). A key distinction between these literatures is their focus either on flexible work (relating to issues such as skills, work hours) or on flexible employment (relating to nature of the employment contract) (Benner 2002). We define flexible work as involving employment arrangements or schedules that vary from the standard working day and week and as including elements of precariousness, such as uncertain working conditions (Vosko, Zukewich, and Cranford 2003). The flexibility of work may relate to workers’ choice of hours that suit personal or family needs, or to the businesses’ ability to organize labour resources (e.g., to hire, lay off) to be in line with customer needs (Government of Canada 2007). Literature on flexible work has grown since the 1980s in line with structural changes to modern economies in response to globalization. Studies have focused on work in the context of the manufacturing sector’s transition to flexible specialization and the ability to vary product lines rapidly via numeric flexibility (Hatton 2011; Smith 1997; Vosko 2000) and the growing trend across all sectors to flexible contracts (Beck 1992; Bone 2006). Within the knowledge work sector, the expansion of high-skilled knowledge and service sectors has prompted a focus on workplace flexibility to support the development of tech-

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nical expertise and creativity (Damarin 2006). Less is known about conditions of flexible work among knowledge workers, how its economic and organizational circumstances favour certain management practices, and how workplace health is managed in such workplaces. Although management texts discuss models of flexible work organization, little has been written about how such work is managed at the level of day-to-day practice (Newell et al. 2002) and about ways that flexible work and flexible employment blend. On the basis of data from a qualitative study of software industry managers’ experiences of managing employees and workplace health, we contribute to the literature on flexible work by examining managers’ ideas and practices in relation to the management of skilled knowledge workers and the workplace dimensions of flexibility. Using a discourse analysis approach, we describe the optimistic discourse of flexibility as elaborated by the managers in this study who emphasized the positive contributions that such flexibility makes to worker satisfaction and work–home balance. We then contrast these optimistic descriptions with the managers’ depictions of flexible work practices as intense and inescapable. We suggest that discourse about flexibility, and the work practices they foster, make possible and reinforce an increased intensity of work that is driven in part by the demands of technological pace and change. We discuss the implosion of personal/ work time and space and what this means for citizenship. Finally, we suggest that the managerial governance of flexible knowledge work expands the terrain of occupational health management that conceptualizes worker health in terms of wellness (Hillier et al. 2005), to include what we call “strategies of resilience” that aim to buttress workers’ capacities to sustain intense periods of work. Flexible Work and the Global Economy

Flexible workplace organization in the computer software industry exists within conditions of a mobile labour force, international networks and competition, and fast-paced product turnaround. A crossnational comparison of information technology firms places this sector at the forefront of industrial globalization because of the prevalence of

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trade affiliates and the international migration of workers in this field (Comeau 2004). Advanced information and communication systems create conditions in which firms can form partnerships, hire staff, and establish customer bases around the globe (Landry, Mahesh, and Hartman 2005). The off-shoring of information technology and software labour to countries such as India and China is common (Carmel and Tjia 2005; Comeau 2004; Ticoll 2005). This global marketplace creates international competition for contracts even within firms’ own jurisdictions (Bell 1995; Clegg, Colado, and Clatke 2000). The fast pace of change in this marketplace creates an urgency to complete work quickly, before a competitor releases similar software (Shih 2004). Under these conditions, the factory model and scientific management methods (which included pre-established processes, welldefined management structures, and clearly delineated time and place of work) have become increasingly non-functional. With transition in advanced economies to a base of knowledge and service work, we see changes including greater organizational flexibility, a more mobile workforce, and also stronger engagement of workers in the work process (Smith 1997). In the knowledge and service economies, the construction of the model worker is no longer one who is predictable, obedient, and reliable, but rather, one who is adaptable, thinking, and innovative. Flexible work organization relies on an entrepreneurial orientation to work (Beck 1992) where workers use their knowledge and experience (or human capital) to contribute to the competitiveness of the firm (Adkins 2005; Gordon 1991) and workers expect changing and brief employment contracts (Olofsdotter 2012; Vosko 2000). Workers enhance their marketability through engagement in continuous lifelong learning, job networking, and readiness for alternate employment opportunities (Beck 1992; Economist 2006; Gordon 1991; Kallinikos 2003; Newell et al. 2002; Reilly 2011). When labour is framed as marketable human capital, the enterprising knowledge worker becomes a type of “one-person small business” working within a larger enterprise (Mythen 2005). Amar (2002), for instance, describes flexible firms as being composed of “a number of people with diverse indivi­ dual goals working together to achieve the fulfillment of their own goals using the organisation as a vehicle” (7). Enterprising workers also

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market their capital via brokers, including temporary work agencies, who thrive on supplying “no strings attached” labour to organizations seeking human resource flexibility (Hatton 2011; MacEachen et al. 2012; Vosko 2000; see also chapter 10 in this volume). Managing Flexible Work in KnowledgeIntensive Organizations

In knowledge workplaces, it is common for workers to be managed through various forms of responsible autonomy (Economist 2006; Frenkel et al. 1995). Managers set goals and objectives, and workers are given discretion over how to do the job (Allvin and Aronsson 2003; Newell et al. 2002). Metaphors about this form of management depict managers as functioning to “coordinate and cultivate” rather than to “command and control” (Malone 2004), and as managing through “visionary guidance” rather than through “direct monitoring” (Allvin and Aronsson 2003). These managers are charged with assigning tasks and facilitating work, not through direct supervision, but through “culture management,” for example, by rewarding innovation, creativity, and dedication (Newell et al. 2002). This relatively indirect management approach is also necessitated by the disparate knowledge bases of manager and workers. Because of the specialized nature of knowledge work, workers often know more than their managers about how to do their work (Damarin 2006). Forms of management within firms can be seen as being influenced by broader political environments. In contemporary Western society, strong tenets of individual freedom, liberty, and rights limit the ability of government to impose rule. Instead, governments use persuasion and citizen self-governance. That is, citizens are guided to utilize their freedom in certain ways via governing initiatives, such as education and incentives. Rose (1996) refers to these dynamics of liberal governance as “seduction rather than coercion” (50). In the same way, enterprising knowledge economy workers have been described as fulfilling their own goals (Amar 2002) and as being guided, rather than as being managed directly. As with the governance of broader populations, this form of workplace management can be seen as oriented ultimately to fulfilling the objectives of the authorities (Gordon 1991).

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Management of Workplace Health in Flexible Work Environments

The pace of change in the information technology marketplace is rapid. Managers in the study described in this chapter described the race to the market of new ideas and products, and emphasized the tenuous hold of their firm on its market position. Flexible workplaces, oriented to survival and with a ready labour supply, regularly hire and lay off staff as market conditions fluctuate (Damarin 2006; Smith 1997; Vosko 2000). Although expert knowledge workers are considered valuable organizational commodities who require excellent working conditions (Newell et al. 2002; Zuboff 2004), high staff turnover can mask awareness of, and concern with, slow-developing health problems (e.g., back pain) that are typical in office workplaces. Under these conditions, it becomes difficult to distinguish health problems arising from personal pursuits from those attributable to the work environment (Allvin and Aronsson 2003). Stress is a significant workplace health issue in flexible knowledge work environments. Scott (2004) locates contemporary concerns about stress as a significant workplace health problem in the context of labour market restructuring and organizational downsizing, which have shifted the balance of power to employers and undermined worker control. Newly structured, agile, and globally competitive firms can expose staff to work-related insecurity, which is known to be a chronic stressor with implications for long-term health outcomes (Dekker and Schaufeli 1995; Ferrie et al. 1995; Heaney, Israel, and House 1994; Scott-Marshall and Tompa 2011). Also, workers who are expected to be enterprising and competitive often engage in an intense input of hours in order to meet market deadlines. Both long work hours and irregular “binge and purge” work hours result in stress and poor health (Heisz and LaRochelle-Côté 2006; Van der Hulst 2003). The management of workplace stress is often cast as a personal health management issue to be resolved through educational approaches, such as wellness campaigns or stress reduction techniques (e.g., Nickel et al. 2007; Welbourne et al. 2007). Critiques of this approach have focused on its neglect of organizational determinants of stress, such as long work hours and work intensity (Handy 1991;

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Houben 1991). They suggest that sustainable stress management requires organizational change (McCluskey et al. 2013; Michie and Williams 2003). Overall, these bodies of literature on flexible work, health, and the global work environment point to a form of work organization based on fluid communication and intense competition between firms and across jurisdictions. These conditions, together with a move in advanced economies to a base of service and knowledge work, have created an environment for a model of the entrepreneurial worker who is managed relatively indirectly through forms of responsible autonomy. While the current literature considers the technological and economic conditions for flexible work (e.g., advanced communications, transition from manufacturing) and various quality-of-life-related outcomes of this form of work (e.g., home–life balance, precarious employment, stress), questions remain about the actual practice and management of flexible work and the conditions for occupational health. Methodology

The findings are derived from a qualitative study originally carried out to examine managers’ views on commitment to workplace health in a new economy sector. Flexible work organization emerged as a key theme that shaped how occupational health issues were framed and managed, and it is the focus of this analysis. A critical discourse analysis approach was taken to the data (Cheek 2004; Clarke 2005; Potter and Wetherell 1995). Managers tend to be skilled communicators oriented towards controlling the content and parameters of conversations and producing ideal accounts (MacEachen 2005). An analytic approach was required, therefore, that moved beyond a face-value examination of accounts to a consideration of discourse as constructing reality through language and practice. Our approach understands discourse as the “scaffolds … which order reality in a certain way” (Cheek 2004) and as constituting reality. Manager accounts were analyzed, therefore, with the intent of understanding how the discourse of flexibility brings forth and legitimizes particular ways of managing knowledge work and worker health, and constrains or excludes other management approaches. The discourse analysis approach assumes that language is neither transparent nor value-free; its goal is to

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unsettle associations that are commonly made between language and meaning that have come to be seen as self-evident. From this point of view, the analyst is not concerned with ascertaining the truth of a participant’s account; rather, emphasis is placed on examining the ways in which participants construct truth and the consequences of accepting such truths (Edwards and Usher 2000). Drawing on this approach, we examined critically the form and content of management talk by looking not only at what managers said about work practices and health, but also at the expressions they used and how they reasoned about their ideas and practices. In-person interviews were conducted at thirty mid-sized computer software firms in Ontario, Canada in 2005. Of the firms sampled, two did not produce software, but specialized in the provision of permanent and temporary staffing to the software industry. Most of the firms (21) employed 150 or fewer staff. The firms developed a variety of products ranging from document management software to Internet applications, to data security software, to specialized scientific software. Thirteen of the firms were privately owned and 17 were publicly traded. Their clients included the financial sector, government, resource sectors, health care, and transportation. We used a theoretical sampling approach (Patton 2002; Strauss and Corbin 1998) that targeted small and mid-sized firms; such firms are representative of the sector in Canada and internationally (Comeau 2004; Da Pont 2003). Managers (and some workers) at ninety-one firms were approached about participation in the study. Eight firms declined interviews and fifty-three firms either were inappropriate (not software firms) or our timeline did not allow for the complex interview scheduling required for coordination with the busy managers. Initially, we sought to interview human resource managers, whom we presumed would have a good understanding of the concerns of employees, managers, and workplace health issues. We learned, however, that many firms were too small to have a human resource manager, or had cut back on human resources as it was considered to be a nonessential support role. (Many of the firms studied had experienced severe fluctuations in size over time; nervousness about organizational survival was common.) In those cases, we targeted other senior management positions that would involve employee contact and oper-

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ational responsibilities. As data collection progressed, and as the theme of flexibility became more central to the analysis, we extended our sampling to include interviews with four experienced programmers. Managers were approached by cold calling the selected firms and requesting staff members either by name or by role. The interviews took place mostly in their offices, although some occurred at nearby cafés. Most managers were talkative and interviews generally lasted sixty to ninety minutes. Our final sample included ten human resource managers, fifteen senior managers, one benefits administrator, and four programmers. Half of the managers interviewed for this study were female. This reflects our targeting of human resource managers, who tend to be female, and not the industry itself, which is overwhelmingly male. The firms studied reflected international trends in the software industry. Consistent with other geographic locations, workers were described by managers as being generally young (under forty-five), male, and well-educated (Comeau 2004; Downie et al. 2004; Gunderson, Jacobs, and Vaillancourt 2005). Information technology workers across jurisdictions tend to have short job tenure (Comeau 2004). In Canada, a study found that 45 percent of software workers had been in their positions for less than two years, and the average tenure at previous jobs was 3.5 years (Gunderson, Jacobs, and Vaillancourt 2005). Similarly, managers in our study described worker job tenure as being three to five years; a manager who had been with his firm for eight years described it as “three lifetimes.” The interviews were conducted by the three authors. They focused on each firm’s market experience, staff turnover and retention issues, description of staff work days, and manager ideas and practices relating to workplace health. All of the interviews (except one for which the manager declined to be taped) were audio-recorded, transcribed verbatim, and organized using a data management program, The Ethnograph (Newell et al. 2002). Thematic codes were developed through discussion and consensus among the three authors, who met in person weekly over the two years of the study. All interviews were read and coded by at least two of the authors. Inter-rater reliability was established, and emerging ideas about the data were developed through analytic memos and at team meetings (Clarke 2005; Strauss

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and Corbin 1998). Ethical approval for this study was obtained through the University of Toronto. All names in the findings are pseudonyms. Findings

The findings are laid out in three parts. First, we show how managers drew on an optimistic discourse of flexibility and emphasized the unique freedoms it offered workers. Then, we illustrate how flexibility in practice is double-edged, as its link with personal autonomy and freedom blurs boundaries between home and work and creates the conditions and possibility for unlimited work hours. Finally, we propose that a model of workplace health management emerges in flexible work that is geared towards the production of resilient workers who can withstand health- and productivity-threatening aspects of intense and relentless knowledge work. The Optimistic Discourse of Flexibility

The discourse of flexibility, as described by managers, emphasized its positive or optimistic elements. They described workplace flexibility as contributing to worker privilege, personal accommodation, creativity, and maturity. Flexibility as a privilege

The managers interviewed regularly emphasized how control over work was in the hands of employees, and how workers were free to come and go as they pleased. In particular, workers were described as having much control over when and where they work. This freedom was typically framed as a privilege, for instance, “We allow employees to work remotely” (Arlette, HR manager) and “We’re also very good at letting people work from home” (Alison, HR manager). Flexibility as worker accommodation

The managers described flexibility as either respecting or accommodating the needs of workers. They explained that the software business included unpredictable product demand and urgent deadlines and so

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work could not necessarily be done between 9 and 5. Although some firms had core hours, most operated on the assumption that people regularly have to, and want to, work at odd times. For example, Laura suggested that flexible hours free workers to have schedules that do not conform to traditional office hours: “We’re flexible in terms of when you come in and when you leave … it is part of the environment where people kind of come in and if they are on to something, they are on to something. It might be 10 o’clock at night when they kind of feel satisfied, that is just the way they work. So there is a respect for that” (Laura, HR manager). Flexibility as enhancing creativity

These managers’ accounts involved explanations of how flexibility (e.g., over hours worked) nurtured worker creativity and thus enhanced knowledge production. Flexible work arrangements, in which workers could (theoretically) come and go as they pleased, were described as making workers “more engaged” and, therefore, making companies more likely to be successful. For instance, a manager noted, “We basically allow them to come up with their own ideas. We nurture that” (Amit, senior manager). A human resources manager in another firm clearly draws on the language of flexibility to link worker control to the nurturance of worker engagement and creativity: “Software companies tend to be a little bit more flexible than other ones … People come in when it’s convenient for them to come in … We turn a lot of the control over to the employees … We’ve found that that makes employees more engaged, more productive, so therefore the company’s more success[ful]” (Alison, HR manager). Flexibility as a “grownup” approach

Related to this stance of “turning control over to employees,” workers were described as “grownups” who “don’t need to be micromanaged.” As managers lacked the specialized technical skills to evaluate the work process, their primary focus on whether or not workers were meeting particular project outcomes was also necessary and pragmatic. Under these arrangements, workers were expected to exercise their own judgment about how and when they must work in order to get the

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work done on time. As suggested in the following passages, flexibility comprised a management rationality that entailed maintaining a “careful” balance between accommodating worker control over when and how they conducted their work and ensuring worker accountability to project timelines and “targets”: You have to be very careful to manage it effectively and to still … allow that flexibility within the system … “You know what? I’m going to let you manage it and these are the kinds of things that you’re going to be accountable for … and as long as these things are met, then you can do that.” (Rita, HR manager) [Flexibility] is more of a management approach. Because we are financially driven, we say as long as we hit certain targets, then people can do almost what they want to get to those targets. Whether they work 14 hours a day or whether they work 6 the next day, however it works out to be, we are very flexible in that way. Nobody’s micromanaging anybody here. (Ross, senior manager) In sum, the optimistic discourse of workplace flexibility, as depicted by these managers, emphasized elements of worker choice, maturity, and autonomy. The managers linked these conditions to the nurturing of worker creativity, which, in turn, was related to business productivity and profitability. Flexibility in Practice

Although flexible work arrangements undoubtedly encompass many elements central to worker satisfaction (e.g., autonomy, choice), we found that flexibility in practice also comes at a cost to the worker. Here we elaborate on the flip side, or less attractive elements, of the managerial discourse of flexibility, particularly in relation to its dependence on certain types of workers. Specifically, we suggest that the conditions and circumstances of flexible work privilege workers who were free of home encumbrances, able to work long hours, pliant and able to

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modify personal life patterns to the needs of the business, and willing to work intensively and without explicit overtime compensation. Free of home encumbrances

An optimistic dimension of flexibility regularly voiced by managers emphasized its accommodation of workers’ personal needs, such as child care or tending to sick elders. The flip side to this positive framing of flexibility, however, was a managerial focus on how employees’ personal lives could impinge on their creativity, and thus the firm’s competitiveness. Managerial concern that the demands of home life might detract from the quality of work meant that management encompassed not just the office but also the territory of home and personal life. Arlette succinctly described the home as a territory with potential negative influence on work quality: “If you are not healthy at home, we are not going to get the best out of you. So, we show an interest in your life” (Arlette, HR manager). Similarly, Alison noted a worker’s difficulty with balancing the demands of work, commuting, and parenting, and explained that flexible work conditions helped to mitigate the worker’s pressure from home: I am not saying that there is no pressure … [Staff] can be … pretty stressed out. But, we do things, like, make sure that people … can do their work from home … One of our guys … was coming in every morning … dealing with the traffic … everything else, just fried by the time he would get here … We figured out if he was to come in later … and leave [later] … he is going to miss most of that traffic and he is going to be able to see his daughter off to school. So, he is going to feel a lot better about the whole thing … It’s just a matter of being quite flexible. (Alison, HR manager) Long work hours

Although the expressed flexibility over when and where workers do their work conjures up an image of fair and relaxed governance that enables workers to balance personal and work demands, the interviews further revealed that such flexibility simultaneously accommodates extended hours of (uncompensated) work. Promoting flexible

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work hours, therefore, does not necessarily translate into not working long hours. We found that, with no fixed office hours or particular work places, the discourse of flexibility in effect accommodated an increased intensity of work through the merging of home with work, and work with home. For example, while managers encouraged workers to return home to their families to “get some balance in their lives,” this did not mean that work necessarily ended: “Rarely do people stay late [in the office]. A lot of people will work from home because we’re connected … So, people are encouraged, rather than discouraged, to go home to their families and get some balance in their life. It doesn’t mean they don’t work long hours” (Vivian, senior manager). Thus, providing the flexibility to be at home did not necessarily entail any distance or time away from the demands of work. As one manager noted, “They’ve got laptops so they can work anywhere, so they may very well be working from home. I don’t think an awful lot of people are physically in this building at all hours. I know I’ve gotten emails from people at, you know, 2 o’clock in the morning kind of thing … I think the ability to work from home is marvellous … you can still BE with your family and kind of sneak away for a little bit” (Olivia, benefits admin). Daniel explained that, although a “good balance” allows staff to attend family events during what normally would be considered work hours, this flexibility comes at the cost of working evenings and weekends: “We understand that they have families and want to see those families, as well … We’ve got lots of work to do and there’s lots of evenings and weekends … But if your son or daughter has a recital or their kindergarten graduation and you got to go there, we get that, no problem at all. So, it’s a good balance” (Daniel, senior manager). Pliant workers

The merging of personal time and space with work enabled a rhythm and form of work that catered mostly to the needs of the firm. We suggest that flexible work scenarios described by these managers produce pliant, flexible workers who modify their work and life patterns according to the needs of the business. For example, Vivian described how she rarely took a break during the day and often brought work

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home with her: “I personally have shifted my work day to come in early cause I rarely get a break during the day. Because I’m working with people across the country, lunch time here is irrelevant … I might take some work with me when I leave but because I’m getting my work done, it doesn’t matter where or how I do it. You know, we are flexible that way, which is great” (Vivian, senior manager). Alysha describes a similar scenario where managerial flexibility for a worker to “come and go as he needs” strategically accommodates high customer demand and the associated elevation of work intensity of being “on call” for extended periods of time: We have somebody who’s in the implementation group, who basically has been carrying a pager and working 24 hours, seven days a week for [the last 8 months] … Basically, we let him come and go as he needs to and make sure he’s getting the proper rest and all that kind of stuff. He needs to be on call, because … the customers are requesting him by name … So, you know, and he wants to do it … We just try to accommodate that individual as much as we can. (Alysha, HR manager) Overtime obscured

The language of flexibility, while giving the impression that workers control their work, obscures the fact that, ultimately, work is driven by deadlines and fluctuations in product demand. In practice, therefore, flexible workers must buy into intense work hours with no negotiated recognition in compensation. In this sense, Pamela emphasized that, while workers were able to “design their own workload,” their compensation for overtime work was less determined: We do not believe in overtime, we believe in, you know, you have a job, you do it. We pay you to do it. You know, if it takes you less time … you don’t have to work the eight hours. If it takes you more … you take off a day. Take time off … during a time that’s not so busy or whatever. We can’t afford to do overtime … So, we just kind of leave it to them to decide, you know … you basically design your workload. (Pamela, HR manager)

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Similarly, Roger elaborated on how being flexible involves an unwritten rule of not complaining about uncompensated overtime: I ran quite a loose system in terms of when they came in. You come in between 9 and 9:30 when you’ve got kids to baby-sit, that’s fine! You take an hour out to go and take the kid to the dentist, that’s also fine, but don’t ever complain when we’ve got to meet a deadline. You know what the deadline is. You decide how you’re going to work the overtime, not me. And we don’t pay you overtime, because … we allow you to adjust your time accordingly. (Roger, senior manager) A closer examination of the discourse of flexibility, therefore, brings forth a number of negative dimensions of flexibility that were silenced or downplayed in managers’ optimistic accounts. In practice, flexibility relies on and requires pliant workers who mould their lives according to the demands of work, and who are readily available at all times including evenings and weekends. Accompanying this pliability is the responsibility to complete tasks to deadline regardless of when and where the work takes place. In practice, we find that flexible work allows for an intensity of work in which workers’ personal lives are eclipsed, rather than accommodated. Workplace Health Becomes Worker Resilience

Although managers put forth an optimistic picture of workplace flexibility, the conditions of work required workers who were themselves unencumbered, pliable, willing, and flexible. These elements of workplace flexibility created a platform for managerial approaches to workplace health that involved a lack of focus on existing health problems and, instead, devoted attention to ways of sustaining workers who could withstand intense work conditions. In this section, we describe the managers’ orientation to workplace health problems and propose the term “strategies of resilience” to describe the particular ways that managers promoted worker health so that workers could maintain productivity even under intense and pressured conditions.

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Poor health as an individual worker problem

In the context of industry pace and competition, and the reality of intense work pace and looming deadlines that encompass workers’ personal space and time, we found that the managers in our study did not see or feel responsible for workers’ occupational health problems. For instance, a senior manager considered the issue to be laughable: “We’re like, you know, accountants. You know, a stapler, you know, you gotta watch that stapler! [sarcastic, laughs] … Paper cuts, that’s what we get.” When asked directly about worker health, managers mentioned employee problems such as neck and back strain, but they did not see these as requiring their attention. For example, Kerry characterized an employee’s back strain as a problem related to individual practice, not to the work environment: “His back bothered him, but that was because he sat, he would never get up … I said, ‘… if you walked around, you would feel better’ … And I mean, I have a little bit of a wrist problem. But, you know, after … years of using a keyboard, of course you’re going to have something, right? … So, we’ve never had anything” (Kerry, senior manager). Strategies of resilience

We found that managers pursued a particular model for workplace health that did not incorporate traditional notions, but that emphasized flexible work as a means of promoting workers’ well-being, and thus achieving corporate success. The managers focused neither on the protection of workers from hazardous work exposures nor on their long-term employability. Instead, their occupational health management strategies were oriented towards ensuring that workers would be able to withstand working conditions. In the context of the fastpaced computer software industry in which workers tend to be young and have relatively short-term tenure at firms, managers’ approaches to workplace health management involved what we call “strategies of resilience.” That is, managers helped workers to be able to cope with the demands of intensive, inescapable work. Individual worker resilience, or, the ability to remain healthy and maintain high productivity during intense project work, was valorized by managers and encouraged in various ways. Kerry noted her own

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resilience and stamina and the company rewards that came with not being too sick to work: “I haven’t had a sick day in years … We get awards … for not having a sick day” (Kerry, senior manager). Worker health, comfort, and stamina were also encouraged through the creation of comfortable offices with informal dress codes, activities, and welcoming physical designs. The offices we visited regularly had comforts such as beer fridges, big screen TV s, sofas, beanbag chairs, hammocks, a gym, and a café. Managers depicted the importance of an environment of leisure: “If you go to the lunch room, [you’ll see] … four people sitting at a table and they’re playing cards, some of them are playing chess … some are playing pool” (George, HR manager). Resilience and the ability to keep working

These efforts, which emphasized comfort and included elements of home, also facilitated staying at the office and working long hours. Jan described how her office was designed with all the comforts of home in mind, which helped to mitigate against potential resistance to working long hours, and opened up the possibility of staying at work late into the night and even sleeping there: They made a conscious effort to make the office nicer than anybody’s house … because they recognized that, periodically, we are going to be asked to do things that are just a bit too much … So, we have a gym … beer fridge … deck … get fed in the morning, bagels and cream cheese and fruit … lots of couches … to create an environment where you don’t mind so much when you have to be there 12 hours a day … If you work really late … a number of people have slept over at the office. (Jan, programmer) Strategies of resilience also involved supporting workers with personal and home-related stress levels so that workers could sustain productivity levels. For instance, Michele explained that the flexibility to take work home also helped with the achievement of deadlines by defusing employee stress: “Mostly, employees go home at a reasonable time, but then work in the evenings. They do work to deadlines, but have had no health problems that I’ve seen. It goes a long way when

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you give employees the flexibility to manage their own hours – it’s less stressful, a LOT less stressful” (Michele, HR manager). In another instance, a senior manager identified how flexibility helped a worker to continue working even with a newborn baby in tow. The needs of the firm, coupled with her central role in a particular project, left her little choice but to keep working during a time that typically would be reserved for family: “We had one of our women … had her baby. But it was at a time when they were [very busy with a job] and she was pretty fundamental to what was happening. And she was back in the office 2 weeks after her baby was born … He became our office baby. He was here every day for 6 or 8 months … She HAD to be here … She was pretty fundamental to the craziness that happens when [this task occurs]” (Vivian, senior manager). Thus, we argue that the discourse of flexibility accommodates and encourages workplace health strategies that focus on the production of pliant and resilient workers and place little emphasis on the longterm health effects of intensive knowledge work. Rather than protecting workers from traditional hazards, such as long work hours, the managers achieved goals of production and competitiveness by buttressing workers’ abilities to carry heavy workloads while sustaining intense work periods. This intense tempo and pace of work was made possible by managerial investment and interest in the personal health and life of workers.

Discussion

This discussion examines the implications of these findings about the pace and organization of computer software development work and the platform this sets for the management of workplace health. We consider ways that power relations inherent in fast-paced knowledge work support an opening of personal time and space to work, and examine how strategies of resilience operate in a context of economic uncertainty. Further, we suggest that there are survivors and losers in flexible knowledge work, and elaborate why highly skilled and marketable workers may consent to the intensity of flexible work conditions.

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In practice, flexibility accommodates work that is both intense and inescapable. It requires responsible workers who can meet project deadlines, regardless of where or when. This study showed that the firm’s bottom line (money- or time-wise) was always in view, and flexible work place and hours rendered workers’ personal time and space both useful and used. Although the managerial discourse of flexibility involved much talk about worker control over process, it was clear that managers were only flexible in some ways. As managers lacked the technical knowledge base to meaningfully engage in how workers arranged their work (Allvin and Aronsson 2003; Newell et al. 2002), they did not oversee the day-to-day work of workers. However, managers retained the ultimate discretion and authority within their firms about task allocation and deadlines (Frenkel et al. 1995; Newell et al. 2002; Webb 2004), leaving workers little flexibility about those critical job components. Indeed, Bauman and Haugaard (2008) describe flexible management of workers as a contemporary technique that broadly extends managerial influence through extensive self-management and self-control: “Self-managing employees can be relied upon to reach for resources which managers could not reach, to deploy the parts of themselves off-limits to the bosses in traditional labor contracts, and not to count hours spent in serving the aims of the employing company – as well as to control and neutralize such parts of themselves which could be potentially counterproductive or disruptive, or at least difficult to tame and disable, if they were admitted to the shared workplace under the rule and direct responsibility of the managers” (117). Flexible work, therefore, serves managers because it leaves workers in a position where all time is potential work time. Echtelt et al. (2006) note an autonomy paradox in flexible workplaces in that independence given by employers to workers often also means that, to get the job done, workers must choose between income and leisure time. Similarly, Shih (2004) finds that a lack of a strict schedule makes it difficult for workers to set any limits on how much they work. Indeed, the intensity of flexible knowledge work is reflected in studies suggesting that much of the productivity gain in the information technology industry could be attributed to the growth of existing labour input (intensity of work) rather than to growth of the industry as a whole (Roach 1998; Sveiby, Gripenberg, and Segercrantz 2012).

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Personal time and space thus become indistinguishable from work time and space when the demands of work merge with home (“sneaking away” to do work at home) and the comforts of home blend into work (drink beer and sleep at work). It is precisely through this discourse of flexibility that the personal time and homes of workers are rendered as a resource that can be exploited and capitalized upon by software firms, which, in turn, compete intensely and struggle for survival in a volatile global industry characterized by constant technological change and flux. As noted by Ziarek (2004), speed and change provide a basis for contemporary power relations. In this study, the pace of technological change, the race for new products and ideas, and the managers’ sense of firm precariousness created conditions in which work became unquestionably urgent. This urgency created amenable conditions for both flexible work and flexible employment (Benner 2002). That is, work hours and place were pliable, as was employment, which included short job tenure. By virtue of such conditions and acknowledgments, life outside of work came to rest within the scope of managerial power and discourse. The expansion of managerial control to encompass domains of worker life normally considered private has been noted by others, who also draw attention to power relations inherent in managerial interest in “the personal.” Conrad and Walsh (1992) find a corporate health ethic that is concerned with the wellness of employees (individual issues such as weight, diet, and exercise) rather than with the conditions of work. Others have also observed a broadening of managerial focus to include personal domains. Managers have transformed sleep into a work-related productivity issue (Baxter and Kroll-Smith 2005; Brown 2004) and slouching and posture into a work-related ergonomics problem (MacEachen 2000). We offer the term “strategies of resilience” to suggest that the discourse of flexibility reframes occupational health management in terms of building individuals’ capacities to withstand intensive and uncertain working conditions. Such strategies build on a blending of home and work by drawing personal health and time into the domain of occupational health management. By introducing this term, we aim to describe how worker health was managed rather than how it should be managed. Because knowledge work is generally viewed as

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non-physical work, it is easily conceptualized as non-hazardous and thus as not having adverse health effects. Once health is constructed as a problem relating to personal life and hardiness, then it becomes difficult to consider in other ways (e.g., as related to work exposures). By describing existing strategies of resilience, we also direct attention to workplace health issues that are not being documented and managed, for instance, neck and back strain, lack of sufficient personal and family time, long-term stress, and burnout. Strategies of resilience involve a minimal focus on traditional hazards and operate on the terrain of what may be considered a wellness approach but with the larger and somewhat insidious goal of maintaining high worker productivity for project-limited periods of time (as workers are not expected to stay with the firm for very long). They create workers with the stamina, attitude, and resources required to stretch their health and personal lives to new limits. These strategies can be considered within the broader context of citizenship in liberal society, which is oriented towards educating and persuading citizens to make the right choices (e.g., lifestyle management, education, immunization). These governance strategies invite individuals to make the right choices (O’Malley 1992) and, in doing so, depoliticize the reasons for the choices (“It was their choice.”) (MacEachen, Kosny et al. 2013; Rose 1996). In this study, a framework of work flexibility allowed managers to shift the responsibility for deciding how to complete work away from the organization on to workers. Strategies of resilience, while seeming to enhance worker freedom, also collapse personal life with work life, and so further contribute to a political ethos that shifts attention away from corporate and state responsibility and towards notions of separate, individual choice-making. We suggest that a resilience approach to occupational health management emerges and thrives in the particular context of knowledge work where the average worker is young and male, and able to keep up with the required work pace, constant (or “lifelong”) learning, and job changes required in fast-changing technological environments. The norm of short job tenure in this cyclical industry supports a workplace health strategy that is geared not to maintaining workers over years, but instead, to buttressing them for short, project-length

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bursts of time (Stager 2002). Although the relative youth of the average worker in this sector (Comeau 2004; Downie et al. 2004; Gunderson, Jacobs, and Vaillancourt 2005) may create some individual hardiness, the managers’ evocations of stress (“staff can be pretty stressed out”) point to stress management as a central component of resilience. Intense work conditions in the computer software industry (Shih 2004) mean that stress and fatigue may be common among workers. While conventional occupational health models suggest that workers can handle greater demands if they also have control over their tasks (Karasek and Theorell 1990), we note that workers’ control is limited by pressures from external stakeholders, customer demands, and international competition. Loose boundaries between home and work may contribute to worker inability to manage personal time, or to keep personal time safe from the demands of work and the adverse health effects associated with unstable hours (Heisz and LaRochelle-Côté 2006; Scoffield 2006). For instance, Cooper’s (2000) study of male software workers finds that the pace and entrepreneurial ethic limited young men’s ability to contribute to family life. Although it was outside of the scope of this study, it would be interesting to examine if firms have written policies about workplace health and stress management and, if so, to examine these policies in relation to our notion of strategies of resilience. The governance of workers through flexible work and resilience strategies raises questions about marginalization on the basis of age and gender. Serious consideration should be paid in future research to the types of workers who are excluded and left behind as flexible workplaces and practices become more acceptable – that is, workers who will not or cannot withstand intensive work and/or mould their family lives in accordance with employer interests and related demands of clients, customers, and stakeholders. As Scott (2014) suggests, in flexible work regimes, workers “have come to bear the burden of organizational and economic performance as never before … workers must ensure they constitute ‘value added’ in order to remain employable” (145). Women are rare in high tech industries and may be excluded because of caregiving and familial responsibilities and strong culturally informed equations between technology and masculinity (Faulkner 2000, 2001; Ranson and Dryburgh 2011; Turkle 1984). In addition,

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based on the present analysis, it is reasonable to assert that any worker with child-rearing or elder care responsibilities may not be able to manage the pace of the resilience approach (Cooper 2000; Shuey and Spiegel 2010). Interestingly then, rather than provide greater freedom to workers who have dual roles as caregivers, the managerial discourse of flexibility – and the intensification of work and worker resilience it demands – in effect reconstitutes gender-based exclusions and discriminations. Within flexible work environments, such discriminations are inevitably informed by the collapse of work/home time and space in ways that favour competition and profitability over worker and family well-being; this was inadvertently articulated by Vivian, a senior manager in this study who described how a female worker’s indispensability to a project led her to return to work two weeks after giving birth, with her “office baby” in tow. As well, older workers may not be able to survive work in the software industry, where they are seen as unreliable, unproductive, and as having little value in comparison to younger workers (Henkens 2003). Indeed, McMullin and Dryburgh (2011) note that women and older workers in the information technology sector are generally found in firms that offer lower wages. This dovetails in telling ways with the ways in which the neoliberal restructuring of retirement, as evidenced by popular discourses on “productive aging,” emphasizes working into later life and flexible work arrangements as a solution to ensure financial security, with particular groups of older workers at greatest financial risk (e.g., women, new immigrants) constructed as benefitting the most from continued work (see Laliberte-Rudman, chapter 4). Thus, future research should examine how workers respond to and resist strategies of resilience and, in particular, how these strategies affect women and older workers and how age, gender, and ethnicity intersect. Our findings raise questions about how workers – most of whom are male, young, and well-educated – consent to the conditions of flexible work. If work conditions are intense and less than ideal, then how is consent to these conditions obtained from highly skilled and marketable workers? Although the intrinsic motivation of knowledge workers to pursue learning through work ceaselessly has been put forth as an explanation (Amar 2002; Gunderson, Jacobs, and Vaillancourt 2005; Ticoll 2005), broader and more convincing explanations have also

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been offered. Some have described how the relentless drive to work at a hectic pace is embedded in worker subjectivity. Based on her study of knowledge workers in Silicon Valley, Cooper (2000) proposes that an identity-based form of labour control produces a “new masculinity” in which “tough guys” “get the job done, no matter what” (403). This win-lose “turbo capitalist culture” pressures workers to prove themselves continually (Cooper 2000, 379), or a desire to “strike it rich” leads workers to construe their hectic work pace as being in their own entrepreneurial interest, rather than in the interest of their companies (Shih 2004). Zoller (2003) found that worker consent to strenuous work schedules in an auto-working factory was constructed through disciplinary discourses that subtly restricted the ways in which workers could voice complaints or attribute their health problems to working conditions. Smith (1997) and Casey (1996) focus on ways that broader economic conditions shape worker consent. They note that consent to new production arrangements is obtained under less than ideal job market conditions. As citizens, individuals are constructed as informed choice-makers; as workers, they are described by managers as free and flexible. Even when worker consent is obtained through workplace discourse and organization, and when conditions include a ready global supply of labour for a smaller pool of jobs, there remains space for resistance (May 1999). An analysis of resistance strategies of temporary agency workers identified mostly small individual acts, such as disobeying some rules and trying to pick “good” jobs (MacEachen, Carrasco et al. 2013). Shih (2006) examines how women and ethnic minorities manage to work in the Silicon Valley knowledge worker environment despite conditions that appear to favour young white men. She identifies avenues for resistance in both groups in which members draw support from social networks such as the “old girls network” or “ethnic networks.” Acts of organizational “misbehaviour” by workers are a focus of increasing interest among organization theorists who argue that organizations produce not only confirmative behaviour but also resistance (Ackroyd and Thompson 1999). Future research could explore misbehaviour among skilled knowledge workers, and also the employment trajectories and experiences of workers who qualify and enter but do not manage to remain employed in the information technology sector.

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In conclusion, this analysis of manager discourse on flexibility in thirty computer software firms provides insight into the flexible management of skilled knowledge workers, the conditions supporting flexible management practices, and workplace health management strategies of resilience that emerge under these conditions. Our study showed that managers felt responsible for productivity but not for the work process or its effects on workers’ bodies and health. Although flexibility was cast by managers as creating desirable freedom, autonomy, and life balance for workers, a closer examination of flexibility in practice showed a double-edged sword. That is, flexibility was oriented strongly toward the needs of production, and the accommodation of workers served to collapse the time and space boundaries between work and home. While this loosening of boundaries was cast as a perk for workers, it also meant that personal time and space were at the disposal of the organization: workers were always potentially at and available for work. An inherent logic of this type of flexibility involves managerial ability to abdicate responsibility for the work process, and its ability to maintain highly productive workers for limited periods of time. This study raises many new questions about work intensity and the ability of skilled knowledge workers to withstand and resist this organization of work. Further, the intensity and fast pace of information technology work, cloaked within managerial discourse of flexibility, requires a worker availability and resilience that is not easily available among workers with child care or elder responsibilities or among older workers, effectively creating a highly gendered and age-restricted occupation. By addressing such age- and genderbased inequities, and the taken-for-granted links between notions of flexibility and worker control, future research could explore and develop more inclusive models of workplace flexibility that consider the unique health and safety aspects of knowledge intensive work.

Acknowledgments

This research was supported by a postdoctoral fellowship from the Social Sciences and Humanities Research Council of Canada. An earlier version of this chapter was published as Ellen MacEachen, Jessica

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Polzer, and Judy Clarke, “‘You Are Free to Set Your Own Hours’: Governing Worker Productivity and Health through Flexibility and Resilience,” Social Science & Medicine 66 (5) (2008): 1019–33. N ot e s

1 Vosko (2010) further notes that the standard employment relationship (SER ) that emerged in the post–Second World War context, with its predictable hours and strict separation of time spent at work from time spent at home, was not universal and did not capture the working realities of women and immigrants. The SER was informed by an existing gender contract, which assumed males as breadwinners who sold their labour in the public sphere for a wage and females as conducting the unpaid and invisible caregiving labour necessary for social reproduction in the (heterosexual) household.

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Ch a p t e r 1 0

Active Citizenship and the Management of Stigma in Contingent Work Marcia Facey

Introduction

In her ethnography of inner city working poor, anthropologist Katherine Newman writes that there is no other measure of social worth that matters as much as the kind of job an individual holds. She says that we have been “committed to the moral maxim that work defines the person. We carry around in our heads a rough tally that tells us what kinds of jobs are worthy of respect and what kinds are to be disdained. It is a pyramid organized by the income a job carries, the sort of credentials it takes to secure a particular position, the qualities of an occupation’s incumbents [and] we use this system of stratification (ruthlessly at times) to boost the status of some and humiliate others” (Newman 1999, 86). The demonstration of one’s attachment to the labour force constitutes a particularly important way to “acquire the status of citizen” (Rose 1999, 164). Labour market participation constitutes a principal mode of social inclusion and is a primary avenue into citizenship (Gordon 1991; Munger 2002; Rose 1999). Without working, one may be denied full citizenship because unemployment assumes a dependency

on social welfare benefits, which is construed as a moral hazard (Rose 1999). If labour market participation is a primary way to achieve citizenship, and if one’s social and moral worth is measured by the type of job one occupies and by his or her level of attachment to the labour market, what does this mean for those whose jobs are stigmatized and who, as Newman (1999) suggests, might not be deemed worthy of respect? In this chapter, I report findings from a qualitative study of contingent workers employed in ostensibly stigmatized jobs. Specifically, I illustrate how day labourers and clerical workers hired through temporary help agencies attempt to manage the stigma associated with their work by espousing opposing discourses of contingent work as both advantageous and disadvantageous. Through these opposing discourses, participants constructed contingent workers simultaneously as disreputable and as morally upstanding persons. Starting from the theoretical premise that discourse is a form of social action, and situating the analysis in the theoretical contexts of governmentality and citizenship, I argue that these discourses function symbiotically to cast these workers simultaneously as inactive and active citizens. The findings illustrate a key paradox of neoliberal governance: that it is both liberating and oppressive. The findings also suggest that, in the context of contingent work, this dynamic operates by constructing the work, and the workers who do it, as stigmatized, and then provides them with a range of discourses through which they reconstruct themselves as active and empowered. I conclude by theorizing some links between this active citizenship and occupational health and safety. Contingent Work as Stigma

Contingent work is characterized by short- or fixed-term contracts, part-time, casual/on-call, self-employment, seasonal, and temporary help agency work. Compared to “standard” employment, contingent work is short-term and unpredictable. Although it involves full- or part-time hours, location of work, time, and wages are often uncertain. It is associated with reduced or no benefits or entitlements for workers; it may involve working in multiple locations, and multiple

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and simultaneous employment contracts; and it is generally associated with reduced regulations and union representation (Burgess and Connell 2004). This form of employment emerged in the context of the globalization of trade, investment, production, and intensified economic competition (Benach et al. 2002; Heery and Salmon 2000), and the associated corporate responses to these changes, including organizational restructuring, downsizing, and outsourcing (Connelly and Gallagher 2004; Mayhew, Quinlan, and Ferris 1997; Sparks, Faragher, and Cooper 2001). In industrialized countries, contingent employment has steadily increased since the mid-1980s, and now forms a significant portion of the labour market (Quinlan, Mayhew, and Bohle 2001; Sointu 2005; de Ruyter 2004). This upward trend is especially evident in the temporary help services industry. Statistics Canada and the Conference Board of Canada data show a fourfold increase in temporary help agencies between 1993 and 2004. In the United States, the number of temporary help agencies doubled between 1990 and 2008 (Luo, Mann, and Holden 2010). Administrative, clerical workers, and industrial trades account for the largest share of this market (Conference Board of Canada 2006; Hamdani 1997). “Flexible,” “non-standard,” “atypical,” “temporary,” and “precarious” are some of the terms that have been used to describe contingent employment. These labels not only reflect different kinds of employment arrangements, but also conflicting perspectives and assumptions about contingent work. For example, “flexible employment” is generally suggestive of firm or employer perspective, particularly numerical flexibility, or the ability of firms to adjust workforce levels as needed. The term conceptualizes flexible work arrangements as a social good and reflects an optimistic view of contingent work, firms, and workers. For workers, it implies “boundary-less careers” (Defillippi and Arthur 1994), entrepreneurship, autonomy, and empowerment, and conceives workers as purposive actors who have high levels of human and social capital (Facey and Eakin 2010) and who are in symmetrical power relations with employers. Other terms such as “precarious,” “marginal,” and “disposable” (Carre et al. 2000; Quinlan, Mayhew, and Bohle 2001) denote the problematic aspects of contingent employment. From this viewpoint, contingent

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employment is largely thought to comprise “bad” jobs – jobs that are low-skilled, low-paid, menial, dirty, inherently exploitive (Carre et al. 2000), and which are concentrated in largely unregulated labour markets (Raijman 2001; Quinlan, Mayhew, and Bohle 2001; Walter et al. 2002). The stigma associated with these forms of work is compounded by the overrepresentation of marginalized groups, including immigrants and women, in this labour market sector (Zey­tinoglu and Muteshi 2000). In Canada, for instance, women are more likely than men to be employed in the part-time labour market and racialized women are more likely than their counterparts to be precariously employed (Cranford, Vosko, and Zukewich 2003b). Participation in fulltime temporary work and self-employment has increased among both men and women; however, women are more likely than men to engage in extremely precarious work (i.e., part-time, temporary work) (Cranford, Vosko, and Zukewich 2003a). Ten percent of racialized women are in part-time temporary work compared to seven percent of white men (Cranford, Vosko, and Zukewich 2003b). The association with degraded work in a secondary, insecure labour market has led some to characterize contingent work as a harbinger of societal disintegration (Facey and Eakin 2010), and others to deem it reprehensible and a euphemism that disguises human suffering (Broad 2000). This view of contingent work, then, is that it is more of a social problem (Kunda, Barley, and Evans 2002) than a social good and is a “means for exploiting workers and undermining their living standards” (Carre et al. 2000, 3). This stands in stark contrast to the social good perspective, which conceives of contingent work as a “free-market innovation that liberates employees and employers from the straitjacket of standardized employment” (Carre et al. 2000, 3). This divergence in perspectives on contingent work in the literature is reflective of a labour market that is comprised of “high-end,” high-status jobs (such as software developer), and “low-end,” stigmatized jobs (such as unskilled day labourer), and of the competing perspectives of those who study contingent work from management versus labour points of view. Such antithetical perspectives raise questions about the range of workers’ experiences in this sector of the labour market and what these mean for health. There is a growing body of literature on the deleterious effects of contingent work arrangements (Lewchuk et al.

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2003, 2005, 2006; Lewchuk, Clarke, and Wolff 2011; Lewchuk et al. 2013; Vosko 2006). This body of research is best summarized by Mayhew et al. (1997), Quinlan (1998), and Quinlan et al. (2001), who attribute health risks to socio-structural factors such as workplace disorganization (such as lack of or inadequate training); regulatory failure (such as inadequate application of occupational health and safety regulations); dysfunctional management practices and reward systems (such as work intensification); and psychosocial factors (such as uncertainty, marginality, low reciprocity, and discontinuity) (see also Facey and Eakin 2010). With few exceptions (Facey 2011; McGann 2012), less scholarly attention has been paid to how contingent workers negotiate the neoliberal imperative for active citizenship through employment in temporary work, which I have suggested is marked by stigma and threatens workers’ sense of self-worth and moral integrity. Neoliberal Forms of Governance and Contingent Work

As a form of governance that is premised on the dominance of the market and the extension of market relations to social relations (Er­ gun and Erdemir 2010; Larner 2000), neoliberalism fashions particular kind of entrepreneurial citizens. Such citizens are constituted by and governed through discourses of autonomy, self-care, discipline, self-examination, individualism, and personal responsibility (Rose 1992, 2000). As discussed in the introduction to this volume, under neoliberalism, this active citizen responds to these discourses by making a venture of his or her life, by projecting a future for him or herself, and by shaping him or herself in the present in order to achieve that vision (Rose 1992). The active citizen assumes responsibility for his or her success or failure, and is driven by a fundamental belief that there is a correspondence between effort and reward, that what one puts into the market is what one gets out of it (Ergun and Erdemir 2010). The active citizen is knowledgeable, makes reasoned choices, bears the consequences of those choices, and exhibits a willingness to take risks in the pursuit of material or economic goals (du Gay 1996a, 1996b). These choices are influenced by the awareness that individuals

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are differentiated, hierarchized, excluded, and included according to how well they measure up to norms of the moral community as defined by neoliberal principles. To gain and retain membership in this community, individuals must adhere to its codes. They must “actively shape themselves in the likeness of prevailing cultural and social models” (Hatcher 2003, 392), and govern themselves and abide by these codes through continuous self-assessment, self-surveillance, and comparison to what is “normal” (Lupton 1999). Those who do not (or who are not able to) comply with such norms will be identified and labelled problematic, and will be seen as “a threat or a reproach to public contentment and political order” (Rose 1996, 340). Such individuals run the risk of being labelled inactive and thus immoral citizens and may experience feelings of shame, which operates as a primary method of upholding community norms (Sayer 2005). For contingent workers who occupy low-end, stigmatized jobs, achieving active citizenship is thus fraught with tension. Although, active citizenship under neoliberalism requires participation in the labour force, labouring in these particular jobs means that workers face continuous threats to their dignity and social worth. As I go on to illustrate, the workers in the present study understood the shame associated with their jobs and they developed strategies to ameliorate these negative attributions and thereby sustain a sense of self-worth. In describing and interpreting their experiences, I reveal the discursive strategy these workers used to manage their experiences of stigmatized, contingent work. Methodology

The data presented here were drawn from a study that sought to understand the work and health experiences of contingent workers in a large city in Ontario, Canada. I conducted face-to-face, semi-structured interviews with nine day labourers (eight males, one female) and fourteen clerical workers (thirteen females, one male) who were employed through temporary help agencies. Recruitment strategies included posters in local social clubs, community centres, laundromats, grocery

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stores; snowball referrals; approaching workers directly outside of temporary help agencies; and enlisting the help of agency managers. The jobs participants did were largely segregated by gender. Clerical workers were mostly females and were employed in “pink collar” jobs in government, financial, and educational institutions. These included administrative and executive assistants, call centre workers, receptionists, and file clerks. Day labourers were mostly male and worked in ostensibly “dirty jobs” in construction, manufacturing, transportation, food processing, and waste management. These included truck driving, warehousing, garbage collection and sorting, meat and poultry processing, and general labourers on construction sites. Participants’ ages ranged from twenty to over sixty years; tenure as contingent workers ranged from three to over twenty years; and educational levels ranged from less than high school to graduate degrees. Fifteen participants were single, two were married, and six were divorced. Three participants (two females and one male) were members of racialized groups. The interviews lasted one to two hours and were audio-taped with the permission of participants, who were given a twenty-five-dollar honorarium at the start of the interview. Interviews were conducted in private meeting rooms on the university campus or in a place that was convenient for the participants (such as coffee shops). A range of topics relevant to the participants’ work and health experiences was covered, including family, educational background, the process of getting work, what a typical day was like, relationships with agencies, co-workers, and clients, conditions of work, wages and benefits, things they worried about, what made their work easy or difficult, and how they managed the everyday aspects of their work. A qualitative data management software program was used to help organize the data and facilitate analysis. Analysis occurred in two stages. The first stage involved sorting and organizing the data by searching for themes and patterns and variations in these. The second stage involved the use of abductive reasoning (Danermark et al. 2002), which facilitated the redescription or recontextualization of data. It involved looking at the patterns in the data and drawing on particular theoretical frameworks that might offer plausible explanations for them. It is a way of “reasoning, thinking and arguing,” of inferring or “seeing universal structures in individual events” (Danermark et al.

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2002, 88). The study received ethical approval through the University of Toronto. All the names used are pseudonyms. Findings

Analysis of workers’ accounts of their contingent work experiences revealed two primary and conflicting discourses: contingent work as disadvantage; and contingent work as advantage. The discourse of disadvantage mirrored the prevailing view of contingent work as precarious, exploitive, and degraded, whereas the discourse of advantage represented contingent work as flexible, autonomous, and empowering. By drawing on both of these discourses, participants effectively “othered” their peers through negative depictions of contingent work and workers. And they managed the stigma associated with contingent work by distancing themselves from such disreputable subject positions and by constructing themselves as active, moral individuals who use contingent work as the basis for self-growth and autonomy. Contingent Work as Disadvantage Contingent work as exploitation and powerlessness

Contingent workers’ experiences of exploitation and powerlessness are, in part, shaped by the tripartite nature of the contingent employment relationship that includes the workers, the agencies who hire them, and the clients/employers on whose premises they work. Workers occupy the weaker position in the relationship. In this study, both day labourers and clerical workers described their employment relationship as a purely economic arrangement, one based solely on the exchange of labour power for wages. They said that they had no relationship with their agencies or with clients/employers. As evidence of this, they pointed to the “very impersonal” and “distant” stance of agencies and the absence of care or concern that the agencies displayed towards them. Several said they felt like “just a number” or like “just bodies.” One worker said that for agencies, “the bottom line is money,” and felt she was perceived only in terms of her “cash register” potential. Participants also suggested that their relationships with clients/employers were similarly characterized by low support and

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commitment, and they pointed to the lack of sufficient supervision and training as evidence of this. In concert with these views about their employment relationship, study participants described their work in terms of exploitation, powerlessness, marginalization, uncertainty, privation, and degradation. One day labourer likened the experience of exploitation to being like chattel. Mindy, a clerical worker, said, “they just made money from me and that’s all I saw … They take advantage of us … I feel like they own me.” Others described feeling like they were “being used,” like they were not able to “get ahead,” and like agencies oppressed them. The workers linked these feelings to the perceived power of agencies to deprive them of relative control over their work lives. Sam, a day labourer, described his employment relationship as being “like slavery.” He explained that he was not, for example, free to sell his labour on the open market because he had to work 480 hours for the agency before a client could hire him as a permanent employee. These clients also had to pay the agency a “finder’s fee.” Some workers implied that agencies took advantage of their economic vulnerabilities by offering them assignments the agency knew they did not want. Some of them said they feared turning down assignments because it “might count against” them later on. For instance, they may not get called for better assignments. Feelings of exploitation were also suggested in workers’ comments that they were socially and economically undervalued and that, despite their hard work, they got none of the social protections or benefits that full-time workers enjoyed. Sam remarked, “I mean these guys [day labourers] are slugging more tonnage than these guys [full-time workers] could do ever … They’ve got no benefits, they got no medical, they got no shareholder value, they’ve got no RRSP , they’ve got nothing. They’re disposable … They’re cheap labour.” Both day labourers and clerical workers pointed to their low wages, inequitable pay, agency and client practices of misrepresenting job tasks in order to get a lower wage rates, and assigning them heavier workloads than their full-time peers as other examples of how they were exploited. Day labourers suggested that agencies further exploited them by passing on some of the costs of doing business; in essence, they were treated as independent contractors who were

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expected to provide or rent their own equipment, such as work boots and hard hats. Workers also described their experience of powerlessness as a lack of control over their work processes, a relative inability to negotiate wages, or to raise health concerns with employers. Some day labourers said they feared pointing out health hazards on the job because this might jeopardize current and future assignments. They might, one worker said, inexplicably have a “no return” stamped on their worksheet, or they might find out the next day when they report to the agency that they would not be returning to that particular job. Likewise, one clerical worker said she felt like she was “always walking on eggshells,” and another said she “[had] no rights” to express any opinions about her workplaces. On this point, Liana, a clerical worker, explained, “When you see something that goes wrong, you don’t have the audacity to raise your voice and tell them that ‘I believe that this is the way you should do it’ because you never know, the environment is so unknown to you that you never know how they will react.” This unfamiliarity with workplaces and its attendant absence of established workplace relationships, coupled with the perceived disposability of contingent workers, factored into Jenny’s observation that a bad temp was someone who thought she or he had rights. Like other clerical workers in this study, she believed that temp workers “come a dime a dozen” and had little value because they were so interchangeable. This kind of powerlessness meant, for instance, that they had to agree to whatever clients wanted because “They will call the agency and [say], ‘yes, well, you know, this person that you sent is a problem’ … There’s thousands of people who can take your place in five minutes; they will replace you” (Jenny, clerical worker). The experience of powerlessness was profoundly illustrated in the comments of Axel, a day labourer, who described it as a pervasive sense of helplessness: “there’s no sense of control, there’s no sense of eh, you know, being in charge or anything at all. You feel like a pawn; you’re a pawn that’s being moved around the board.” Contingent work as deprivation and degradation

Workers characterized their experiences of deprivation and degradation as a lack in both the material sense (no benefits, inadequate wages

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with no regularized increases) and in the psychosocial sense (low respect, job satisfaction, personal/skill and career development). Some felt they were being deprived of a “normal” life course because the uncertainty associated with temporary work meant that they could not set personal goals or make long-term plans such as getting married, having children, or owning a home. Many of them said that chronic employment uncertainty – never knowing when and whether they will get their next job and how long it would last – was one of the “worst things” about contingent work. The constant apprehension about jobs and instability in wage rates translated into personal economic uncertainty. Mindy, a clerical worker, said that she could go from making seventeen dollars an hour one day to twelve dollars an hour the next. For day labourers, the unpredictability of wages was exacerbated by their transience – the possibility of being at a new workplace every day. The workers’ accounts also suggested that this deprivation and transience was experienced as social marginalization and, correspondingly, a lack of social support. Both clerical workers and day labourers said they felt like they did “not belong anywhere” and described themselves as “outsiders” and “nomads” who were “just roaming.” Axel explained that no one wanted to “strike up a friendship” with him because he did not stay in one place for any length of time and so he often felt isolated and lonely. Among clerical workers, marginalization was described and experienced as exclusion from the “work family.” This was manifested most often in being left out of work-related social activities, not having access to insider information, and the inability to develop friendships that they could draw on to help them do their jobs. Participants also described contingent work in ways that conveyed loss of dignity, respect, and self-worth. For clerical workers, the experience of contingent work as degrading was suggested by their assertions that clerical jobs were “very remedial.” The perceived lack of skills requirements led these workers to believe that others, including employers, had very low expectations of them. Anna, for example, explained how her most “mediocre performance would bring praise” from employers. Views of contingent work as degraded and inferior were further suggested in Wally’s characterization of day labouring as “dirty work.” He said, “It’s demeaning, it’s menial, you know, like, you’re doing something that somebody else wouldn’t do … Like the

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tradesmen wouldn’t clean up themselves, so they phone the temp agency, come and clean up the shit, like we’re glorified caretakers/ garbage men.” In sum, the discourse of disadvantage was characterized by the workers’ accounts of their experiences of powerlessness, exploitation, deprivation, and degradation. These accounts can be understood in the context of the weak, transactional, and tripartite employment relationship. Within this relationship, the workers saw themselves as pawns of both employers and agencies, accountable to both of them but receiving very little loyalty or support from either. They felt that the perceived limited skill sets required for the jobs, the characterization of some jobs as dirty work, and the concomitant interchangeability of temp workers made them easily exploitable, disposable, and stigmatized. Their disposability, along with a general lack of social support, the experience of economic and employment uncertainty, and the absence of career or normal life-course trajectories were posited as evidence of their deprivation and degradation. Interestingly, many of the workers appeared to reinforce this stigmatized view of temp workers by either implicitly or explicitly suggesting that contingent work was not bona fide employment because the jobs were transient, had no career trajectory, had few responsibilities, and required little commitment. As illustrated in the next section, at the same time that the workers articulated a discourse of disadvantage that casts their work as stigmatized and undesirable, they also espoused a discourse of advantage that depicted this work as worthwhile and desirable, and as flexibility and empowerment. Contingent Work as Advantage Contingent work as empowering, flexible, and worthwhile

In stark contrast to the workers’ descriptions of contingent work as powerlessness, this representation of contingent work as advantage comprised notions of individual freedoms and choices. Many participants asserted that contingent work afforded them freedom from anxiety, stress, and the tedium and obligations of full-time work. They also said that they had the freedom to move in and out of the labour market, and to refuse assignments whenever they chose to because they were

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“not like real employees.” For example, Anna, a clerical worker, said she chose to do this kind of work because the flexibility afforded her the time she needed to pursue other activities (“I was working on a couple of screen plays … and I was taking some acting lessons”). Also, in contrast to their characterization of contingent work as degradation and privation, participants also extolled its virtues. Helen, a clerical worker, described it as a “very, very good thing” and as a “massively broad, area for self-growth” that was “just magnificent” for her. Likewise, Lucy suggested that this sector of the labour market was a good training ground for her. It was, she said, helping her to develop soft skills such as conflict management and conflict resolution. Kirk, a day labourer, explained that, despite the widespread view of his work as dirty work, he found dignity, satisfaction, and value in doing it. Other participants stressed the character-building outcomes of this work. One clerical worker suggested that continuing to do work that was stigmatized meant she had to develop survival skills – particular qualities and abilities that would sustain a strong sense of self-worth. Their accounts also suggested that contingent work was rewarding because it provided a way to access otherwise inaccessible (internal) labour markets and afforded the possibility to build social networks. Their talk also suggested that participation in the contingent labour market was a trading off of what Goffman (1959) called spoiled identities. That is, workers suggested that doing contingent work meant they could avoid other, more stigmatized identities such as being unemployed or being on social assistance, which one worker described as “denigrating” and a “huge stigma in this society.” Also, in an effort to sustain their sense of self-worth, workers asserted that temporary jobs were in fact real jobs. This was the case for Marie, a clerical worker, who said, “I used to sort of talk myself down about, like, you’re doing temp work, like come on, get a real job or whatever, right. And I’ve sort of accepted the fact that these are real jobs; they’re just shorter stints.” Through this kind of talk, the workers constructed a discourse of advantage that redefined stigmatized work as empowering. Thus, the workers interviewed in this study held opposing views of contingent work. On the one hand, it was seen as an advantage, which they described in terms of freedom and flexibility. On the other hand, they represented it as disadvantage, which they described as exploitive,

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marginalizing, and degrading. This dual representation of contingent work was mirrored in the participants’ portrayal of contingent workers. On the one hand, they described them as disreputable, and, on the other, they depicted them as morally upstanding. Contingent workers as moral persons

In some of their talk, workers acknowledged and mirrored the view of contingent workers as stigmatized and disreputable. They said that there was a general perception that such workers were “not very bright” and were “not good enough” to have real jobs. Real jobs, as they conceived them, were permanent and full-time, with benefits, had a career trajectory, and involved having real responsibilities. They felt that contingent workers were defined by jobs that were neither valued nor respected. Lucy, a clerical worker, commented that her family thought she was wasting her time and talents. She believed that they did not think highly of her because she was not fulfilling her potential. She said, “Like, they think [I’m] … a loser in the job world and, I mean … they probably see me as a loser because … they see me as being smarter than doing what I’m doing.” Interestingly, some of the workers in this study reproduced this unfavourable view of contingent workers. Day labourers used particularly caustic language to describe other day labourers – as “lazy,” and as “vagabonds,” as people who “lack[ed] experience and skill,” who “can’t hold down or want a steady job,” and who were “unintelligent,” “self-indulgent,” “undependable welfare bums and alcoholics,” and “losers.” Although not as scathing in their criticisms, clerical workers also described their peers in unfavourable terms. They said that temps were generally unreliable, exploited their temp status because “they can get away with more,” and did not use their “common sense or logic” but rather they expected to be “spoon-fed every detail” of their tasks. While participants assailed the character, work habits, and intelligence of other contingent workers – and thus reproduced to some extent the stigma associated with contingent work – they also articulated a counter-discourse in which they depicted themselves as rational decision makers and morally responsible persons. For instance, contrary to their portrayals of contingent workers as disreputable “others,” participants in this study would often describe themselves as workers

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with a good work ethic, who were responsible, respectable, and professional. They extolled the virtues of hard work, and said they experienced job satisfaction even in instances where they had described their jobs as low paid, “gruelling” and “dirty.” Kirk, a day labourer, said, “I’m a good worker, that’s one thing I’m proud of it … I like to work and keep busy … Sometimes, you know I’ll come home and feel satisfied like I did a good day’s work and even though it’s only $9 an hour or something like this … You still feel satisfied.” Likewise, clerical workers explained that, even though their tasks were not challenging, they found imaginative ways to expand on and complete them. Helen, who described herself as a “workaholic” who turned “each piece of paper work into a work of art,” maintained that she not only welcomed hard work, she viewed what she did as a craft. To demonstrate their strong work ethic, clerical workers described how they took initiative and offered their skills in ways that went beyond the requirements of their assigned tasks. They claimed that taking on additional tasks added “a bit of variety” to their jobs and made their work days better. The workers pointed to their backgrounds, education, skills, and good character as evidence of their respectability. In the interviews, they described themselves in terms of other professional identities, such as writers/playwrights, editorial cartoonist/artists, skilled draftpersons, graphic designers, actors, journalists, “overachievers,” and Type A personalities. And, to create and maintain this persona of respectability, some workers said they made it a point when they were on assignments to talk about their backgrounds. The need to appear respectable was particularly evident among day labourers, such as J.T., who described himself as a “self-starter” and “the captain of his ship.” Likewise, Sam implicitly underscored his respectability by pointing out that he was a regular listener to public radio. Avoiding the use of generic job titles that were associated with temp work was another strategy the workers used to represent themselves as respectable. Lucy, a clerical worker, explained that outside the workplace she never introduced herself as a “temp.” She often worked in the banking industry and said that she opted for more impressive titles such as “bank officer” or “consultant.” Disavowing the contingent worker label meant these workers had to constantly strive to maintain

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their reconstructed personas and thus their respectability. Anna explained, for example, that in addition to talking up her post-secondary education, she made sure she had “other things going on, on the side” to talk about if the topic of work came up. When asked about her job, she would often say, “no, really, this isn’t my real thing, I’m not a receptionist. I’m writing a screenplay … I’m doing translation work … I’m doing graphic design.” Contingent workers as rational and calculative

As part of their counter-discourse to the view of contingent workers as disreputable, a rational and calculative stance was implied in the workers’ talk about choosing temp work, and in their transactional and dispassionate approach to work and work relationships. Both day labourers and clerical workers maintained that, despite the stigma and disadvantage associated with their work, their decisions to do temporary work were reasoned and calculated. Axel alluded to the stigmatized nature of his work but also said that it was his choice to do it: “you know what you’re getting into, you know why you’re doing it, you know what the end result will be, you know the type of work you’re gonna be doing.” With regard to accepting or rejecting assignments, many workers said that they took a “what’s in it for me?” approach to these decisions. Although many of the clerical workers admitted their fears about turning down (too many) jobs, they also said they weighed the long- and short-term benefits of the assignments they were offered, and that they accepted or rejected them based on personal priorities and goals. Clarina, a clerical worker, remarked, “[you] know what your priorities are, like, what is your career goal, what is important to you at that particular time, that particular moment … That will affect your decision, in terms of accepting the job.” The calculative process that workers engaged in when deciding whether to accept work assignments at times involved weighing any potentially humiliating aspects of the work against other personal goals or benefits. For example, Jenny, an information technology specialist, recounted a story of taking a less-than-ideal job playing an Easter bunny. Her narrative revealed that she engaged in a calculative process of weighing a potentially embarrassing assignment against dwindling savings; the future possibilities of getting better paid assignments;

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being able to get as much chocolate as she wanted; “doing something good for humanity”; and the fact that she was “not shovelling guts.” For Liana, a mechanical engineer who worked as an executive assistant, the threat to her self-esteem and her concerns about skills attrition figured more prominently in her calculations about accepting or rejecting assignments. She explained, for instance, that she would take file clerk jobs only if they were short-term and if it was close to holidays such as Christmas and she really needed money. These workers also said they weighed low wages and poor work against the possibilities for getting inside information about companies or making connections in labour market sectors that were generally hard to access. Relationships with co-workers and clients were also described in a dispassionate and calculating way. Clarina explained that she would go the extra mile or do favours for clients if she thought it would help to build her resume or enhance her future employment prospects (such as the possibility that clients/employers might provide her with a good reference). This transactional rather than relational view of their work relationships was also suggested in the assertions of some workers that the clients were not friends, and that the agencies were not exploiting them. Agencies, one worker said, were simply brokers who were facilitating the purchase and sale of labour between workers and clients. Jenny, a clerical worker, made clear that emotional attachments should not be considered part of the relationship: “I treat it like a business contract … [Agencies] are there to make money off your butt, and you should consider yourself there to get paid off their butt.” In general, these workers suggested that social attachments were risky and onerous because they constrained their ability to effectively fulfil the contingent worker role. Referring to her relationships with colleagues, Liz explained that she was not interested in making friends with co-workers or listening to their problems. She was, she said, “there for a paycheque” and had no desire “to get wrapped up in their lives.” In a similar vein, Sam, a day labourer, said that he did not interact with co-workers; he just went in, did the job, and got out. Some of the clerical workers explained that they put up “shields” or went into “self-protective mode,” that they “trusted no one,” and they did not “get attached” to people they met on their assignments. Other workers

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saw relationships with co-workers in purely instrumental terms. For instance, relationships were built with the sole aim of exploiting them as needed (such as using full-time peers as resources to help get their assignments done). Contingent workers as risk takers

The portrayal of contingent workers as risk takers was suggested by the ways that some of the study participants seemed to embrace the transience and uncertainty that characterized their work. They described risk taking variously as “flying by the seat of your pants,” living “one day at a time” and “on the edge.” For these workers, there seemed to be an acceptance of the uncertainty of never knowing “for sure if [they will] work the next day,” “what kinds of situations [they will] face” on each assignment, or “what’s really coming next.” Not knowing, one clerical worker claimed, was one of the more exciting aspects of the job. They characterized this uncertainty as “intrigue,” “freedom,” and “adventure.” Lucy, a clerical worker, associated the transience of contingent work with freedom and creativity, and implied that the transience represented ever-present chances to escape bad jobs: “Like, I’m glad this job, I don’t think I could do it for three years, six years, like, are you crazy (laughter), like, honest. I need to feel challenged; I need to be creative.” Some participants suggested that the transience and inherent risks of contingent work were sources of motivation, personal satisfaction, and freedom. For instance, Anna repeatedly talked about being new to workplaces. When asked what it was like to be new all the time, she said that because the jobs she did were boring, the “only thing that could possibly be stimulating was the challenge of always going somewhere new.” In sum, in recounting their experiences of contingent work, the participants in this study constructed two contradictory discourses. One discourse portrayed contingent work in ways that reinforced the prevailing view of such jobs as degraded and undesirable. Concomitantly, their talk constructed a view of contingent workers that was characterized by shame, stigma, and marginalization. On the other hand, they depicted contingent workers in ways that countered the stigma and

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shame associated with contingent work. In this construction, contingent work was recast as worthwhile and desirable, with an attendant worker subjectivity that was characterized by honour, respectability, and dignity. Discussion

This analysis of temporary help agency workers’ experiences of stigmatized work suggests that they created and simultaneously held opposing discourses as a way to manage stigma, preserve their dignity, and construct themselves as morally worthy. On the one hand, the discourse of disadvantage illustrates that these workers were mirroring the prevailing view of contingent work as inherently negative and of workers as disreputable. Conversely, the discourse of advantage illustrates that workers drew on neoliberal principles to represent contingent work as fulfilling, to represent workers as risk takers, as rational and autonomous in their choices, and as morally upright individuals. Although prima facie the co-existence of these two contradictory discourses suggests a tension in their experience of contingent work, they nonetheless function symbiotically in the workers’ constructions of themselves as active neoliberal citizens. In their self-constructions, the workers both acknowledged and contested the stigmatized view of contingent work and its concomitant notion of the disreputable worker. In other words, this dual construction of contingent work as both disadvantage and advantage enabled them to distance themselves from the stigma associated with it and its disreputable workers, and to construct themselves, instead, as good workers by accentuating the moral and symbolic worth of their work. In describing other contingent workers as dependent, lazy, unreliable, welfare bums, study participants claimed for themselves a subjectivity characterized by entrepreneurial selfhood and active citizenship. Their talk suggested that they did not see themselves as mere objects of exploitation. Instead, they saw themselves more as partners in relatively symmetrical power relationships with agencies, and they embraced what they conceived as a rational, mutually exploitive employment relationship. Thus, the benefits of contingent work were

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understood to extend beyond the purview of employers to include the workers who constructed themselves as active citizens who made free and reasoned choices to participate in contingent employment. For many of the workers in this study, temp work was not only a way to make ends meet financially; it also provided a means to an end. Their identities were not defined by their jobs, and they discursively resisted the stigma associated with this employment arrangement. This resistance was evidenced in their reconstructions of stigmatized work. For instance, despite the disreputable characterization of their work (e.g., as dirty, demeaning, and mindless), these workers as active citizens recast this work as desirable and worthwhile. Indeed, they suggested it was an essential path to personal meaning. And, although uncertainty was a problematic feature of their work experiences, these workers reconceived this uncertainty as risk taking and embraced it (“I like living on the edge”). By recasting uncertainty as risk taking, and by claiming that contingent work was a choice and a source of personal meaning, these workers portrayed themselves as autonomous, rational individuals who found dignity in their work. The workers also constructed themselves as active citizens through their reconceptualization of transience as flexibility and autonomy (“I’m going to do exactly what I want to do”) and by claiming the ability to self-actualize (“I wanted to sort of go off and try to pursue my dream”). Hence, like uncertainty, transience is ennobled; it is no longer associated with drifters, tramps, and bums or with shiftlessness and untrustworthiness (Adler and Adler 1999). Instead, transient workers are accorded the “benefits of a moral passage and are reconceptualized as on-the-go and highly mobile” (Adler and Adler 1999, 52). The active citizen re-enchants the stigmatized character of temporary work, “restoring to it that which has been crassly repressed – the possibility of pleasure” (du Gay 1996b, 25). These findings suggest that, even in the face of widespread disadvantage and stigmatization, “resistance is always on the horizon of the possible” (Callero 2003, 120). The “horizon of the possible” is evinced in these workers’ re-presentations of themselves as enterprising selves and active citizens – in their claims of making a venture of their lives, of navigating their work worlds as calculating agents who,

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for example, use work and work relationships to their personal advantage, and who draw on neoliberal ideologies of flexibility, individual freedom, and choice to resist the stigma associated with their work. This interpretation of the experience of stigmatized work illuminates the pervasiveness and tenacity of neoliberal forms of governance that rely on particular constructions of active, entrepreneurial citizenship. Neoliberal governance regulates, incites desire (De Cock, Fitchett, and Volkmann 2005), and constitutes subject positions for people located in different social positions (Hall cited in Larner 2000, 9). The capacity of neoliberal contingent employment arrangements to produce active, entrepreneurial citizens across a range of social positions is illustrated by the findings of this study. It has been well established that contingent labour markets are highly gendered, and men and women experience work differently; even when men and women share similar job tasks and titles, their experiences may vary by virtue of how gender roles and relations are enacted (Cranford and Vosko 2006; Fuller and Vosko 2008; Stanford and Vosko 2004; Vosko, MacDonald, and Campbell 2009). The findings of this study reveal that, despite the workers’ gendered and economically disadvantaged positions, both men and women espoused the dominant ideas of active citizenship that are central to neoliberal governance. Because the study sample included only three members of racialized groups, it is not possible to confidently examine how members of racialized groups compare in terms of negotiating the stigma associated with contingent work. Exploring this in greater detail in future qualitative research would add an important intersectional dimension to the well-established relationship between disadvantaged social positions (e.g., gender, race/ethnicity), work experiences, and health (Coburn 2004; Fuller and Vosko 2008; Raphael 2008). This tendency of neoliberal governance to incite and shape active citizens across social positions finds an illuminating comparison with MacEachen, Polzer, and Clarke’s analysis in chapter 9 of how managers in knowledge-intensive organizations draw on a “flexibility” discourse to reframe worker health in terms of “strategies of resilience.” These strategies aim to buttress the workers’ capacities to sustain intense periods of work that are required by unpredictable and highly competitive markets. Although focused on distinct types of contingent work, these

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studies both point to how workers’ capacities to withstand uncertainty, work intensity, and other undesirable work conditions become privileged targets for neoliberal governance. This governance is illustrated by the managers in chapter 9 who redefine worker health in terms of resilience and by the workers in this chapter who embody competing discourses on contingent work (as advantage, as disadvantage) to reconstruct their experiences in ways that are commensurate with active citizenship, as a way to make themselves resilient in the context of uncertain economic conditions and stigmatized, temporary work. This chapter extends insights into how worker subjectivity is shaped by neoliberal discourse on active citizenship in ways that may perpetuate inequitable contingent employment practices and arrangements that are known to have deleterious effects on health. The study findings reveal how neoliberalism can be both emancipatory and oppressive (Burchell 1995; Dean 1995; Rachleff 2006). On the one hand, it creates the conditions of possibility for disadvantage because it stigmatizes and consequently enervates the self-worth of contingent workers. On the other hand, it is emancipatory because it offers workers possibilities for solutions to disadvantage. Workers’ management of stigmatized work through a discourse of active, moral citizenship is not, however, without consequences. A discursive management strategy suggests a double burden: these workers must not only be productive citizens; their precarious and disadvantaged labour market status notwithstanding, they must also engage in an ongoing discursive (re)production of themselves as active neoliberal citizens. By reconstructing their experiences in concert with neoliberal imperatives for active citizenship, these workers risk reinforcing and reproducing their structurally disadvantaged positions. This discursive management also has implications for occupational health and safety and policy in the context of contingent work. By constructing themselves as active citizens, workers may internalize personal responsibility for the management of their own health within temporary workplaces, thus obscuring the location of occupational health risks in social and organizational structures and deflecting attention from the development and enforcement of policies that could effectively manage these risks. This “personalization of public problems” can reinforce existing occupational health and safety concerns such as

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poor working conditions, disorganized work, and inadequate training, supervision, and protections (Quinlan, Mayhew, and Bohle 2001), and thus contribute to a kind of structural inertia whereby work-related policies or regulatory systems remain inadequate, unchallenged, and unchanged. In other words, concerns about health and safety issues that should be part of what Mills (1959) calls the “public issues of social structure” (8) might instead come to be viewed and/or be undertaken as personal troubles. This individualization of work-related risks means that workers turn in on themselves, and in so doing they not only displace the broader social aspects where responsibilities for work and health lie (Rose 1999), they might also unintentionally exacerbate threats to their health. Put another way, while the appeals these workers made to their individual-level resourcefulness and creativity might protect them from the stigma associated with contingent work, such an emphasis may also deflect attention from and diminish possibilities for structural and organizational change that will promote workplace health and socially just labour market policies for contingent workers.

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Ch a p t e r 1 1

Self-Management and the Government of Disability: Reinforcing Normalcy through the Construction of Able-Disabled Subjectivities Erika Katzman Once my father told me that in ancient China the very rich or powerful families would bind the feet of young girls. As these girls grew up they became unable to walk more than a few hobbled steps. If a woman were truly rich and powerful she would give up walking altogether and she would also grow her finger nails until her hands were heavy and functionless. She would be carried about all day by slaves who bore her chair and her cushions to support her hands. They would feed her and look after her every need. Now what is interesting to me about this story … is that my body works as if I were one of those ancient Chinese ladies. I get around in a fancy motorized wheelchair and a van adapted with a wheelchair lift. I type on a computer with a breath control that reads my puffs and sips as Morse Code and translates the code into letters and computer controls. Otherwise my every physical need from eating to driving the van must be met by a team of attendants. These attendants cover a 24-hour shift and their wages are funded with government dollars. One critical difference between my life and that of an ancient Chinese lady is that she was considered to be of value in her society just because she was there. Her mere presence as a symbol was of more value than any other potential contribution she could make and she was

supported and shaped through great suffering to become that symbol … In my world, people are valued according to their conspicuous function and activity. Few things are viewed more negatively than disability in my society. Judith Snow, “Creating What I Know about Community”

Introduction

In From Behind the Piano, Jack Pearpoint (1990) chronicles one segment of the manifold barriers and challenges his friend and colleague Judith Snow faced as she waged war against bureaucracy, in a fight to be recognized by the province of Ontario “as a citizen, not as a body awaiting rigor mortus in a decorated mortuary” (32). Judith was born in Toronto, Ontario, in 1949, a place and time where segregating disabled individuals from the community and moving them to medicalized institutions represented a generally uncontested norm. Defying all medical advice, Judith’s parents chose not to have her institutionalized. Due to the absence of infrastructure for facilitating alternative arrangements for providing support, Judith’s parents fulfilled her attendant needs, from infancy until she was nearly twenty years old. As a student at York University in the early 1970s, Judith was able to manage her attendant needs with the support of a student grant. However, upon graduating, Judith was again confronted with the lack of infrastructure for organizing and funding attendant supports outside of an institutional environment. To the bureaucratic institutions responsible for dealing with disabled people, Judith was practically incomprehensible. A person with a disability, and a master’s degree, and a professional life, Judith defied all bureaucratic logic. In March of 1980, following eleven years of futile struggle for legislative recognition, Judith was on “the brink of suicidal stress” (Pearpoint 1990, 22). As friends and colleagues coalesced around Judith, the decision was made to go public with her “case history of frustration” (25), in one last-ditch effort to demand legislative change. Ten years later, to the day – ten more years of dedication to a cause, at once private and public – the Government of Ontario, at long last, announced

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that “funding would be made available to individuals to allow them to live their own lives” (95). The inconceivably great lengths Judith and her networks had gone to finally culminated (another four years later, in 1994) in the introduction of a self-managed model of attendant supports in Ontario. I introduce Judith here and integrate her story (as told by Jack Pearpoint) for several reasons. The first is on account of the striking parallels between Judith’s life and the modern history of disability. The second is for the important role Judith has played in Ontario’s local history of disability. The third is that Judith’s life tells a tale of triumph. However, as is a reality for many disabled people, it also tells of constant struggle, beset by an imminent shadow of potential crisis. For this reason, Judith’s story lends itself particularly well to the critique of self-management I present in this chapter. Finally, the perils of living with disability are often not well understood. Illustration of this discussion through one individual’s “case history of frustration” (Pearpoint 1990, 25) helps to bring the analysis to life, underscoring not just the reality of the problem at hand, but also the urgency with which it needs to be pursued. Judith’s story reminds us that valuable human lives are at stake. This chapter begins with a brief introduction to the modern history of disability in North America to contextualize the following analysis of the self-managed model for organizing attendant supports. I then introduce biopower as a conceptual framework to demonstrate the centrality of neoliberal governmentality to both the modern history of disability and the contemporary politics of disability in modern Western societies. My primary contention is that, while self-management facilitates the construction of a new genre of disabled subjectivities, it simultaneously serves to reinforce contemporary networks of normalizing power. I argue that, insofar as they are constructed in terms of neoliberal political rationalities – which are foundational to discourses surrounding self-management – new “able-disabled” (Titchkosky 2003) subjectivities work within, and serve to reinforce, not only traditional conceptions of disability but also accepted norms of neoliberal citizenship. Certainly, the right to self-manage attendant services represents a form of resistance that is a significant and important

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achievement of the disability rights movement. However, insofar as that resistance becomes co-opted as a mechanism of constraint, it is susceptible to critique by contemporary critical disability studies and radical disability activism. A secondary aim of this chapter is thus to exhibit the value of approaching contemporary disability theory from the perspective of governmentality. This work is situated within an emergent body of disability theory that is often called critical disability studies. Margrit Shildrick (2009) describes one central focus of the field as “an investigation of what it is that continues to impede the evolution of equitable conditions of possibility” (2). The aim of this critical approach is not to discredit the initiatives undertaken by previous waves of disability studies and activism – initiatives such as inclusion and disability rights, which developed in light of the social model of disability – but to interrogate their shortcomings and build upon their successes. In congruence with this “postconventional” (Shildrick 2009, 2) approach, I have taken a deliberate choice in this chapter to use the term disabled people rather than people with disabilities. This is consistent with Shildrick, who explains, The current preference within both critical disability studies, and some but no means all activist circles, is for “disabled people” rather than “people with disabilities.” After a recent history in which the latter was promoted as a reaction to older and more evidently stigmatizing terms such as handicapped, retarded, cripples and so on, or to supposedly more positive alternatives such as differently abled, physically challenged or special needs, the use of so-called people-first language form is now seen as a confirmation of the person that fails to encompass the significance of disability … It is as though disability were a contingent add-on rather than a fundamental element of identity. (178) A.J. Withers (2012) expresses similar concern about the separation of disability from personhood implied in people-first language, noting that “the language … implies that disability is something separate and apart from personhood or humanity, unfortunate conditions attached to otherwise normal people” (6–7).

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Withers (2012) identifies as an additional problem with the lexicon “the ease of interchangeability of the word disability with medical diagnoses: people with autism, people with spinal muscular atrophy, people with schizophrenia, people with epilepsy, people with disabilities and so on” (7). Conflation of disability with medical diagnoses reflects the antiquated medical model of disability, a conception of disability as tantamount to a medical condition. A more contemporary conception of disability, represented by the social model of disability, recognizes disability not as a direct effect of an individual’s “impairment,” but rather of a disabling physical and social environment. Withers thus advocates for the reclamation of the term disabled people, emphasizing that “disability exists as a consequence of an active process of marginalization – people are disabled” (7). Withers contends that “while the phrase has a negative connotation … disabled people have largely reclaimed it” (7). This debate concerning language parallels a broader tension that stands between disability activists and the academic field of critical disability studies. To reiterate, the contemporary critical turn in disability academics is not concerned with discrediting or disproving the social model of disability. Yet, because the social model has figured so prominently as a driving force behind contemporary disability politics, such poststructuralist and postmodern approaches have themselves met with much skepticism and critique, in particular for being overly complex, and insufficiently accessible (Corker and Shakespeare 2002). Mairian Corker and Tom Shakespeare agree that critical analyses must remain pertinent and accessible, but simultaneously stress the importance of developing a “theoretical base” to support the “conceptual power” of the social model (13). In their esteem, “people’s lives are far more complex than modernism likes to believe” (14), and “disability studies has little choice but to engage with these ideas” (13). In response to ethical concerns about the purpose and usefulness of critical disability studies, Corker and Shakespeare caution that “theory has to be conceived as a means to an end, rather than an end in itself” (15), and remind us that in the previous wave of disability studies and in the current wave alike, “the goal remains the same: to contribute to the emancipation of disabled people, whoever they are, and whatever they decide that emancipation means, and to the development of inclusive

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societies” (15). In this sense, critical disability studies offers the social model an expanded theoretical toolbox through which to further the disability movement. A Brief Introduction to the Modern History of Disability in North America

What is disability? To this seemingly simple question there really is no singular answer. Disability is a fluid concept, whose definition “depends not only on the context in which it is defined, but also who defines it” (Withers 2012, 3). Governments who provide financial support for disabled individuals, for example, lean towards a narrow biomedical definition of disability. Some activists and academics, by contrast, tend to draw on broader definitions of the concept; from a radical perspective, it is possible to imagine that we are all disabled in some sense of the term (Shildrick 2009; Titchkosky 2003; Withers 2012). For as long as some humans with diverse embodiments and abilities have been labelled “disabled,” normalizing societies have enforced their exclusion. Concurrent with the increase in industrialization of western Europe and North America in the late eighteenth and nineteenth centuries, there was a shift in popular understandings of disabled people who came to be viewed as passive, needy, vulnerable, and dependent. This same period was characterized by the increasing scientific pathologization and classification of various “abnormal” embodiments, as well as the rise of hospital-based medicine and the creation of asylums (Thomas 2007). Indeed, for much of the modern era, segregation and institutionalized ways of living have represented a norm for disabled people. Governments have most often dealt with biologically (physically, psychologically) diverse humans by medicalizing their differences and relegating them to institutions. During the 1960s and 1970s, however, the social climate surrounding disability began to change. Some disabled people living in institutions began to demand recognition of their rights – the right, for example, to live a “normal” life, free from the confines of a medical institution. Alongside and informed by contemporary social movements such as deinstitutionalization, community integration, consumerism,

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and civil rights (Yoshida et al. 2004), as well as women’s rights and feminist movements, a disability rights movement emerged. Traditional understandings of disability began to be taken up and challenged by activists and academics, both in North America and abroad. In North America, this set the groundwork for a burgeoning independent living (IL ) movement. The IL philosophy builds on deinstitutionalization with two added fundamental principles: first, “that people with disabilities know best their needs and … second, that living in the community requires appropriate supports and services to meet those needs” (Yoshida et al. 2004, 180). These principles helped to define the IL platform, and contributed to the demedicalization of disability and to the articulation of disability in relation to individual rights and freedoms. The IL movement aimed to overturn traditional conceptions of disability, typically referred to as medical or rehabilitation models. Such dominant medicalized perspectives conceived of disability as akin to an illness or a disease and consequently sought “to cure” disabled people or to “educate them out of their differences” (Snow 2012). The IL movement, by contrast, taken up by academics and advocates alike, was framed in terms of the neoliberal principles of independence and self-sufficiency. The political strategy was to demonstrate that, given the proper supports, disabled people could participate more fully in consumer capitalist society. Reflective of this strategy, the IL platform adopted a neoliberal lexicon, re-naming disabled individuals consumers and appealing to their rights as citizens. “Illegal or Just Annoying?”: The Origins of Ontario’s Self-Managed Model

Around the same time that the IL movement was forming in the United States, Judith Snow was actively living a parallel struggle in Toronto, Ontario. Upon graduating from York University in 1975, Judith faced yet another unique challenge. She was no longer eligible for the student grant that had previously supported her, and in 1975 there was no attendant services program in Ontario that was equipped to provide support to an individual who had both a disability and a professional

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life. Pearpoint (1990) writes, “She insisted on going to work every day. No one could quite decide if this was illegal or just annoying. The legal question arose because under Ontario law, if you are disabled, you are by definition unemployable. Ergo, if you are employable, you are not disabled. As ever, Judith didn’t fit” (17). Judith’s seemingly contradictory embodiment and ambivalent legal status exemplified not only the human potentiality that is stifled by the practice of institutionalization, but also the impending necessity of a proper legislative response to disabled persons who are both employable and require support services. But bureaucracies move slowly, and Judith’s need for both a place to stay and the physical supports to live were immediate. She was deemed “too needy” for contemporary attendant support alternatives (which, ironically, she had helped to create) (Pearpoint 1990, 16). The bureaucratic response was to offer Judith residence in a geriatric ward at a long-term care facility, “where she could be ‘attended to’ while waiting for death” (Pearpoint 1990, 16). After all, Judith was due to expire any day. “She was told from birth that ‘people like that’ don’t live past 30” (18). Institutionalized, as an adult and for the first time in her life, Judith’s health deteriorated. When her work schedule conflicted with the schedule imposed by the hospital, Judith was forced to choose between eating and going to work. When Judith chose work, she became severely malnourished. It was weeks before anyone realized the ensuing illness was in large part due to a severe reaction to the vitamin supplements she was given to compensate for missed meals. Judith was expected to die before her thirtieth birthday. She almost did; not because of her disability, but because of the way it was (mis)understood and (mis)managed by the bureaucratic institutions in charge of dealing with her. As Judith’s private life plummeted towards rock bottom, her friends and colleagues were oblivious: “None of us really understood the intensity of Judith’s survival workload, because we knew her in the context of her job. She wanted to keep us thinking that way. She loved that. We didn’t see ‘the handicap called Judith who also works,’ but rather a very talented colleague who happens to use a wheelchair and needs someone else’s hands to eat, go to the bathroom, get dressed and

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go to bed” (Pearpoint 1990, 20). Judith’s situation deteriorated to such a point that she decided she would rather die than continue to live in an institution: “We all had to decide if we wanted Judith in the world – and if so, how we were going to make it happen” (21). Judith’s friends and colleagues pooled their collective resources – first to fabricate a makeshift system for attendant supports, then to take a political stand. To make a long (fascinating, infuriating, and awe-inspiring) story short, in the years that followed, Judith became a living prototype for what would eventually come to be known, much to the credit of Judith and her “unique circle of friends” (Pearpoint 1990; Snow 2012), as Self-Managed Attendant Services (SMAS ). In response to demands for a model of service delivery “which had as its foundation the independent living principles of choice, flexibility and control on the part of the consumer” (Yoshida et al. 2004, 189), SMAS offers some physically disabled individuals the opportunity to receive funding (more-or-less) directly from the government, to independently recruit, hire, train, and manage support staff. As a result of the IL movement, programs of this sort now exist across Canada and internationally. The SMAS program in Ontario has received much praise and appears to provide great consumer satisfaction (Roeher Institute 1997; Yoshida et al. 2004). Yoshida et al. (2004) conclude their descriptive evaluation by stating that the “challenge now in Ontario will be for the selfmanaged attendant service user community to transform the concept … into workable service models for the benefits of all people living with disabilities” (202), which implies that the model is just some finetuning away from a universally workable program. However, Yoshida et al.’s focus is on identifying the social and political factors that led to the creation of SMAS , as well as some of the program’s major achievements in its first ten years. Representing only the perspectives of program participants, the existing literature on SMAS is limited in scope, and critical perspectives are lacking. Failure to include the voices of those individuals excluded from participation in the program, whether willingly or not, actively silences the experiences and discourses that may counter the dominant narrative of praise for the program. I feel particularly strongly about the importance of critically appraising the self-managed model for organizing attendant supports,

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in large part because Judith’s story affirms what I observed during my experience working as an attendant to individuals who organize their attendant supports through the self-managed model, which is that the self-managed model, although it represents a better option for many physically disabled individuals, is not without its shortcomings. As I explore in this chapter, the self-managed model devolves responsibility for organizing and managing attendant supports – an endless(ly taxing) occupation – onto disabled persons themselves. The program is discursively framed as a privilege, an opportunity for some disabled individuals to obtain full(er) citizenship by becoming more fully participating workers and consumers; in particular through the realization of increased financial independence, achieved through the absorption of increased personal risk and responsibility. I certainly do not mean to suggest that self-managers or disabled people should not pursue these goals. However, it is important to draw attention to the “invisible work” (Church et al. 2007) – that is, the unpaid and most often unrecognized labour – that goes into the task of selfmanagement. Such critique is necessary to evaluate the purported goals of the SMAS program, including the promise that IL -inspired models contribute to the transformation of disempowering attitudes towards disabled people and to overcoming their social oppression. Shildrick (2009), for example, notes that legislative changes inspired by the IL movement have “undoubtedly promulgated a more inclusive organization of social life” (5). But the transformative success many had optimistically hoped for has yet to be seen. As I will demonstrate in the following analysis, it is outside the scope of IL -inspired models to achieve such transformation. I contend that this is because the legislative alterations and spaces for resistance incited by the IL movement are founded on neoliberal models of citizenship that foster particular ideals of normalcy, and ultimately perpetuate many of the attitudes and oppressions disabled people face. Disability: An Effect of Biopower as a Form of Neoliberal Governmentality

As a preface to the following critique of the self-managed model for organizing attendant supports, I begin by introducing biopower as a

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conceptual frame to demonstrate the centrality of neoliberal governmentality to the contemporary politics of disability in modern Western societies. According to Foucault (1978), political power in the modern era operates differently than in pre-modern times. Power has historically been conceptualized as the domain of the sovereign, who possessed the power to allow life or enforce death. Power in this sense has traditionally been understood as a repressive, constraining force administered in a juridical manner. In the modern age, by contrast, Foucault theorizes the emergence of a different type of power; a power that is multi-local, and which, operating at a distance from the state, is a power “to foster life or disallow it to the point of death” (Foucault 1978, 138). This power over life operates at two poles, both of which are concerned with the optimization of life. The first pole – anatamopolitics – is focused on the discipline of individual bodies, with the second pole – bio-politics – focused on the regulation of the population. Concerned with the optimization of life at both of these levels, biopower is productive rather than repressive; it produces people with certain kinds of subjectivities, and demarcates the parameters of their possible and acceptable conduct (Tremain 2006). Biopower informs the particular form of governmentality exercised by liberal governments, and is characterized by “liberalism’s insistence that political authority had necessary limits, bounded by individual freedom and the self-regulatory properties of social domains such as the market” (Power 2005, 644). Whereas political strategy in the pre-modern era could be enforced through the repressive rule of law, in the modern age a discourse of rights and freedoms displaces traditional, repressive strategies of government. Elaine Power notes that in the modern era, “liberal governments had to learn to govern through the freedom of individual citizens” (644, original emphasis). This characteristic ability of liberal government to govern through the exercise of freedom has been described as a “polymorphous” form of domination (Shildrick 1997). Foucault (1978) explains that “another consequence of this development of biopower was the growing importance assumed by the action of the norm, at the expense of the juridical system of the law”; biopower “effects distributions around the norm” by constructing and hierarchizing bodies based on their (economic) “value and utility”

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(144). Economically productive bodies, assigned greater value, correspond to subjectivities constructed as “normal,” whereas those deemed to be unproductive, or counterproductive, are constructed as “abnormal.” Thus, while biopower is a disciplining and regulating force, it is also normalizing. Neoliberal governmentality, inasmuch as it operates through the exercise of biopower, is dependent upon this deeply entrenched valuation of normalcy. As the crux of contemporary neoliberal governmentality, biopower operates by constructing “subjects whose actions are governed through the exercise of their own capacity to choose in accordance with the norm(al)” (Tremain 2006, 50). Thus, for neoliberal governmentality to operate, it is essential to foster the desire for such normalcy and to educate the population about how to achieve it. Foucault (1978) locates the origins of biopower at roughly the same historical moment as Carol Thomas (2007) observes the emergence of the concept of disability. This, I contend, is not coincidental, but rather suggests that the concept of disability emerged as an effect of biopower. As a normalizing force, biopower fosters and perpetuates many of the attitudes and oppressions that inform the way that disabled people have historically been treated and managed, and that disabled people continue to face. Disabled subjectivities have historically been constructed in terms of vulnerability and interdependence. Construction of disability in this way stands in marked contrast to requirements of neoliberal citizenship, which are most often defined in terms of (economic) independence and self-sufficiency. Inasmuch as it “effects distributions around the norm” (Foucault 1978, 144), biopower also effects the construction of disabled subjectivities as abnormal, unproductive, and thus without value, thereby excluding them from the possibility of achieving full citizenship. This overview of biopower sets out the conceptual framework from which I approach the following analysis of the SMAS program in Ontario. In the analysis that follows, I show how neoliberal governmentality produces disabled bodies and subjectivities through programs such as SMAS , “by guiding, influencing, and limiting their actions in ways that accord with the exercise of their freedom” (Tremain 2006, 46). Discourses of self-management facilitate the construction of an

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able-disabled subjectivity that is constructed in terms of neoliberal citizenship, and that reinforces contemporary networks of normalizing power. Insofar as it supports norms of neoliberal citizenship, the able-disabled subjectivity that is promoted through discourses of self-management at once reproduces traditional conceptions of disability, and contributes to the perpetuation of negative attitudes and oppressions towards disabled people. Self-Management and the Government of Disability

In 1994, the Government of Ontario launched Self-Managed Attendant Services (SMAS ) as a pilot project, offering one hundred physically disabled individuals the opportunity to self-manage their attendant supports (Yoshida et al. 2004). After receiving an overwhelmingly positive review by the Roeher Institute in 1997, it was decided that a full program would be launched in 1998. By 2004, the program had 691 participants, with 300 applications pending (Yoshida et al. 2004). Ten years later, in 2014, the program was full with 750 participants. That same year, the province announced plans to expand the program to support an additional 250 participants by 2016. New applications are accepted on an ongoing basis, but are only considered “when spots open up (due to people departing the program) or when new funding becomes available” (Direct Funding Program 2016). Programs like SMAS have made it possible for some people with certain disabilities to conduct their lives at a far greater distance from the supervision and guidance of medical institutions than has ever before been possible. However, this model of self-management mimics the rehabilitation model of disability; while rehabilitation in the medical sense is concerned with restoring the physical functioning of the disabled body, the self-managed model is concerned with restoring the societal functioning of the disabled subjectivity. In other words, the self-managed model promotes ideal disabled subjects whose desires and capacities for self-management align with the requirements of neoliberal citizenship: full participation in consumer society, financial independence, and self-sufficiency. In this way, through the

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construction and promotion of an able-disabled subjectivity, the SMAS program reinforces the very networks of normalizing power that are responsible for the ongoing oppression of disabled people. SMAS, and other IL-inspired models like it, respond to the desire of disabled people to conduct their lives at a distance from supervision and guidance by the institution of medicine. Disabled people have justified this demand by asserting that their disability is not a medical condition; provided the appropriate supports are made available to them, disabled people are capable of meeting their own needs, governing themselves appropriately, and thus living independently in the community (Stienstra 2012; Yoshida et al. 2004). On one hand, SMAS responds to this demand, insofar as it allows self-managers to inhabit accommodations of their choosing, and receive support from attendants not necessarily associated with the formal health or caring professions. On the other hand, while self-managers are freed from the direct surveillance and control of the medical institution, they are still subject to the “continuum of apparatuses (medical, administrative, and so on) whose functions are for the most part regulatory” (Foucault 1978, 144), because the direct funding self-managers receive is distributed as a form of social assistance (Yoshida et al. 2004). As receivers of social assistance, SMAS program participants are subject to intensive surveillance by the Government of Ontario. The operation of biopower is evident here in the ways that the program aims to “qualify, measure, appraise, and hierarchize” (Foucault 1978, 144) all interested applicants. Pearpoint (1990) describes the tedious and superfluous administrative processes Judith was repeatedly subjected to when the province was deciding (whether) to provide her funds: The waiting process was long. Governments need time to work out procedures. We had no choice but to be patient. During this phase, Judith was measured, weighed, examined, scrutinized, and assessed on every known government form, and by almost every known assessment expert. After the tenth set of enormously complex forms that required staff visits and detailed information of the most intimate, personal and irrelevant nature, we rebelled. We said, “No more.” It was redundant to document

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once again that in fact Judith was disabled and needed assistance to brush her teeth, etc. No. She would not get better. Yes, she would need attendant care services for the rest of her life. (29) This same type of procedure is echoed in the SMAS application process (CILT 2015a, 2015b), which requires the potential self-manager to surrender excessively detailed information about their personal care regimes. The application guidebook stresses that applicants should be prepared to “answer questions of a personal nature” (CILT 2015b, 11), in person, at their interview with the selection panel. Applicants are further required to sign a form authorizing “any provincial, federal, or municipal government ministry, agency or body; any financial institution; any attendant service provider or any health care provider who has knowledge, information, or documentation pertaining to [their] disability” (CILT 2015a, 6) to share information with representatives of the program; thereby waiving the applicant’s right to confidentiality of health information as protected under provincial and federal legislation. The SMAS application process is rigorous and space in the program is limited. It is essential that potential self-managers present themselves to the selection committee in such a way as to demonstrate their capacity to self-manage in accordance with a predetermined set of norms (CILT 2012). Writing about social assistance in Canada, Power (2005) has observed that “those who are not, or not yet, ready for freedom must be governed through older disciplinary methods, with the goal of instilling enough self-discipline and self-responsibility that they will one day be able to properly exercise their freedom and be governed accordingly” (644, original emphasis). The application process thus serves not only to “qualify, measure, appraise, and hierarchize” (Foucault 1978, 144), but also to present interested applicants with a clear picture of the requisite self-discipline and self-responsibility expected of responsible self-managers. The program literature explicitly lists prerequisites for eligibility. Details of the program’s features also provide a tacit set of requirements for eligibility. For example, the program provides a maximum average of seven hours of support per day, and is thus only suitable for individuals who are not overly “needy,” or those

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who have either adequate support networks or supplemental income to purchase additional support. For individuals who do not currently qualify for the program, the program literature indicates the level of self-discipline and self-responsibility they would need to achieve in order access the “freedom” promised by the program. The Able-Disabled and Neoliberal Citizenship

By setting certain standards of self-discipline and self-regulation, the SMAS literature conveys the message that it is possible for disabled people to access rights and freedoms. However, it is abundantly clear that access to these rights and freedoms is conditioned. The above example suggests that disabled people worthy of government support possess a certain requisite social status or social situation, which may be expressed in terms of economic stability, family supports, social networks, employability, and so on. Regardless of the means through which they achieve it, it is essential that disabled self-managers demonstrate their capacity for (economic) independence and self-sufficiency. Access to the “freedom” the program promises is thus conditional upon adherence to the norms of neoliberal citizenship: increased “choice, flexibility and control” is made available, but only to those willing and able to take on increased personal “risk and responsibility” (CILT 2012, 10, emphasis added). Self-managers are required to accept full responsibility for all administrative and human resources tasks associated with organizing their own attendant supports. Examples of these tasks include registering as a business with Canada Revenue Agency; managing accounts and keeping records; filing accountability reports; recruiting, hiring, training, managing, and scheduling a support team. The program thus promotes “neo-liberalism’s promise of government through market freedom” (Power 2005, 655); however, it does so in such a way as to devalue and/or delegitimize potential alternative forms of occupation and support provision. It is worthwhile to note that self-managers are in no way compensated for the administrative and human resources responsibilities they absorb as self-managers, work that would elsewhere merit financial compensation. As the above examples have shown, SMAS promotes disabled individuals’ use of self-management as a means to citizenship, as defined, for

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the most part, in terms of economic participation, independence, and self-sufficiency. In this way, the program reproduces a specific standard of normalcy, expressed in terms of citizenship, that promotes adherence to certain idealized norms of embodiment. The able-disabled, also called “super-crips” (Shildrick 2009; Titchkosky 2003; Withers 2012), are an increasingly common image of disablement, representing those disabled people who have successfully distanced themselves from traditionally constructed disabled subjectivities. The abledisabled achieve such ends by adhering to able-bodied norms, such as maintaining economic independence through paid employment. Images of the able-disabled convey a message that disability is an individual problem, a personal tragedy that, if one works hard enough, can be overcome. This construction is problematic for several reasons. First, it reinforces a traditional construction of disability as the problem of the disabled person, one they can and should overcome. Second, it obscures the countless hours of invisible work, not to mention the personal (including financial) resources that go into crafting such an image. Finally, the image of the able-disabled serves not only to mark what is the “proper” way for disabled people to conduct themselves in the face of disability; it extends much further, to the population at large: Statistics and stories of “citizens with disabilities” can best be understood as the new morality tale told to all Canadians: If people with disabilities can, then anyone can, govern their conduct so as to actualize their participation in the normative order, all of us can crystalize our identities as the “able-disabled.” After all, today, almost any difference from the demands of normative social order can be reified as a disability (or illness), and still we all can seek to overcome the challenge of difference and become able to function within society, such as it is. (Titchkosky 2003, 538) What Tanya Titchkosky outlines here is the way in which promoting the able-disabled as a newly possible (and preferable) disabled subjectivity reinforces norms of neoliberal citizenship, assimilates the able-disabled into these norms, and reminds able-bodied citizens

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that they, too, can and should conduct themselves in accordance with these norms. Discussion

The SMAS program is founded on the assertion that disability is not inherently medical in nature; that disability does not require constant medical attention; and that it is within both the rights and the capabilities of many disabled people to be primary, if not sole, decision makers regarding the organization and management of their own attendant services. A key element of the argument for SMAS is that disabled people should be free to choose who will provide their attendant supports; since the attendant support needs of physically disabled people are not necessarily medical in nature, attendant supports need not necessarily be provided by trained professionals. The appeal to selfmanaged care is informed by, and maps easily onto, a neoliberal framework that values individual responsibility to take control over one’s own life, and the personal exercise of one’s freedom to choose. However, framing the program as an opportunity to access neoliberal citizenship, via (economic) independence and self-responsibility, shrouds the underpinning claims that purport to demedicalize attendant services specifically, and disability in general. The dynamic is similar to that observed by Polzer (chapter 5), wherein the feminist language of “choice” is mobilized to market pharmaceutical and biotechnology products oriented to promoting “women’s health.” In both cases, language that was initially and intentionally employed as a means of resistance to medicalization is co-opted and deployed in a political strategy that capitalizes on individuals’ desires for autonomy. Like women “empowered” to make “informed decisions” in the context of genetic testing, disabled people are “empowered” to exercise their freedom to choose in accordance with a predetermined set of options and norms, in ways that may ultimately subject them to a more intense network of medicalizing gazes. In the case of SMAS , this co-optation of resistance may thus have a counterintuitive effect. A second element of SMAS that is obscured when the privileges associated with SMAS are emphasized is the aforementioned “invisible

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work” of self-managing attendant services. It was previously suggested that this work includes the countless hours of labour that organizing and managing attendant services entails, but disabled self-managers do not shoulder this workload alone. Although attendants are not the focus of this particular analysis, the self-managed model for organizing attendant supports fundamentally revolves around a dyad, a relationship between members from not one but two marginalized populations: disabled employers who are charged with the responsibility and freedom of organizing their own attendant services, and attendants who are often women, and, more specifically, women of colour and/ or immigrant women (Church, Diamond, and Voronka 2004; Cranford 2005). Lacking any protection in the form of organized labour, the precarious nature of informal attendant work endangers the protection of attendants in their workplace (Church, Diamond, and Voronka 2004; Cranford 2005). As a particular form of precarious work in neoliberal societies (see also chapters 9 and 10), the health-related aspects of informal attendant work is an area of research that is deserving of further critical inquiry. Of particular interest is the apparent conflict that is constructed by programs such as SMAS between the rights of (often female or otherwise marginalized) attendants and those of individuals living with disabilities. Insofar as programs such as SMAS are dependent on these forms of labour, critical analysis is necessary to explore how they affect, and perhaps further entrench, socioeconomic and other intersecting inequalities (gender, race) that are central to practices of neoliberal governance. An example of such inequality, also related to the work of managing SMAS, is the social stratification that the program effects. The work involved in organizing and managing attendant services, so subtly downplayed in the program literature, ultimately acts as the crux of eligibility for the program. Those disabled people who demonstrate the desire and ability to act in accordance with a certain set of neoliberal norms, and to take on the associated workload, gain access to that newly possible able-disabled subjectivity. Those deemed incapable or unwilling to take on this work are constructed as undeserving Others (Power 2005; also see Orchard, chapter 8). Similar to Polzer’s observation in chapter 5 regarding participation in genetic testing as a form of

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biological citizenship, one effect of this stratification is to emphasize the role of personal rather than social factors that impact an individual’s capacity to act in accordance with that socially sanctioned set of neoliberal norms. A second effect is that those disabled people who are, even temporarily, denied access to the “freedom” to self-manage stand to remind other citizens of the potential consequences should they fail to abide by neoliberal societal norms (e.g., subjection to a more repressive form of government). As Power (2005) notes, liberalism “depends on the ‘unfreedom’ of some to ensure that the rest will consent to be governed in and through freedom” (Power 2005, 644). Albeit in a slightly different way than the able-disabled encourage adherence to neoliberal norms, so too do traditionally disabled subjectivities. In these ways, the normalizing power exercised through neoliberal forms of government maintains, and actively works against the possibility of overcoming, the negative attitudes and oppressions that continue to shape the lived experiences of people with all kinds of disabilities. My primary aim in this chapter has been to demonstrate how the neoliberal construction of disabled subjectivities contributes to the government, not just of disabled people, but of all citizens. As I have illustrated, the discourse of self-management promoted by SMAS appeals strongly to disabled persons’ desires for independence and selfsufficiency, and reinforces norms associated with able-bodiedness and neoliberal citizenship more generally. Thus, while self-management facilitates the construction of a new genre of disabled subjectivities, it simultaneously serves to reinforce contemporary networks of normalizing power. Consequently, while self-management contributes to the very important project of creating new possibilities for the lives of disabled people, it is an incomplete means, and by no means an end to the reconceptualization of disability as a means of gaining broader social acceptance for, and thereby improving the lives of, all people who are labelled “disabled.” SMAS and other programs like it represent a significant and important achievement of the disability rights and independent living movements. However, inasmuch as they promote adherence to norms of neoliberal citizenship, their conceptual underpinnings are at odds with the contemporary critical turn in disability studies and radical turn in disability activism. Disability academics and activists alike are

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beginning to pay more attention to the hidden operations of power that impact the lives of disabled people; both are similarly concerned to problematize neoliberal modes of governance and their tendency to perpetuate the marginalization of disabled people, despite their claim of increased inclusion in consumer capitalist society (Graham and Slee 2008; Titchkosky 2003; Withers 2012). Given these aims of contemporary disability theory and activism, there is great value in approaching contemporary disability studies from the perspective of governmentality. This chapter contributes to a growing body of Foucauldian analyses of power in the field of disability studies (Corker and Shakespeare 2002; Shildrick 2009; Titchkosky 2003; Tremain 2005, 2006). However, Foucauldian approaches to disability studies are relatively new, and their full potential remains, as yet, unexplored (Thomas 2007). I do not intend to imply that Foucauldian analyses represent the only way forward for critical disability studies; rather, they represent an important resource, especially given the current critical turn in disability academics and radical turn in disability activism. Inasmuch as they are concerned to redefine disability by deconstructing traditional conceptions of normalcy, a Foucauldian lens represents an invaluable resource for critique and social change. Judith and others who have allowed their stories to become a platform for such change have enabled incredible strides in the direction of changing attitudes towards, and ending the oppression of, disabled people. Had Judith accepted her prescribed role as a passive and needy disabled person, destined for a brief life of institutionalization, she may well have died as “the handicap called Judith” (Pearpoint 1990, 20) on that geriatric ward (or another one like it) before reaching the age of thirty. She certainly would never have had the opportunity to explore the possibility of becoming a student, an artist, an activist. Given the opportunity, Judith demonstrated many possible facets of life for a disabled person, living outside of the oppressive walls of a medical institution. However, in celebrating the many triumphs Judith achieved in her lifetime, it is important not to overlook the abundance of unnecessary hardship she faced, which she, like many (most? all?) disabled people continue to confront. For, while government funds provided for Judith’s attendant needs, it is still the case that “few things are viewed more negatively than disability in [our] society” (Snow 2012).

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Acknowledgments

This research is supported by a doctoral fellowship from the Social Sciences and Humanities Research Council of Canada.  References

Centre for Independent Living in Toronto (CILT ). 2012. Direct Funding General Information. Toronto: CILT . http://www.dfontario.ca/application/ application-and-guide.html. – 2015a. Direct Funding Application Form. Toronto: CILT . http://www.df ontario.ca/info/general-information.html – 2015b. Direct Funding Application Guide. 6th ed. Toronto: CILT . http://www.dfontario.ca/application/application-and-guide.html. Church, Kathryn, Timothy Diamond, and Jiji Voronka. 2004. In Profile: Personal Support Workers in Canada. RBC Institute for Disability Studies Research and Education, Ryerson University Church, Kathryn, Catherine Frazee, Melanie Panitch, Teresa Luciana, and Victoria Bowman. 2007. Doing Disability at the Bank: Discovering the Work of Learning/Teaching Done by Disabled Bank Employees. Toronto: Ryerson RBC Foundation Institute for Disability Studies Research and Education. http://www.rbc.com/diversity/pdf/Ryerson_Report_Oct-07.pdf. Corker, Mairian, and Tom Shakespeare. 2002. Disability/Postmodernity. New York: Continuum. Cranford, Cynthia J. 2005. “From Precarious Workers to Unionized Employees and Back Again?: The Challenges of Organizing Personal-Care Workers in Ontario.” In Self-employed Workers Organize: Law, Unions and Policy, edited by Cynthia J. Cranford, Judy Fudge, Eric Tucker, and Leah F. Vosko, 96–135. Montreal and Kingston: McGill-Queen’s University Press. Direct Funding Program (Ontario). 2016. “Waiting List.” Accessed 16 January. http://www.dfontario.ca/application/waiting-list.html. Foucault, Michel. 1978. The History of Sexuality. Volume 1: An Introduction. New York: Random House. Graham, Linda J., and Roger Slee. 2008. “An Illusory Interiority: Interrogating the Discourse/s of Inclusion.” Educational Philosophy and Theory 40:277–93. Pearpoint, Jack. 1990. From Behind the Piano: The Building of Judith Snow’s Unique Circle of Friends. Toronto: Inclusion Press. Power, Elaine M. 2005. “The Unfreedom of Being Other: Canadian Lone Mothers’ Experiences of Poverty and ‘Life on the Cheque.’” Sociology 39: 643–60.

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The Roeher Institute. 1997. Self-Managed Attendant Services in Ontario: Direct Funding Pilot Project Final Evaluation Report. North York, ON : The Roeher Institute. Shildrick, Margrit. 1997. Leaky Bodies and Boundaries: Feminism, Postmodernism and (Bio)Ethics. New York: Routledge. – 2009. Dangerous Discourses of Disability, Subjectivity and Sexuality. New York: Palgrave Macmillan. Snow, Judith. 2012. “Creating What I Know about Community.” Inclusion Network. http://www.inclusion.com/artcreatingwhatiknow.html. Stienstra, Deborah. 2012. About Canada: Disability Rights. Halifax: Fernwood Publishing. Thomas, Carol. 2007. Sociologies of Disability and Illness: Contested Ideas in Disability Studies and Medical Sociology. New York: Palgrave Macmillan. Titchkosky, Tanya. 2003. “Governing Embodiment: Technologies of Constituting Citizens with Disabilities.” Canadian Journal of Sociology 28:517–42. Tremain, Shelley. 2005. Foucault and the Government of Disability. Ann Arbor: University of Michigan Press. – 2006. “Reproductive Freedom, Self-Regulation, and the Government of Impairment In Utero.” Hypatia 21:35–53. Withers, A.J. 2012. Disability Politics and Theory. Halifax: Fernwood Publishing. Yoshida, Karen, Vic Willi, Ian Parker, and David Locker. 2004. “The Emergence of Self-Managed Attendant Services in Ontario: Direct Funding Pilot Project – An Independent Living Model for Canadians Requiring Attendant Services.” In Chronic Care, Health Care Systems and Services Integration, edited by J. Jacobs Kronenfeld, 177–204. Bingley, UK : Emerald Group Publishing.

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Con tr ibu tor s

MA, is a PhD candidate in the Department of Women’s Studies and Feminist Research at the University of Western Ontario. Her research examines the intersections of postfeminism and health in online sexual health information directed at young women and girls. 

Laura Cayen,

Judy Clarke,

MA, worked as a research associate at the Institute for

Work and Health in Toronto subsequent to her graduate studies in anthropology. A major focus of her research was workers’ return to the workplace after a work-related injury. Marcia Facey, PhD, researches work and health using qualitative research methodology and critical social theories. She holds an appointment at the Leslie Dan Faculty of Pharmacy at the University of Toronto and is author of Contingent Employment, Workforce Health and Citizenship (Cambria Press, 2011). Rebecca Hasdell, MPH , is a PhD candidate at the Dalla Lana School of Public Health, University of Toronto. Her research explores public health responses to environmental health issues with a specific focus on food policy.   Erika Katzman, MS cOT , is a PhD candidate in the Health and Rehabili-

tation Sciences Graduate Program at the University of Western Ontario. Her research aims to improve the delivery of health services by

examining differences between constructions of disability in health policy and lived experiences of disability.   Susan Knabe, PhD, is an associate professor in the Department of

Women’s Studies and Feminist Research and associate dean (Undergraduate Programs) in the Faculty of Information and Media Studies at the University of Western Ontario. Her research interests include feminist and queer theory, HIV /AIDS and cultural production, young women’s sexual and social dissidence, and sexuality and the media. Debbie Laliberte-Rudman, PhD, is an associate professor at the University of Western Ontario in the School of Occupational Therapy and the Graduate Program in Health and Rehabilitation Sciences. Her research examines the political reconfiguration of later life, work, and retirement in contemporary society, with a focus on how possibilities and boundaries for identity and occupation are shaped by neoliberalism. Ellen MacEachen, PhD, is an associate professor with the School of Public Health and Health Systems at the University of Waterloo. She is co-director of the Centre for Research on Work Disability Policy. Her research focuses on social and organizational determinants of work and health systems and how qualitative methods can inform health systems policy and practice. Treena Orchard, PhD, is an associate professor in the School of Health

Studies at the University of Western Ontario. A medical anthropologist, Treena’s research focuses on sexuality, gender, and the politics of health using community-based methods with marginalized populations, including women in the sex trade, Aboriginal peoples, and people living with HIV /AIDS . Her recent projects include an arts-based study that examines how women and men living with HIV approach taking their medications and a community-based research project with women in the sex trade in Southern Ontario. Jessica Polzer, PhD, is an associate professor at the University of

Western Ontario with appointments in the Department of Women’s

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Studies and Feminist Research and the School of Health Studies. Her research focuses on the biopolitics of women’s health in the twentyfirst century, with a specific focus on the ways in which risk discourse and biotechnology converge in neoliberal forms of governance and the implications of this for gendered constructions and embodied experiences of health. Her studies to date include critical analyses of public and personal accounts of human papillomavirus (HPV ) vaccination and BRCA 1/2 mutation testing. Elaine Power, PhD, is an associate professor at Queen’s University

in the School of Kinesiology and Health Studies, cross-appointed in Gender Studies, and associated with the Cultural Studies program. She researches food, health, the body, and class using qualitative methods and critical social theory, and is co-author of Acquired Tastes: Why Families Eat the Way They Do (UBC Press, 2014). Sarah Sanford, PhD, is a social scientist who completed her graduate training at the Dalla Lana School of Public Health, University of Toronto. Her research focuses on the global biopolitical regulation of health problems, such as infectious disease and pandemic. Her interests include examining the ways in which discourses related to preparedness enable particular forms of pre-emptive intervention to manage the emergence of novel threats to health. Sara Tedford, PhD, is an independent writer, content developer, and

filmmaker with a background in community-based capacity building. She is a sociologist who has worked for the past fifteen years on local governance and sustainability. Her short films have screened throughout Canada and she works with organizations developing story- and video-based educational and promotional tools.

C O N T R I B U TO R S  

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i ndex

abductive reasoning, 286 able-disabled citizens, 25, 309, 319–20, 323–4, 325, 326. See also disability Aboriginal peoples: and authoritarianism, 16–17; colonialism and governance, 199; community-based agencies, 228, 230–1; and dependency, 207, 216, 218, 219; health care and governmentality, 210–11; HPV vaccination, 102; self-determination vs self-government, 198–200; social inequities, 102; tuberculosis, 190n1; and unfreedom, 16–17, 199. See also Inuit; Inuit Nunavummiut abstinence, sexual, 98 activation technologies: aging workers, 124; welfare state citizens, 114 active citizenship. See citizenship; entrepreneurial citizenship activist movements, 28–9, 310. See also resistance addictions: community-based agencies, 228. See also community-based agencies and gifts, case study ageism, 27, 111, 123–4, 126–7 agencies, community-based. See community-based agencies

aging: about, 20, 29–30, 109–10; cancer care, 135–6; contingent employment, 122–3, 126–7, 269–70, 272; critical gerontology, 26, 111; dependency, 109–11, 114, 124; as economic risk to societies, 20, 109, 115–17; health care, 109, 111, 124–5; individualization, 110, 125; positive aging discourse, 20, 110–11, 125–7; problematization of, 109–10; productive aging, 20, 29–30, 108, 111–16, 119–20, 122–7, 270; responsibilization, 110, 124–5; as risk category, 124–7; social inequities, 122, 125–7; statistics on, 109, 116, 121, 122. See also pensions; retirement agriculture. See food production amalgamation of organizations. See community-based agencies Amar, A.D., 250 animal–human boundary transgression and infectious disease: and mutual vulnerability, 179–82; and responsibilization of nation-states, 184; and traditional farming, 22, 179–80, 188; viral transgressions, 22, 177, 179–80. See also pandemic influenza and policy planning

antivirals and pandemics, 178, 183, 189. See also pandemic influenza and policy planning anxieties, social: and aging, 117–18; and child obesity, 44, 45, 47–8, 50–2, 58–9; and food consumption, 44, 50–1, 56–60; and pandemics, 187; sexual health and parental anxieties, 94–6, 98–9, 103 Asia: avian influenza, 167, 177, 180, 183, 189; risky locales for pandemics, 21–2, 171, 179–81, 185, 188 askesis (ethical work), 138, 145 Asquith, Nicole, 109, 125 asymptomatically ill, 137, 139–40. See also predictive genetic testing (PGT ) attendants to disabled people, 25, 324–5. See also self-managed attendant supports (SMAS ) authoritarianism: and unfreedom, 16–17 authoritarianism and marginalized populations, 16–17 autonomy: and contingent employment, 24; and medicalized agency, 154; neoliberal governance through freedom, 11–12, 15; and self-governance, 15. See also freedom avian influenza, 167, 177, 180, 183, 189. See also influenza Bashford, Alison, 181 Bathurst Mandate Pinasuaqtavut (Nunavut), 196, 214, 218 Batt, Sharon, 84 Bauman, Zygmunt, 52–3, 266 benevolence and gifts. See gifts and gift-giving Bingham, Nick, 183 biological citizenship, 133–4, 140–2, 152, 157–8 biomedicalization: of cancer risk, 134, 153–4; and healthism, 8; stratified biomedicalization, 154

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biopolitics and biopower: about, 10–11, 169, 172–5, 317–18; discipline of the individual, 10–11, 83–4, 172, 317; Foucault on, 172–3; genetic risk as biopolitical hinge, 139; and HPV vaccination, 83–4; infectious disease, 172–5, 184–5, 190; lives deemed valuable or not, 10–11, 174, 318; normalizing force, 317–18; parent-child axis and biopower, 88, 101, 172; as productive, 10, 32n2, 317–18; regulation of populations, 10–11, 169, 172–3, 190, 317; risk governance, 10–11, 172–3, 184–5; social inequities, 189; and state racism, 174, 188; surveillance systems, 10, 173; and tween sexuality, 83–4, 86–8, 100 Boddington, Paula, 141 body: ageism, 111, 123–4, 126–7; as cultural metaphor, 44, 45; fitness, 50–1, 53–8; genetic risk and surveillance of, 20–1; and genomic science, 132–3; governmentality studies, 44; as malleable, 20, 84; need for risk management, 19; obesity vs overweight, 49, 54–5; sexually naive bodies and “hystericization,” 99; social anxieties and consumerism, 51. See also children and obesity; obesity; sexual health body of the female: beauty and femininity, 47; breast cancer risk, 137, 146–7, 153–4; representations of, 132–3. See also breast cancer and predictive genetic testing; HPV (human papillomavirus) vaccination; sexuality of female tweens body mass index (BMI ), 61n1 borders of nation-states and infectious disease: desirable and undesirable circulation, 187–8; liminal states of populations, 185, 187; mutual vulnerability, 179–82, 190; and securitization, 175–7, 180–1; and trade, 181, 187–9; WHO ’s International Health

Regulations, 170, 180, 182. See also securitization and infectious disease boundary transgression (animal– human) and disease. See animal– human boundary transgression and infectious disease boundaries of work-home life. See work-life balance Bourdieu, Pierre, 234, 244 BRCA1/2 genetic mutations, 21, 133, 134, 143 breast cancer: screening for, 133, 144, 161nn1–2; witnessing disease, 145, 153, 155, 156, 160 breast cancer and predictive genetic testing: about, 20–1, 132–4, 158–60; access to health system, 147–51; biological citizenship, 15, 144, 152–3, 157–8; biological risk discourses, 155–6; BRCA 1/2 mutations, 21, 133, 134, 143; duty of self-care, 133–4, 144–7; future as options, 147–52; insurable services in Ontario, 134–5, 136, 161nn1–2; lifestyle modifications, 144–46; and postfeminism, 33n7; “proactive manager” of genetic risk, 133–4, 144–52, 156–7; prophylactic mastectomy, 148, 151, 159–60; resistance and ambivalence, 15–16, 146–7, 153, 159; risk management options (Tamoxifen, mastectomy, MRIs), 144, 147–54, 156; surveillance, 20–1, 136–7, 145–6, 153, 156–7. See also predictive genetic testing (PGT ) breast cancer and predictive genetic testing, case study: about, 133–4, 158–60; discussion, 152–60; governmentality theory, 133; interviews and participants, 143, 153; themes, 143–52 businesses: pandemic readiness planning, 178–9; retirement as risk to, 117, 118, 124. See also consumerism; market economy; privatization

Cairns, Kate, 74 Canada Pension Plan, 20, 118–19 Canadian Pandemic Influenza Plan for the Health Sector (CPIP ), 178 Canadian Partnership for Children’s Health and Environment (CPCHE ), 73–4 Canadian Society of the Sociology of Health, 4 Canadian Strategy for Cancer Control (CSCC ), 135–6 Canadian Women’s Health Network, 29, 34n9 cancer: aging populations, 135–6; biomedicalization of risk, 153–4; colon cancer, 133; “crisis” in services, 134–6, 156; HPV and oral and anal cancer risks, 19; Inuit experiences, 204, 207; media representations, 135; ovarian cancer, 133, 134, 147; privatization of care, 135, 156. See also breast cancer; cervical cancer; HPV (human papillomavirus) vaccination; predictive genetic testing (PGT ) capitalism. See consumerism; market economy Cardona, B., 124 care of the self, Foucauldian, 138–9, 145. See also self-care Carpenter, Lori, 89 case studies: critical interdisciplinary health studies, 25–32; overview by chapter, 18–25. See also breast cancer and predictive genetic testing, case study; community-based agencies and gifts, case study; contingent employment, case study; flexible employment, case study; HPV (human papillomavirus) vaccination, case study; Inuit Nunavummiut, case study; retirement, case study Casey, Catherine, 271 Casper, Monica, 89

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Cayen, Laura, 18–19, 82–107 CC (Community Care) initiative. See community-based agencies and gifts CDA. See critical discourse analysis (CDA ) Centers for Disease Control and Prevention (CDC ), 171, 189 Centre for Independent Living in Toronto (CILT ), 321–2 cervical cancer: and genital warts, 82, 90, 95; and HPV , 89–90, 93–7, 99, 185; Pap smears, 93–4, 96; and postfeminism, 33n7; vulnerable women, 102. See also cancer; HPV (human papillomavirus) vaccination Charles, Nicole, 157 Chatelaine, 90, 93 Cheek, Julianne, 114 chemical bioaccumulation, 71. See also environmental citizenship children: advertising to children, 47, 60, 62n4; and authoritarianism, 16–17; child as “at risk,” 19, 45, 59, 60–1; child as symbolic of social order, 58–9; child poverty, 44; constructions of, 52, 58–60; as consumer-citizens, 47, 60, 62n4; and environmental hazards, 73–4; Foucault on sexuality of, 87; sexual development, 92–4; and social anxieties, 52, 58–9 children and obesity: about, 44–6, 60–1; body as “at risk,” 19, 45; consumerism, 45, 52–8; duty to choose, 52–5; failed citizenship, 59–60; House of Commons report on, 44, 45, 46–50; maternal responsibilization, 18, 45, 49, 52, 58–61; media representations, 48; and moral duty, 47, 58; obesity epidemic, 44–50; overweight vs obesity, 49; and regulation of desire, 50–2, 57–60; science of, 47–8; social anxieties and the

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body, 44, 45, 47–8, 50–2; surveillance of, 60–1 China: avian influenza, 167, 177, 180, 183, 189; off-shoring of labour to, 250; risky locales for pandemics, 21–2, 171, 179–81, 185, 188 choice: about, 14–17; and consumerism, 53–4, 57–8; co-optation of discourses, 15–16, 29, 142–3; and desire for normalcy, 318; duty to consume vs duty to be healthy, 57–8; and environmental citizenship, 69; foodscapes, 55–7; and genetic information, 103, 141–2; governance through freedom, 11–12, 14, 30; and HPV vaccination, 103; and marginalization, 16–17; maternal responsibilization, 45–6; predictive genetic testing and options, 147–52. See also consumerism; freedom; responsibilization of the individual CILT (Centre for Independent Living in Toronto), 321–2 circulation, desirable and undesirable, 187–8 citizenship: about, 13–14, 18; biological citizenship, 133–4, 140–2, 152, 157–8; deservingness, 199; duties of, 13, 19–20; informed decisions, 4; labour market participation, 280–1, 284–5. See also choice; consumerism; entrepreneurial citizenship; environmental citizenship; freedom; morality and ethics Clarke, Juanne, 89 Clarke, Judy, 23–4, 247–79, 300 clerical workers, 24, 285–97. See also contingent employment, case study; temporary work agencies climate change, 66–7. See also environmental citizenship Clyde River, Nunavut, 208–9 colon cancer and PGT , 133

colonialism and Inuit, 200, 202–4, 207–10, 211–13, 217. See also Inuit Common Sense Revolution, Ontario, 226–7, 228 communication: maternal responsibilization, 96–7, 101, 103–4; parent-child axis, 88, 101; risks of HPV, 96–7, 101, 103; youth resistance to, 95, 97–8 community-based agencies: grassroots practices, 226, 229, 238, 244; Harris government’s policies, 226–8; pandemic readiness planning, 178 community-based agencies and gifts: about, 22–3, 225–9; amalgamation tensions, 23, 233, 235–8, 235–41, 243–4; autonomy, 237, 243–4; CC (Community Care) initiative, 228, 232; employees, 237–8, 239, 244; financial gift with conditions, 228, 233, 235, 241–3; funding, 229–30, 231, 232, 239, 245–6; gift exchange theories, 234–5, 242–3; historical context, 225–9, 230; homelessness, 229, 230, 233, 240; marginalized women, 226, 229–32, 240; neoliberal governance, 234–5, 241–6; new building, 233, 236; power relations, 235–6, 241–4; regulation, 235–7; resistance, 23, 236–7, 242, 244; sex trade workers, 226, 230, 232; social support and outreach, 229–32, 239; SSMH (Supporting Social and Mental Health) agency, 228, 231–2, 233, 236–8; staff and volunteers, 231, 232, 235–7, 242, 245; surveillance and control, 233, 235–7, 241–2; unfreedom, 236, 241–2, 244; WW (Women Welcome) agency, 229–32, 236–8, 243–5 community-based agencies and gifts, case study: about, 232–4; amalgamation tensions, 235–41; discussion, 241–6; gift exchange theories, 234–5,

242–3, 245; interviews and participants, 233; methodology, 232–4 Community Care (CC ) initiative. See community-based agencies and gifts community health representatives in Nunavut, 209–10 computer software industry. See knowledge workers condoms, 93–4 Connell, Erin, 84, 101 Conrad, Peter, 267 consumerism: about, 18; and body weight, 50–1, 53–5, 57–8; children as, 47, 60, 62n4; citizens as consumers, not producers, 52–4, 61n2; and citizenship, 18, 62n3; conspicuous consumption, 54; duty to consume vs duty to be healthy, 57–8; and environmental citizenship, 67, 69, 71, 76; foodscapes, 55–7; “good mothers,” 51; green consumerism, 68–72, 75–8; health care patients as consumers, 4; and healthism, 54–5, 57–8; HPV vaccination, 103; and patriotism, 62n3; responsible choices, 57; and social anxieties, 51; as tweens’ rite of passage, 19, 87–8, 102; “want less but spend more,” 56. See also market economy contingent employment: about, 23–4, 280–2, 287; advantages and disadvantages, 24, 287–91, 291–8; aging workers, 122–3, 126–7, 269–70, 272; attendants to disabled people, 325; citizenship, 274–5, 298–301; deprivation and degradation, 289–91; employment and social worth, 280–1, 293, 294–5; empowerment, 291–3; and freedom, 123, 291–3, 297–9; gendered labour, 285–6, 300; and globalization, 282; marginalization, 290, 292, 296–8; meaningfulness, 291–3, 299; moral worthiness, 285, 293–5,

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298; neoliberal governance, 300–1; powerlessness, 287–91; rationality of workers, 24, 295–7; research scholarship on, 283–4; resistance, 271, 299–300; responsibilization for health, 301; risk takers, 297–9; as social problem vs free-market innovation, 283; stigma, 24, 281–5, 292–5, 297–9; uncertainty, 24, 248, 290–1, 297, 300; workspaces, 247. See also flexible employment; precarious employment; temporary work agencies contingent employment, case study: data analysis, 286–7; discussion, 298–302; findings, 286–98; interviews and participants, 24–5, 285–6, 294, 300; methodology, 285–7; research needed, 300 Cook, Daniel, 88 Cooper, Marianne, 269, 271 co-optation of resistance, 15–16, 28–9, 103, 187, 310, 324 Corker, Mairian, 311 corporations. See businesses; market economy CPCHE (Canadian Partnership for Children’s Health and Environment), 73–4 CPIP (Canadian Pandemic Influenza Plan for the Health Sector), 178 Crawford, Robert, 8, 44, 52, 54, 56, 84, 85, 139, 149, 199 Crighton, Eric, 74 crisis in cancer care, 135–6, 156 critical disability studies, 25–6, 310–12. See also disability critical discourse analysis (CDA ): study on flexible workers, 249, 253–4, 255–6; study on HPV vaccination, 90–1; study on retirement, 108, 112–15, 124 critical interdisciplinary health studies: about, 25–6; critical social theory and other fields, 25–7; everyday

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practices, 27–8, 30–1; Foucauldian perspectives, 4–5; goals of, 31–2; governmentality studies, 26–31; institutional support for, 31–2; interdisciplinary studies, 25–32; intersectional approaches, 17, 27, 34n10; scholarship on, 26 CSCC (Canadian Strategy for Cancer Control), 135–6 cultural studies, 26 Dalla Lana School of Public Health, 31 Davies, Sara, 175 day labourers, 24, 285–96. See also contingent employment, case study; temporary work agencies deinstitutionalization of disabled people, 15, 312–13. See also disability demedicalization, 313 dependency: and Aboriginal peoples, 207, 216, 218, 219; and aging, 109–11, 114, 124; and citizenship, 14; and disability, 25 desire: body size and regulation of desire, 51, 57–60; foodscapes, 55–7; maternal regulation of childhood desire, 60; want less but spend more, 56 Dhamoon, Rita, 34n10 diarrheal disease, 171 direct funding of disability supports. See self-managed attendant supports (SMAS ) dirty work and day labourers, 286, 290–1, 292, 294, 299. See also contingent employment, case study disability: about, 309–13; able-disabled subjectivity, 25, 309, 319–20, 323–4, 325, 326; autonomy, 311–13; citizenship, 309–10, 313, 318; as consumers, 313; critical disability studies, 25–6, 310–12, 326–7; demedicalization, 313, 320, 324; deservingness, 325; disability rights movement, 15, 309–10,

312–13; disabling environments, 311; and governmentality, 310, 327; history of, 312–14, 318; independent living (IL ) movement, 313–16, 320, 326–7; intersectional approaches to, 17, 27; marginalized population, 327; medical model, 311, 313; rehabilitation model, 25, 313; resistance, 15, 309–10; social model of disability, 310–12; stigma, 307–8; “super-crips,” 323; terminology, 310–12; as tragedy, 323; vulnerability, 318. See also self-managed attendant supports (SMAS ); Snow, Judith discipline of the individual: biopolitics and biopower, 10–11, 83–4, 172, 317; and media representations, 86; power relations, 317. See also maternal responsibilization; media representations; self-discipline discourse, 7–8. See also specific topics discourse analysis. See critical discourse analysis (CDA ) discourse of flexibility. See flexible employment discrimination: intersectional approaches to, 17, 27, 34n10. See also ageism; inequities, social and health; marginalized populations; race and ethnicity disease, infectious. See infectious disease disparities, health. See inequities, social and health distributional injustice, defined, 77 Dryburgh, Heather, 270 Dubriwny, Tasha, 33n7, 154, 159–60 Dupuis, Melanie, 56 duty, generally. See citizenship duty of nation-states. See responsibilization of nation-states and pandemics duty to age well, 110–11, 115, 117–27, 124–5. See also aging; retirement

duty to be healthy: about, 19–20; citizenship model, 13; duty to consume vs duty to be healthy, 57–8; HPV vaccination, 103; maternal responsibilization, 19–20; obesity as failed citizenship, 53, 54–5; thin, toned body and successful citizenship, 53, 54, 55–8. See also healthism duty to care for self. See self-care duty to care for the environment. See environmental citizenship duty to choose. See choice duty to consume. See consumerism; market economy duty to know genetic risk. See predictive genetic testing (PGT ) ecological modernization, 69–70. See also environmental citizenship ecosystem degradation, 66–7. See also environmental citizenship Egypt and avian influenza, 183 elite risk managers, 155, 156–7. See also predictive genetic testing (PGT ) emergency planning: pandemic planning with emergency preparedness, 179; role of major “events,” 186; securitization and policies on, 176; “whole-of-society” approach, 178–9, 186 emerging infectious disease, 169–73. See also infectious disease; pandemic influenza and policy planning employment relationship: and citizenship, 280–1; and discourse of “flexibility,” 23–4. See also contingent employment; flexible employment; labour market entrepreneurial citizenship: about, 24, 284; accommodation of long hours, 24; aging workers (productive aging), 114, 123–4; contingent employment, 24, 271, 284–5, 298–301; employee assistance programs, 24, 300;

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freedom, 11–12; masculinity and resilience of flexible workers, 271; neoliberal governance, 11–12, 300. See also citizenship environmental citizenship: about, 18, 69–71, 75–6; choice, 69; co-optation of resistance, 29; duty to be green and healthy, 69, 71, 73, 75; environmental degradation, 66–7, 77; focus on risks, not causes, 67, 69, 75, 77–8; foodscapes, 55–7, 71–2; and governmentality, 67–71, 74; green consumerism, 68–72, 75–8; individualization, 18, 68–71, 73–8; intersectional approaches to, 77; and market economy, 70–1, 74; maternal responsibilization, 71–2, 74–5; normalization of green practices, 75–6; precautionary consumption vs precautionary principle, 18, 68, 72–3, 78; and public health, 66–78; research needed, 75–8; resistance, 76; and risk discourses, 68–9, 73–5, 77–8; social inequities, 68, 75–8 epidemic, as term, 48 epidemic, obesity. See obesity epidemic, worldwide influenza. See pandemic influenza and policy planning ethical food, 71–2. See also environmental citizenship; food consumption; food production ethics. See morality and ethics ethnography: and gift-giving, 234; and governmentality, 30. See also community-based agencies and gifts, case study; Inuit Nunavummiut, case study eugenics, 141–2 expert discourse: childhood sexuality, 88; environmental risk, 68–9, 72; expert and PGT patient, 158; magazines and medical knowledge, 85; retirement, 113, 115–19, 121, 124

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exploitation and workers. See contingent employment; flexible employment Facey, Marcia, 24–5, 280–306 familial cancer, testing for. See predictive genetic testing (PGT ) families: environmental citizenship, 69, 71; link between social body and individual, 19, 101; neoliberal modes of governance, 13–14; parent, as term for mothers, 49, 95; parent-child axis and biopower, 88, 101, 172; political attitudes on, 52; responsibilization for food consumption, 59; sexual health and social anxieties, 94–6, 98–9, 103; terminology of parents/ mothers, 49, 95. See also children; maternal responsibilization; tweens FAO (Food and Agriculture Organization of the UN ), 183 Farmer, Paul, 171 farming. See food production fat studies, 26. See also critical interdisciplinary health studies; obesity female adults. See women female body. See body of the female female children. See children female tweens. See sexuality of female tweens; tweens feminism and postfeminism: co-optation of discourse by neoliberalism, 14–15, 142–3; critical interdisciplinary health studies, 26; postfeminism, 15, 33n7; vulnerable empowered woman, 154, 160 fieldwork in Nunavut, 200–1, 220n6 First Nations people: terminology, 220n3. See also Aboriginal peoples fitness: and consumerism, 57–8; discipline and fun, 57; thin, lean body, 50–1, 53–8. See also obesity flexible employment: about, 23–4, 247–9, 282; accommodation of

worker needs, 248, 256–7, 259–62; autonomy and freedom, 251, 253, 256–8, 261–2, 266, 271; choice, 257–8, 268–9, 271; citizenship, 249, 268; comfortable offices, 264, 267; creativity of workers, 257, 259; gender and age, 268–72; global economy, 248, 249–51, 267, 282; health effects, 248, 252–3, 262–5; ideal workers, 23–4; individualization of health, 263, 268; intensity of work, 24, 249, 260–2, 265–6, 269, 270–2, 301; knowledge workers, 247–51; marginalization of workers, 269–70; neoliberal governance, 300–1; optimistic discourse, 256–62; overtime (unpaid), 259–62; pliant workers, 260–1; postwar standard, 247–8, 273n1; power relations, 265–7; practice of, 258–62; privilege of flexibility, 256; resilience of workers, 23–4, 262–5, 267–8, 300–1; resistance, 271; self-governance, 251, 266, 268; social inequities, 272; unlimited and long work hours, 24, 256, 258–61, 266–7, 272; wellness of workers vs working conditions, 267–8; work-life balance, 248–9, 258–60, 267–9, 272. See also knowledge workers flexible employment, case study: about, 23–4, 249, 256, 272; critical discourse analysis, 249, 253–4, 255–6; discourse, defined, 253; discussion, 265–72; findings, 256–65, 272; interviews and participants, 249, 254–5; methodology, 253–6; research needed, 272 flu. See influenza Food and Agriculture Organization of the UN (FAO ), 183 food consumption: access to healthy food, 205–7; environmental citizenship, 57, 71–2; foodscapes, 55–7; healthism, 56–7; Inuit nutrition

education, 205–6, 218; maternal responsibilization for environmental health, 74; parental responsibilization, 59; and social anxieties, 56–60. See also children and obesity; obesity food production: environmental citizenship, 183; FAO global norms, 183; food corporations, 55–7, 183; responsibilization of nation-states, 183; traditional farming and transgression of animal–human viral boundaries, 22, 177, 179–80, 188 Forster, A., 89 Foucault, Michel: askesis, 138, 145; care of the self, 138–9, 145; ethics, 137–9, 145, 152; family as link between social body and individual, 19; influence on sociological health studies, 4–5, 30–1, 32; on liberalism and government, 10; parent-child axis, 88, 101; power/knowledge, 7, 17, 27, 138; power relations, 28; productive aspects of power, 32n2; sexuality, 10, 86–8, 152; technologies of the self, 136; versions of neoliberalism, 33n5. See also biopolitics and biopower; discipline of the individual; governmentality; power relations; regulation; risk fowl and influenza, 167 freedom: about, 11–12; and authoritarianism, 16–17; and choice, 16; critique of neoliberalism, 12; cultural models, 138; and environmental citizenship, 69; governance through freedom, 11–12, 13, 27, 30; maternal duty to train children in disciplined freedom, 46; precondition for ethics, 138; and resistance, 28; and responsibilization, 13, 199; and unfreedom, 16–17, 199, 236, 241–2, 326; women in welfare programs, 227–8, 241

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free market environmentalism, 70. See also environmental citizenship From Behind the Piano (Pearpoint), 308. See also Snow, Judith future: hope and PGT , 140–1, 151–2, 154, 157–8; predictive genetic testing and future as options, 147–52. See also uncertainty future planning for pandemics. See pandemic influenza and policy planning Gardasil vaccine, 82, 89–90, 95, 102. See also HPV (human papillomavirus) vaccination gender: about, 19; attendants to disabled people, 325; contingent employment, 283; defunding of organizations, 34n9; family as link between social body and individual, 19; flexible workers, 268–70, 272; Foucault’s sexual ethics, 152; intersectional approaches to, 17, 27, 34n10, 77; postfeminism and gender equality, 33n7; research needed, 19; social construction of, 33n4; social inequities and infectious diseases, 184; standard employment relationship (SER), 273n1; terminology of parents/mothers, 49, 95; treatable infectious diseases, 184. See also males; maternal responsibilization; sexuality of female tweens; women genetic information: as biopolitical territory, 133; and eugenics, 141–2; human genome, 132–3; right to, 141–2; and self-care, 138–9, 143–7. See also predictive genetic testing (PGT ) genetic risk: biopolitical hinge, 139; and BRCA 1/BRCA 2 mutations, 133, 134; and “crisis” in health system, 135–6, 156; “proactive manager” of

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genetic risk, 7, 133–4, 144–52, 156–7. See also predictive genetic testing (PGT ) genital warts, 82, 90, 95 Gentilini, Marc, 184 gerontology, critical, 26, 111 gifts and gift-giving: gift exchange theories, 234–5, 242–3; neoliberal governance, 241–6; obligatory relationships, 23, 228–9, 234, 242. See also community-based agencies and gifts global biopolitics, Foucauldian. See biopolitics and biopower globalization and infectious disease: border mobilities, 181, 187–9; mutual vulnerability of nation-states, 179–82, 190; racialization of, 21–2; risk hierarchy of states, 180–1; SARS , 21–2, 169–70, 176, 187; securitization, 175–7; social inequities, 171, 184; surveillance of risky locales, 171, 179–81, 185, 188. See also pandemic influenza and policy planning; SARS (Severe Acute Respiratory Syndrome); trade and infectious disease; WHO (World Health Organization) and pandemics globalization and labour markets, 282 Globe and Mail, 113, 117–18 Goffman, Erving, 292 governmentality: about, 5–7, 26–9, 32n1; as analytical toolbox, 6–7, 26–7, 29–30, 35n12; authorizations, 6–7; critical interdisciplinary health studies, 26–7; critique of, 28, 35n12; everyday practices, 27–8, 30; green governmentality, 68, 70–2; individuals and populations, 5–6; normalizations, 6–7; problematizations, 6–7; as rationalizing means and ends, 9–11; resistance to neoliberalism, 28–30, 200; spatializations, 6–7; sub-

jectivity, 6–7; terminology, 5–6, 32n1. See also choice; citizenship; discipline of the individual; regulation government and governance, terminology, 32n1 grassroots organizations. See community-based agencies green consumerism. See environmental citizenship Guthman, Julie, 56

H1N1 influenza, 167, 187, 189 H5N1 influenza, 167 Hankivsky, Olena, 34n10 harm reduction, 231–2. See also community-based agencies Harris, Mike, government, 226–7, 228 Hasdell, Rebecca, 18, 60, 66–81, 101 Haugaard, Mark, 266 Health and Citizenship panel, 4 Health at Every Size (HAES ) movement, 47 Health Canada: environmental degradation, 66–7; funding for Aboriginal health, 211; HPV vaccinations, 82 health care: access to resources, 154, 158; “crisis” in cancer care, 135–6, 156; deservingness, 9, 158; elite risk managers, 155, 156–7; intersectional approaches to, 17, 27; market economy, 86; neoliberal subjects, 142–3; patients as consumers, 4; privatization, 156; resource distribution mechanisms, 154–5; and responsibilization, 86, 103, 156; right to care vs individual responsibilization, 3–4, 5, 9; right to genetic information, 141–2; risk management, 4; technological management of risk, 103. See also inequities, social and health healthism: about, 8, 13–14; and biocapitalism, 139; and consumerism, 54, 55; ethical discourse, 139; health

as metaphor for the good life, 199; health as supervalue to establish moral worth, 14; individualization, 8, 85–6; and moral duty, 85–6; responsibilization of the individual, 8, 199; risk discourse, 84 Healthy Weights for Healthy Children (House of Commons), 46–50 hereditary breast cancer. See breast cancer and predictive genetic testing Herizons, 90, 93–4, 100, 102 Hinchcliffe, Steven, 183 History of Sexuality, The (Foucault), 86–8 HIV/AIDS, 175–6 homelessness, 228, 229, 230, 233, 240 home-work balance. See work-life balance hopefulness and PGT , 140–1, 151–2, 154, 157 households, green, 71, 74. See also environmental citizenship House of Commons Standing Committee on Health, 44, 45, 46–50 HPV (human papillomavirus) vaccination: about, 18–19; age for vaccination, 82–3, 87, 90; biomedicalization of cancer risk, 153–4; biopower, 84, 185–6; cervical cancer, 19, 82, 89, 90, 93–7, 99, 101–2, 104; duty to communicate risks, 96–7, 101, 103; federal vaccination program, 82–3; Gardasil as cancer prevention, 82, 89–90, 95, 102; genital warts, 82, 90, 95; HPV as STI , 18–19, 82, 89; impact on sexual activity, 83, 89, 98, 100; male vaccination, 82–3, 100–1; maternal responsibilization, 19, 83–5, 88–9, 91, 94–8, 99–100; media representations, 83, 84; pathologizing of tween sexuality, 91–4; resistance to HPV vaccination, 92–3, 103; as rite of passage, 19, 87–8, 102; safety and efficacy of vaccine,

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99; social inequities, 102–3; SOGC ’s recommendations, 95, 98, 101; tween as link between state and maternal responsibilization, 100; tweens as sexually “at risk,” 19, 84–5, 89, 91, 99–100 HPV (human papillomavirus) vaccination, case study: about, 18–19, 83–5, 185–6; critical discourse analysis, 90–1; discussion, 99–104; findings, 92–8; governmentality, 83–4, 100–1; methodology, 90–1; research needed, 100 human genome, 132–3 Hunt, Alan, 84, 101 Igloolik Elders Project, 201 Igloolik fieldwork, 200–1, 204, 220n6 IHR (International Health Regulations), 170, 180, 182 Ilcan, Suzan, 11 immigrants and newcomers: attendants to disabled people, 325; border mobilities and disease, 181, 187–8; contingent employment, 283; financial insecurity, 122; HPV vaccination, 102; knowledge workers, 250; pension inequities, 122, 126; standard employment relationship (SER ), 273n1 income inequalities. See inequities, social and health independent living (IL ) movement, 313–16, 320. See also disability; self-managed attendant supports (SMAS ) Indigenous peoples, terminology, 220n3. See also Aboriginal peoples individualization. See responsibilization of the individual Indonesia and viral strains, 189 inequities, social and health: about, 12–17; access to health care, 154, 158; aging population, 122, 125–6;

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attendants to disabled people, 325; biopolitics, 174, 189; co-optation of discourse by neoliberalism, 143; deservingness, 158; environmental citizenship, 68, 76–8; exclusion of marginalized, 17; flexible employment, 272; global infectious diseases, 171, 173–4, 182–4; and healthism, 13; HPV vaccinations, 102–3; intersectional approaches, 17, 27; Inuit vs non-Inuit health care, 208–9; lives deemed valuable or not, 174; marginalized populations, 9; maternal responsibilization and axes of inequity, 102; and neoliberal rationality, 12–17; pandemic influenza and policy planning, 173–4, 182–4, 189; pension inequities, 122, 126; poverty in Ontario, 227–8; public health goals to reduce, 8; securitization and infectious disease, 189; social determinants of health, 8–9, 173–4, 300; vaccines and vaccination, 189; and vulnerable empowered woman, 154. See also marginalized populations; welfare programs infectious disease: (re)emergence of, 169–73; and globalization, 170; policy planning, 169–70; risk techniques and biopolitics, 173–4, 184–5; SARS , 21–2, 169–70, 176, 187; securitization of global health, 175–7; social inequities, 171, 173–4, 184; treatable diseases, 184. See also influenza; STI s (sexually transmitted infections); tuberculosis influenza: antivirals, 178, 183, 189; avian flu, 167, 180, 183, 189; benign viruses, 177, 186; H 1N 1 and H 5N 1 flu, 167, 187, 189; history of, 167–8; as potential pandemics, 185; swine flu, 180, 183–4; and transgression of animal–human boundaries, 22, 177, 179–80, 188; uncertainty and biopol-

itics, 172, 177, 185–6. See also animal– human boundary transgression and infectious disease; pandemic influenza and policy planning information technology sector. See knowledge workers Ingram, Alan, 176, 180, 188 inherited breast cancer. See breast cancer and predictive genetic testing Innuqatigittarniq Qaujimajatuqangit (IQ ), terminology, 214, 220n11. See also Inuit knowledge (IQ ) (Innuqatigittarniq Qaujimajatuqangit) interdisciplinary health studies. See critical interdisciplinary health studies International Health Regulations (IHR ), 170, 180, 182 International Sociological Association Research Committee on the Sociology of Health, 4 intersectional approaches, 17, 27, 34n10, 77 Inuit: disease, 197, 204, 207; education and IQ (Inuit knowledge), 214; health care funding, 211; historical context, 197–8, 203; infectious diseases (tuberculosis), 197, 203; media representations, 204–5, 208; medicalization and colonialism, 203, 208–10, 217; self-determination, 22, 195–6, 198–200, 210–11, 215–20; terminology for health, 220n3; “ward of the state” mentality, 200, 217. See also Nunavut Inuit knowledge (IQ ) (Innuqatigittarniq Qaujimajatuqangit): about, 22, 213–14, 218; Bathurst Mandate, 196, 214, 218; community strength vs individual responsibilization, 218–19; defined, 214, 220n11; food (country food), 205–7, 218; integration into government programs, 220n10; inuusiqattiarniq (better life), 212–13;

IQ Working Group, 214–15; and local governance, 212; marginalization of IQ , 22, 202, 209–10; notions of health, 212–13; pre-colonial IQ , 203; and promotion of self-reliance, 212; resistance using, 200, 211–19; tension between IQ and Canadianized care, 198, 218; well-being, 202, 214–15; worldview, 203, 213 Inuit Nunavummiut: about, 21; access to health care, 207–10; Bathurst Mandate, 196, 214, 218; citizenship processes, 196–7; collective identity and citizenship, 198, 215–18; colonization of everyday life, 200, 202–4, 207–10, 211–13, 217; community health representative (CHR ), 209– 10; community vs individualization, 218–19; counter-discourse of Inuit well-being, 202, 214–15; demographics, 204–5; funding for health care, 210–11; healthism, 199; historical context, 196, 212; individualization, 22, 205, 218–19; infectious diseases, 190–1n1, 201, 203; marginalization of IQ (Inuit knowledge), 22, 202, 209–10, 214, 217; media representations, 204–5, 208; multiple perspectives, 211–12; North as “risky,” 202, 204–8, 217; nutrition, 205–7, 218; resistance, 200, 211–19; risk problematization, 22, 196–7, 200, 202, 204–8, 217–19; self-determination, 22, 195–6, 198–200, 210–11, 215–20; social determinants of health, 218; social inequities, 207–9; South as source of “health care,” 202–4, 217; suicide, 215, 216–17; tension between Canadianized care and IQ (Inuit knowledge), 198; terminology, 202–4, 220n3, 220n8. See also Nunavut Inuit Nunavummiut, case study: discourse analysis, 201–3; interviews

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and participants, 201, 220n7; methodology, 200–3, 220nn6–7; terminology for health, 203–4; themes and discussion, 202–4, 217–20 Inuit Qaujimajatuqangit Workshop, 220n10 Inuit Tapiriit Kanatami (ITK ), 197, 220n3 Inuit Tapirisat of Canada (ITC ), 197–8 Inuktitut, 200–1, 203 IQ. See Inuit knowledge (IQ) (Innuqatigittarniq Qaujimajatuqangit) Iqaluit fieldwork, 200–1, 206, 220n6 Johnston, Josée, 56–7, 74 Katzman, Erika, 25, 307–29 Knabe, Susan, 18–19, 82–107 knowledge workers: demographics, 255, 268–71; examples of, 247–8; flexible work, 248–9; and globalization, 249–51; health of, 252–3, 267–8; management of, 251; model workers, 250; office workspace, 264; resistance, 271; short job tenure, 255, 263; social inequities, 272; unsuitability of factory model, 250. See also flexible employment labourers, day. See contingent employment, case study labour market: aging workers, 122–4; labour market and workplace studies, 26; and neoliberal citizenship, 280–1; productive aging discourse, 20, 29–30, 108, 111–16, 119–20, 122–7, 270; and social and moral worth, 280–1, 293; standard employment relationship, 248, 273n1, 283. See also contingent employment; flexible employment; knowledge workers Laliberte-Rudman, Debbie, 20, 108–31 Lemke, Thomas, 11, 24, 159, 172, 185

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liberalism: and Aboriginal peoples, 198–9; and authoritarianism, 16; and excess governance, 10, 11, 33n6; limits of political authority, 317; risk discourses, 199 life-work balance. See work-life balance Lippman, Abby, 16, 84, 142 Live Longer, Work Longer (OECD ), 112 Lupton, Deborah, 68–9, 199 MacEachen, Ellen, 23–4, 247–79, 300 MacKendrick, Norah, 71, 72, 74 Maclean’s, 90, 93, 96 magazines: disciplinary power of, 86; expert medical discourse, 85; HPV vaccination, 18–19, 83–4; and individual responsibilization, 83, 85–6; social norms, 86. See also HPV (human papillomavirus) vaccination, case study magnetic resonance imaging (MRI ), 144, 147, 148–9, 156 malaria, 171, 184 males: day labourers, 24, 285–96; HPV vaccination, 82–3, 100–1; masculinity and resilience of flexible workers, 271 mammalian influenza viruses. See influenza managers of attendants. See self-managed attendant supports (SMAS ) managers of employees. See contingent employment; flexible employment marginal employment. See precarious employment marginalized populations: about, 12–17; access to vaccines, 189; aging workers, 126; attendants to disabled people, 324–5; and authoritarianism, 16–17; biopolitics and lives deemed valuable or not, 174; biopolitics and state racism, 174, 188; commun-

ity-based agencies, 226, 229–32, 240; contingent employment, 283; deservingness, 9; and environmental citizenship, 75–6; flexible workers, 269–70; and individualization, 16–17; infectious diseases, 190–1n1; intersectional approaches to, 17, 27, 77; and liberal governance, 198–9; and neoliberal rationality, 12–17, 199, 242; poverty in Ontario, 226–8; as risks to body politic, 17; and unfreedom, 16–17, 241–2. See also Aboriginal peoples; disability; gender; inequities, social and health; race and ethnicity; women market economy: about, 11; and biomedicalization, 16; and environmental citizenship, 70, 75–7; and health care, 86; and individualization, 84; neoliberal modes of governance, 13; and population health, 18; versions of neoliberalism, 33n5. See also choice; consumerism; privatization mastectomy, prophylactic, 148, 151, 156, 159–60 maternal responsibilization: childhood obesity, 19, 45–6, 49–50, 52, 58–61; domestic work of, 49–50; duty to train children in self-discipline, 45–6; environmental citizenship, 71–2, 74–5; family as link between social body and individual, 19; “good mother” of consumer society, 51; HPV vaccination, 19, 85, 88–9, 94–8, 101–4; media rhetorical devices, 88–9; parents, as terminology for mothers, 49, 102; tween sexuality, 84, 94–8, 99–104; work-life balance, 50. See also children; families; tweens; women Mauss, Marcel, 234, 242 Mayhew, Claire, 284 McGregor, Sue, 86

McMullin, Julie, 270 media representations: and biopower, 86; cancer care, 135; childhood obesity, 48; disciplinary function of, 86; Nunavut, 204–5, 208; responsibilization for health, 8, 86. See also HPV (human papillomavirus) vaccination, case study; retirement, case study medical anthropology, 26. See also critical interdisciplinary health studies medicalization: and assessment of “at-risk,” 199; and biological citizenship, 142; co-optation of feminist discourse, 103; disability and medical model, 311, 313, 320, 324; Inuit medicalization and colonization, 203, 208–10, 217; neoliberal co-optation of feminist discourse, 15; postfeminist interventions, 33n7; of sexuality, 94; of tween bodies for HPV vaccination, 103 men. See males mental illness, 228, 231. See also community-based agencies and gifts Merck Canada, Gardasil vaccine, 82, 89–90, 95, 102. See also HPV (human papillomavirus) vaccination Métis people: health care funding, 211; terminology, 220n3. See also Aboriginal peoples Mexico: pandemics, 183, 187–8; public pensions, 110 Mills, Charles Wright, 302 Ministry of Health and Long-Term Care, Ontario: predictive genetic testing (PGT ), 133, 134–5, 136, 161nn1–2 mobile workforce. See flexible employment morality and ethics: about, 12, 14; askesis (ethical work), 145; body size and moral worth, 14, 43, 47, 50–1, 53–8;

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and citizenship duties, 14; deservingness, 9, 158; duty of self-care, 136–7; duty to age well, 124–5; employment and moral worth, 280–1, 293–5, 298; ethical substance, 138; failure as lack of risk management, 14, 58; Foucault on, 137–9, 152; freedom as precondition for ethics, 138; hazard of social assistance, 281; health as supervalue of moral worth, 14, 54; and healthism, 139; history of consumerism and responsibilization, 52–3; PGT as ethical practice, 137–40, 152–3, 157; and political contingency, 158–9; and proactive management of future disease, 158–60 mothers. See maternal responsibilization; women MRI (magnetic resonance imaging), 144, 147, 148–9, 156 Mykhalovskiy, Eric, 186

NAFTA, 183, 187. See also trade and infectious disease National Health Indicators Report, 205 nation-states: intersectional approaches to risks, 17, 27; shift to neoliberal approaches, 4 nation-states and pandemics: duty to report disease, 182; global surveillance networks, 182; mutual vulnerability and trade, 179–82; neglect of treatable diseases, 184; responsibilization of nation-states, 182–4, 188–9; securitization of global health, 175–7; social inequities, 182–4; WHO ’s International Health Regulations, 170, 180, 182. See also borders of nation-states and infectious disease; responsibilization of nation-states and pandemics; securitization and infectious disease nature, construction of, 71. See also environmental citizenship

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Negra, Diane, 33n7 neoliberalism: about, 4–12; citizenship, 13; economic model for social domain, 11; governance through freedom, 11–12; history of, 4, 33n5; marginalization and inequities, 12–17; patients as consumers, 4; as privatization of responsibility, 11; as rationality of government, 9–12, 34n11. See also citizenship; freedom; inequities, social and health; market economy; responsibilization of the individual; unfreedom newcomers. See immigrants and newcomers Newman, Katherine, 280 new public health, 68 News/North, 204 newspapers and discourse on aging, 29–30, 112–13. See also retirement, case study normalizations: about, 6–7, 284–5; biopower, 318; labour market participation, 284–5; magazine articles, 85–6; self-managed attendant supports (SMAS ), 25, 320, 322–4, 325–6 Novas, Carlos, 140, 141, 157, 158 Nunatsiaq News, 204 Nunavummiut. See Inuit Nunavummiut Nunavut: Bathurst Mandate, 196, 214, 218; government, 195–6, 198, 219n1; historical context, 21, 195–8, 220n2; IQ (Inuit knowledge) as part of governance, 195, 209–10, 220nn10–11; media representations, 204–5, 208; resistance, 200, 211–19; self-determination, 22, 195–6, 198–9, 210–11, 215–20. See also Inuit Nunavummiut Nunavut Food Guide, 205–6, 218 Nunavut Land Claims Agreement, 195, 197–8

obesity: body mass index (BMI ), 61n1; citizenship duties, 53, 54–5; conflation of obesity and overweight, 49; maternal responsibilization, 19, 45–6, 49–50, 58–61; and moral duty, 43, 47, 50–1, 55–6, 57–8; obesity epidemic, 43, 48; science of, 47–9; and social anxieties, 44, 50–1. See also children and obesity occupational health and safety: health management, 267–8; resilience strategies, 267–9; responsibilization of workers, 301–2; wellness of flexible workers, 267–8; working conditions, 267–8, 284, 301–2 occupational science: occupational possibilities, 114; and productive aging, 113–14, 119–20, 125–7. See also retirement Occupy movement, 29 OECD (Organization for Economic Cooperation and Development), 109, 110, 112, 116 Old Age Security, 20, 118–19 older people. See aging O’Malley, Pat, 28, 35n12, 200 Ontario: Harris government’s austerity budgets, 226–7, 228; legal status of disabled people, 314; mandatory retirement, 113, 119; predictive genetic testing (PGT ), 133, 134–5, 136, 161nn1–2; social assistance, 227–8. See also breast cancer and predictive genetic testing, case study; community-based agencies and gifts, case study; contingent employment, case study; flexible employment, case study; self-managed attendant supports (SMAS ) Orchard, Treena, 22–3, 76, 225–46 organic food, 71–2. See also environmental citizenship organizational culture and flexible and contingent employment. See

contingent employment; flexible employment organizational culture of community-based agencies. See community-based agencies and gifts Organization for Economic Cooperation and Development (OECD ), 109, 110, 112, 116 ovarian cancer, 133, 134, 147. See also BRCA1/2 genetic mutations overtime and flexible employment, 259, 261–2 overweight body: ageism, 123–4; and obesity, 49 paid work and aging. See retirement pandemic influenza and policy planning: about, 21–2, 167–9, 185–6; and biopower, 185; contact tracing, 178; (re)emergence of infectious disease, 169–73; and governmentality, 22; knowledge systems, 178; as “most feared security threat,” 177; mutual vulnerability discourse, 179–82, 190; pre-emptive regulation, 168–70, 177–9; preparedness discourse, 21–2, 168–70, 175, 179, 188–9; responsibilization of nation-states, 22, 190; risk vs vigilance technologies, 185; risky locales, 21–2, 171, 179–81, 185, 188; SARS as successful event, 170; social inequities, 173–4, 182–4, 189; stockpiling of vaccines and antivirals, 178, 182–3, 189; surveillance, 170; trade and preparedness, 183, 187, 188–9; travel restrictions, 178; uncertainty discourse, 22, 168–9, 172, 177–9, 184–6; “whole-of-society” approach, 178–9, 186; WHO policy documents, 174–5, 178, 180; WHO ’s International Health Regulations, 170, 180, 182. See also animal–human boundary transgression and infectious disease; borders of nation-states

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and infectious disease; securitization and infectious disease; WHO (World Health Organization) and pandemics Pap smears, 93, 96 parents. See families part-time workers. See contingent employment pathologization of tween sexuality, 92. See also sexuality of female tweens patients: as consumers vs recipients of care, 4 Pearpoint, Jack, 308–9, 314–15, 320–1, 327 pensions: assumption of future reduction, 119, 121–2; economic risk for societies, 116; individualization, 122; inequities, 122, 126; private plans, 109–10, 111–12, 119; public plans, 20, 110–12, 118–19, 122. See also aging; retirement people-first language of disability, 310–11. See also disability personal responsibility. See responsibilization of the individual Petersen, Alan, 14, 68–9, 141–2 Petryna, Adriana, 141 PGT. See predictive genetic testing (PGT ) PHAC (Public Health Agency of Canada), 178 pharmaceutical industry and vaccines, 189–90 philanthropic gifts. See gifts and gift-giving Plows, Alexandra, 141 Poland, Blake, 77 Policy Research Institute (PRI ), 116 political economy of hope and PGT , 140–1, 151–2, 154, 157 Polzer, Jessica, 3–42, 18–19, 82–107, 247–79, 300 popular media. See media representations

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population aging. See aging population and biopolitics. See biopolitics and biopower population health: and biopolitics, 172; and market economy, 18; and public health policies, 77–8; regulation of populations, 10–11. See also biopolitics and biopower; public health positive aging, 20, 110–12, 125–6. See also aging postcolonial theory, 26. See also critical interdisciplinary health studies postfeminism, 15, 33n7, 154. See also feminism and postfeminism Potter, Jonathan, 114 poverty: aging population, 121; childhood poverty, 44; and choice, 16; deservingness, 227; individual vs civic responsibilities, 243; and neoliberal policies, 9, 226–7. See also community-based agencies and gifts; inequities, social and health; marginalized populations; welfare programs Power, Elaine, 3–42, 43–65, 101–2, 241, 317, 321, 326 power/knowledge, 7, 17, 27, 138 power relations: about, 6–7, 28, 317; discipline of the individual body, 317; everyday practices, 27–8, 30; governmentality studies, 28, 34n11; intersectional approaches to, 17, 27, 34n10; and marginalization, 16, 199; productive aspects, 6–7, 16, 28, 32n2; regulation of populations, 317; repressive aspects of, 6, 16; resistance and counter-discourse, 28–30; symmetrical power relations, 282, 298. See also discipline of the individual; regulation; resistance; self-discipline; surveillance precarious employment: and stigma, 282–3. See also contingent employment; flexible employment

precautionary consumption: individualized approach to risk management, 18, 72–3, 78 precautionary principle: state protection of public health, 18, 72–3, 78 predictive genetic testing (PGT ): about, 20–1, 134–7, 158–60; access to health resources, 147–8, 154–5; asymptomatically ill, 136–7, 139–40; biological citizenship, 133–4, 140–2, 152, 157–8; duty to know and manage genetic risk, 139–40, 152, 159–60; elite risk managers, 155, 156–7; as ethical practice, 137–40, 152–3; expert discourse, 158; hierarchies of risk managers, 154; individualization, 136, 140–1; insurable services in Ontario, 133, 134–5, 136, 161nn1–2; political economy of hope, 140–1, 151–2, 154, 157; research needed, 153; resistance and ambivalence, 15–16, 146–7, 153, 159; responsibilization, 136, 140–1, 152, 158; right to information, 141–2; as self-governance, 134–7; surveillance, 20–21, 136–7, 145–6, 153, 156–7. See also breast cancer and predictive genetic testing pre-emptive regulation and pandemics, 168–70, 177–9. See also pandemic influenza and policy planning preparedness for pandemics. See pandemic influenza and policy planning privatization: cancer care, 135, 156; and neoliberalism, 4, 11; pensions, 109–12 “proactive manager” of genetic risk, 7, 133–4, 144–52, 156–7. See also genetic risk problematizations, 6–7, 199–200 procedural injustice, defined, 77 producer societies and neoliberalism: citizens as consumers, not producers, 52–3, 61n2 prophylactic mastectomy, 148, 156, 159–60. See also predictive genetic testing (PGT )

Provincial Advisory Committee on New Predictive Genetic Technologies, Ontario, 136 public health: decline of political project, 77; environmental citizenship, 66–78; precautionary principle, 18, 72–3, 78; research needed, 75–8. See also critical interdisciplinary health studies; health care; social determinants of health Public Health Agency of Canada (PHAC ), 178 Quinlan, Michael, 284 race and ethnicity: attendants to disabled people, 325; biopolitics and state racism, 174, 188; contingent employment, 283, 300; environmental citizenship, 77; flexible workers, 270; and global infectious disease, 21–2, 174; HPV vaccination, 102–3; “illegal aliens” and disease, 187–8; intersectional approaches to, 17, 27, 34n10, 77; lives deemed valuable or not, 174; maternal responsibilization and axes of inequity, 102; predictive genetic testing, 143; social construction of, 33n4; treatable infectious diseases, 184; tweens constructed as white, 87. See also inequities, social and health; marginalized populations Ramidurai, Vandhana, 33n7 Rankin Inlet fieldwork, 200–1, 216, 220n6 Raphael, Dennis, 33n3 rationalities of government, 12–17, 34n11. See also governmentality re-emerging infectious disease, 169–73. See also infectious disease; pandemic influenza and policy planning refugees. See immigrants and newcomers

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regulation: and authoritarianism, 16–17; biopower and regulation of populations, 10–11, 172, 190, 317; body size and regulation of desire, 50–4, 57–8; community-based agencies and gifts, 235–7; of the marginalized, 17; maternal regulation of childhood desire, 60; precautionary principle and environmental citizenship, 72–3, 78; pre-emptive regulation and infectious disease, 168–70, 177–9; and productive power, 7, 32n2 rehabilitation model of disability, 25, 313, 319. See also disability religion and social anxieties, 50–1 resilience of flexible workers, 23–4, 262–5, 267–8, 300–1. See also flexible employment resistance: about, 15–16, 28–30; activist movements, 28–9, 34n9; agency vs structure, 28; community-based agencies, 23, 236–7, 242, 244; contingent employment and stigma, 271, 299–300; co-optation of resistance, 14–16, 28–9, 103, 187, 310, 324; counter-discourses, 15–16, 28–9; disability rights movement, 15, 309–10, 312–13; environmental citizenship, 76; governmentality studies of, 28–30; and Inuit knowledge (IQ ), 200, 211–19; predictive genetic testing (PGT ), 15–16, 146–7, 153, 159; and productive power, 28, 32n2; and retirement, 115; social anxieties and the body, 47–8; strategies of knowledge workers, 271; vaccines and vaccination, 92–3, 103, 189–90 responsibilization of nation-states and pandemics: biological risk discourses, 155–6; food production techniques, 183; mutual vulnerability discourses, 179–82, 190; planning by nation-states, 182–4, 188–9; treatable infectious diseases, 184; WHO ’s

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International Health Regulations, 170, 180, 182. See also pandemic influenza and policy planning responsibilization of the individual: about, 8, 52; biological risk discourses, 155–6; body weight, 52; contingent employment, 301–2; environmental citizenship, 69; genetic testing, 103; and governance through freedom, 11–12; and healthism, 13; history of consumerism and responsibilization, 52–3; HPV vaccination, 103; intersectional approaches, 17, 27; and marginalization, 16–17; and market economy, 84; media representations, 8, 84, 85–6; media rhetorical devices, 88–9; and neoliberal rationality, 11–17, 284; pandemic readiness planning, 178; production of “at-risk” citizens, 13; and resistance, 15–16; right to health care vs individual responsibilization, 3–4; self-care movements, 8; self-managed attendant supports (SMAS ), 25, 316, 321–2, 324; technologies of the self, 136. See also healthism retirement: about, 20, 29–30, 108; ageism, 111, 123–4, 126–7; contingent employment, 122–3, 126–7, 269–70, 272; duty to age well, 110–11, 115, 117–27, 124–5; duty to work, 115–17, 124–7; economic risk for societies, 20, 115–17, 119, 124; financial insecurity, 118–24; governmentality, 113, 114; ideal individual, 124; individualization, 114–15, 121–6; mandatory retirement, 113, 119, 121; moral duty, 125; occupational choices, 113–15, 119–20, 124–7; positive aging discourse, 110–12; problematization of, 109–12; productive aging, 20, 29–30, 108, 111–16, 119–20, 122–7, 270; resistance, 115; responsibiliza-

tion, 112, 117; risk for individuals, 20, 117–21, 124; risk in aging discourses, 108, 112–15, 124–7; social anxieties, 117–18; social inequities, 122, 125–7. See also aging; pensions retirement, case study: about, 29–30; critical discourse analysis, 108, 112–15, 124; expert discourse, 113, 115–19, 121, 124; findings, 115–24; governmentality theory, 29–30, 112–13; newspapers, 29–30, 113 risk: about, 4, 7; asymptomatically ill, 136–7, 139–40; and citizenship duties, 13–14; co-optation of discourse by neoliberalism, 142–3; and environmental degradation, 66–7, 69; and healthism, 8, 13; individualization of risk, 13, 69; intersectional approaches to, 17, 27; liminal states of populations in pandemic planning, 185; moral duty, 14; “new public health,” 68–9; risk management technologies, 15; risky locales and disease, 21–2, 171, 179–80, 185, 188; and sociology of health, 68; and subjectivity, 7, 13; vulnerable empowered woman, 160. See also specific topics Robertson, Ann, 137 Rose, Nikolas, 6, 14, 28, 35n12, 59, 139–40, 141, 157, 158, 173, 251 Roy, Stephannie, 85–6, 88 Safer Future, A (WHO ), 177 safe-sex practices: sex trade workers, 228, 239–40; young people, 93–4. See also sexual health Sanford, Sarah, 21, 167–94 SARS (Severe Acute Respiratory Syndrome), 21–2, 169–70, 176, 187 Sassatelli, Roberta, 57 Scott, Heather, 252, 269 Scott, S., 149

seasonal workers. See contingent employment Securing an Open Society (Canada), 176 securitization and infectious disease: about, 175–7; and biopolitics, 169, 172; desirable and undesirable mobility, 187; federal policy on health emergencies, 176; infected and uninfected bodies, 188; mutual vulnerability of nation-states, 179–82, 190; non-health social sectors, 178; pre-emptive regulation, 177–9; social inequities, 189; stereotypes of subjectivities, 188; stockpiling of vaccines and antivirals, 189; surveillance networks, 182; terrorism, 176; and trade, 180, 187; uncertainty discourse, 172, 176, 186; Western states vs developing states, 176; “whole-of-society” approach, 178–9, 186; WHO ’s International Health Regulations, 170, 180, 182. See also borders of nation-states and infectious disease; infectious disease; pandemic influenza and policy planning self-care: and environmental citizenship, 68; Foucauldian approach, 138–9, 145; and healthism, 13; lifestyle modifications, 144–6; and market economy, 11; and moral duty, 136–7; and predictive genetic testing, 138–9, 143–7, 153; and responsibilization, 13; self-care movements, 8; technologies of the self, 136 self-determination of populations: Inuit, 22, 195–6, 198–9, 210–11, 215–20; marginalized populations, 242 self-discipline: duty to be healthy, 57, 68, 86; and freedom, 13–14; maternal responsibilization, 45–6, 60, 101–2; and power relations, 7; and SMAS

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eligibility, 321–2; and welfare assistance, 321; and women’s bodies, 51, 54. See also discipline of the individual self-examination. See self-surveillance self-managed attendant supports (SMAS ): about, 15, 25, 315, 324–7; able-disabled subjectivity, 25, 309, 319–20, 323–6; attendants, 320, 324–5; biopower, 316–19; and choice, 322, 324, 326; co-optation of resistance, 324; critique of, 316, 323–7; demedicalization, 313, 320, 324; deservingness, 325–6; eligibility and application process, 321–2, 325–6; funding as social assistance, 320–1; governmentality, 316–19, 326–7; history of, 309, 319; independent living (IL ) principles, 315, 316; marginalization, 25; and neoliberal citizenship, 25, 309, 316–19, 322–4; normalizing power, 15, 25, 320, 322–4, 325–6; and oppression, 316, 320; and rehabilitation model, 25, 313, 319; research needed, 225; responsibilization, 25, 316, 321–2, 324; social inequities, 325; “super-crips,” 323; unpaid and “invisible” work, 25, 316, 322–3, 324–5. See also disability self-surveillance: in community-based agencies, 233–4, 235; and contingent employment, 285; and health norms, 86; and responsibilization, 13 seniors. See aging sexual health: abstinence, 98; biopower vs sovereign power, 86–7; discipline of the individual, 86; duty to communicate risks, 96–7, 101, 103; medicalization of, 94; parental anxieties, 94–6, 98–9, 103; pathologizing tween sexuality, 92–4, 185; sex trade workers and safe-sex practices, 228, 239–40; youth and safe-sex practices, 93–4; youth resistance to

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communication about, 97–8. See also HPV (human papillomavirus) vaccination; STI s (sexually transmitted infections) sexuality: family as locus of power, 101; Foucault on, 86–8, 99, 101, 139, 152 sexuality of female tweens: pathologizing female sexuality, 93–4; resistance to safe-sex practices, 93–4; as sexually “at risk,” 19, 83–5, 87, 89, 93–4, 99–100; as soon-to-be sexual, 92–3, 97 sexual orientation: tweens constructed as heterosexual, 87 Shakespeare, Tom, 311 Shih, Johanna, 266, 271 Shildrick, Margrit, 310, 316 Singer, Merrill, 187 SMAS. See self-managed attendant supports (SMAS ) Smith, V., 271 Smithfield Foods, 187–8 Snow, Judith, 307–9, 313–16, 320–1, 327 Sobal, Jeffrey, 55 social activist movements, 28–9, 310. See also resistance Social and Behavioral Health Sciences, Dalla Lana School of Public Health, 31 social anxieties. See anxieties, social social assistance. See welfare programs social class: health as symbolic marker of, 9; HPV vaccination, 102–3; maternal responsibilization and axes of inequity, 102; tweens constructed as middle-class, 87. See also inequities, social and health; poverty social determinants of health: childhood poverty, 44; defined, 33n3; defunding of women’s health organizations, 16; and global disease transmission, 173–4; individualization vs public policy, 8; Inuit con-

ditions, 204–5, 218; and neoliberal public policy, 8–9; and obesity, 46; and public policy, 77–8; and right to health care, 4, 5; social inequities, 8–9, 173–4, 300 social good and contingent employment, 282–3 social inclusion of disabled people, 310. See also disability social inequities. See inequities, social and health social justice: neoliberal co-optation of discourses of, 14; procedural and distributive injustice, defined, 77; social activist movements, 28–9, 310. See also inequities, social and health; resistance social marginalization and contingent employment, 290, 292, 296–8. See also contingent employment social norms. See normalizations social theory, critical. See critical interdisciplinary health studies social worth and employment, 280–1, 293–4. See also labour market societal disintegration and work, 283. See also contingent employment Society of Obstetricians and Gynecologists of Canada (SOGC ), 95, 98, 101 socioeconomic inequities. See inequities, social and health sociology of health, 4, 68. See also critical interdisciplinary health studies software industry. See knowledge workers somatic ethics, 139 “Spanish flu,” 168 spatializations and governmentality, 6–7 spoiled identities, 292. See also contingent employment SSHRC (Social Sciences and Humanities Research Council of Canada), 32

SSMH (Supporting Social and Mental Health) agency. See community-based agencies and gifts standard employment relationship, 248, 273n1, 283 state-centred activities, terminology, 32n1, 33n6 Stearns, Peter, 50–1 Stephenson, J., 89 stigma of contingent employment. See contingent employment, case study stigma of disability, 307–8. See also disability STIs (sexually transmitted infections): about, 18–19; abstinence, 98; genital warts, 82, 90, 95; human papillomavirus (HPV ), 18–19, 82, 89; maternal responsibilization, 89, 94–8, 99–100, 103–4; parental anxieties, 94–6, 98–9, 103; resistance to communication, 95, 97–8; safe-sex practices, 89, 93; STI screening, 93; youth as “at risk,” 93. See also HPV (human papillomavirus) vaccination stratified biomedicalization, 154. See also inequities, social and health stress in workers: individualization, 252; resilience of workers, 264–5, 267–9; work-life balance, 259, 264–5; workplace health issues, 252–3, 268; work-related insecurity, 252 subjectivity: able-disabled citizens, 25, 309, 319–20, 323–4, 325, 326; asymptomatically ill, 139–40; child “at risk” for obesity, 19, 45–6, 50–5, 59–61; desirable subjectivities, 29; and discourse, 7; entrepreneurial subject, 16, 73, 84, 136–7, 250, 253, 269, 271, 284, 298, 300; female tweens as sexually “at risk,” 19, 83–5, 87, 89, 93–4, 99–100; “flexible worker,” 23–4, 250–1, 256–8, 271, 282; “good mother,” 45, 51, 71–2, 96; and governmentality, 6–7; “green con-

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sumer,” 68–73; “proactive manager” of genetic risk, 7, 133–4, 144–45, 147–52, 156–7; “resilient worker,” 23–4, 262–5, 267–8, 300–1; and risk, 7, 13, 84; and “successful ager,” 108, 110–12 suffering and witnessing disease, 145, 153, 155, 156, 160 suicide, Inuit, 215, 216–17 super-crips, 323. See also disability Supporting Social and Mental Health (SSMH ) agency. See community-based agencies and gifts support services for disabled people. See self-managed attendant supports (SMAS ) surveillance: and authoritarianism, 16–17; biopolitics and biopower, 10, 173; of children and obesity, 60–1; co-optation of resistance, 29; power relations, 7; predictive genetic testing, 20–1, 136–7, 145–6, 153, 156–7; SMAS funding as social assistance, 320–1; technologies of the self, 136. See also self-surveillance surveillance and pandemics: border mobilities, 181, 188–9; epidemiological techniques, 173; gathering of flu samples, 189; pandemic influenza and policy planning, 170; risky locales, 171, 179–81, 185, 188. See also borders of nation-states and infectious disease; WHO (World Health Organization) and pandemics sustainable consumerism. See environmental citizenship swine influenza, 180, 183–4 taking care of self. See self-care Tamoxifen, 147–8 Tasker, Yvonne, 33n7 technologies of government: concept of, 34n11; discourses of “choice” and “freedom,” 330; governmen-

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tality studies of, 30–1. See also governmentality technologies of the self, 136 technology sector. See knowledge workers Tedford, Sara, 21, 22, 195–224 teenagers. See children and obesity; tweens temporary work agencies: about, 24–5, 282; case study on stigma, 285; employment relationships, 287–8, 296, 298–9; exploitation of workers, 288–91; marketability of flexible workers, 251; portrayal as opportunity, 24; power relations, 298–9; statistics on, 282. See also contingent employment; flexible employment terrorist attacks, 176 Thomas, Carol, 318 Time (Canadian Edition), 90, 96–7 time and work-life balance. See worklife balance Titchkosky, Tanya, 323–4 Today’s Parent, 90, 92, 94–5, 98 Toronto Star, 113 trade and infectious disease: border mobilities, 181, 188–9; mutual vulnerability of nation-states, 179–82, 190; risky locales, 21–2, 171, 179–81, 185, 188; trade agreements and preparedness, 183, 187. See also borders of nation-states and infectious disease Tremain, Shelley, 317, 318 tuberculosis: in Inuit, 197, 201, 203; world-wide, 169–70, 171, 184, 190–1n1 Tulloch, John, 199 tweens: age span, 87; case study on HPV vaccination, 18–19; construction of, 87; consumerism and rites of passage, 19, 87–8, 102; duty to communicate risks to, 96–7, 101, 103; Foucault on biopower, 86–8;

maternal responsibilization, 19, 87, 88–9, 94–8, 99–100, 103–4; normalization, 93; resistance to communication, 95, 97–8; resistance to HPV vaccination, 103. See also HPV (human papillomavirus) vaccination; sexuality of female tweens uncertainty: and biopolitics, 172, 177, 185–6; contingent employment, 23, 248, 290–1, 297, 300; and preemptive regulation of viral uncertainty, 177–9; and securitization of global health, 176; and terrorism, 176 unfreedom, 16–17, 199, 236, 241–2, 326. See also freedom University of Toronto, 31 unpaid labour: flexible workers, 259– 62; SMAS (self-managed attendant supports), 25, 316, 322–3, 324–5 Use of Pleasure, The (Foucault), 152 vaccines and vaccination: low-cost vaccines for developing countries, 189–90; pandemic influenza and stockpiling of vaccines, 178, 182–3, 189; resistance, 189–90. See also HPV (human papillomavirus) vaccination Valverde, Mariana, 6, 28, 34n11, 35n12 vulnerable populations: cervical cancer, 102; and environmental citizenship, 77; infectious disease, 171–2; mutual vulnerability and infectious disease, 179–82, 190; vulnerable empowered woman, 154, 160. See also aging; breast cancer and predictive genetic testing; disability; HPV (human papillomavirus) vaccination; pandemic influenza and policy planning Waller, J., 89 Walsh, Diana, 267 Walters, William, 181

Wardle, J., 89 wealth inequalities. See inequities, social and health Weir, Lorna, 186 welfare programs: activation technologies, 114; charity vs welfare, 243; deservingness, 9, 241–2, 243; disciplinary methods, 321; eligibility programs, 227; gendered eligibility requirements, 227–8; history of, 18; individual vs community responsibilities, 243; intersectional approaches to, 17, 27; as moral hazard, 281; neoliberal damage to, 8, 226–7, 243; and responsibilization of individual, 11; SMAS funding as, 320–1; stigma of, 292; unfreedom, 227–8, 241, 243 Wetherell, Margaret, 114 WHO (World Health Organization) and pandemics: about, 21–2, 168; documents on planning, 174–5, 177, 178–80, 186; IHR (International Health Regulations), 170, 180, 182; planning for pandemic phases, 182; preparedness discourse, 21–2, 168–9, 188–9; responsibilization of nation-states, 188; securitization of global health, 175–7; uncertainty discourse, 21, 168, 177, 184–5. See also pandemic influenza and policy planning; securitization and infectious disease Whole Foods Market, 56–7 “Whole-of-Society Pandemic Readiness” (WHO ), 178–9, 186 Williams, Penelope, 149–50 Withers, A.J., 310–11 witnessing disease, 145, 153, 155, 156, 160 women: aging workers, 126; and authoritarianism, 16–17; caregiving labour, 121–2, 126, 273n1; and choice, 16; clerical workers, 24, 285–97; con-

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tingent employment, 283; defunding of women’s health organizations, 16, 34n9; financial insecurity, 121–2, 126; homelessness, 229, 230, 233, 240; knowledge workers, 270–1; marginalization of, 22–3; mental health, 228, 231; neoliberal co-optation of feminist discourse, 14–15; pension inequities, 121–2, 126; poverty in Ontario, 227–8; responsibilization of, 19; stratified biomedicalization and social inequities, 154; wage gap, 270; welfare programs, 227–8; worklife balance, 50, 60. See also body of the female; gender; maternal responsibilization Women’s Health Contribution Program, 34n9 Women Welcome (WW ) agency. See community-based agencies and gifts workers and workplaces: neoliberal modes of governance, 13–14; as sites for subjectivity, 23–4; workplace disorganization, 284. See also

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contingent employment; flexible employment; knowledge workers; occupational health and safety; temporary work agencies work intensity, 249, 260–2, 265–6, 269, 270–2, 301 work-life balance: flexible workers, 248–9, 259–60, 267–9, 272; stress, 259, 264–5; women’s management of, 50, 60 World Health Organization. See WHO (World Health Organization) and pandemics WW (Women Welcome) agency. See community-based agencies and gifts Yoshida, Karen, 315 youth as sexually “at risk,” 93–4. See also sexuality of female tweens youth obesity. See children and obesity Ziarek, Krzysztof, 267 Zoller, H.M., 271