«Tactics of Diabetes Control Turkish immigrant experiences with chronic illness in Berlin, Germany. Cornelia Guell PhD by Research The University of ...»
[T]his power over life evolved in two basic forms [...]. One of these poles – the first to be formed, it seems – centered on the body as a machine: its disciplining, the optimization of its capabilities, the extortion of its forces, the parallel increase of its usefulness and its docility, its integration into systems of efficient and economic controls, all this was ensured by the procedures of power that characterized the disciplines: an anatomo-politics of the human body. The second, formed somewhat later, focused on the species body, the body imbued with the mechanics of life and serving as the basis of the biological processes: propagation, births and mortality, the level of health, life expectancy and longevity, with all the conditions that can cause these to vary. Their supervision was effected through an entire series of interventions and regulatory controls: a biopolitics of the population. The disciplines of the body and the regulations of the population constituted the two poles around which the organization of power over life was deployed. (Foucault 1998 : 139; emphasis in the original) Foucault called these two techniques of power – anatomo-politics and biopolitics – bio-power (ibid. 140). Bio-power is acting on populations and their individual bodies as a form of governing the masses.
This research project may be readily located with a body of literature on biopower, as it looks at the public health issue of chronic illness in the population group of Turkish migrants. Foucault’s legacy is immense and, although his own work remained in the realm of theoretical, philosophical enquiry, it provides the theoretical basis for a plethora of empirical research, for example on public health and healthcare. Foucault’s popularity surely owes to a range of developments within the biomedical realm that his work pre-empted. On the one hand, biomedicine seems to have ever perfected the medical gaze and surveillance with its biotechnological advances in human genetics. On the other hand, biomedical resources are increasingly occupied with caring for chronic illness instead of curing infectious disease, so that prevention, the discipline of healthy living, have gained unprecedented significance.
Turner (1992) welcomed Foucault’s endeavour of bringing the body into social theory. “Essentially the argument behind the sociology of the body is, first, that sociology is genuinely a sociology of action, and that the social actor is not a Cartesian subject divided into body and mind but an embodied actor whose
practicality and knowledgeability involve precisely this embodiment.” (Turner 1992:
170) As Foucault’s frameworks offer such an abundant field of enquiry, the list of Foucault’s legacy could continue endlessly. An interesting compilation is the edited volume of Petersen and Bunton (1997) that includes contribution by Tuner alongside fascinating discussions, for example of surveillance in regard to menopause and hormone replacement therapy (Harding 1997), and an account of Brazilian health education as bio-power (Gastaldo 1997). Lupton’s The Imperative of Health (1995) investigates the public health movement and health promotion through Foucault’s lens. She discusses such issues as vaccine use and hygiene campaigns to “govern the masses”, and how risk management, its measurement, estimation and eliminations, stands at the centre of “taming uncertainty”. Health promotion aims to create wilful, docile bodies that refrain from risky sexual practices, extensive alcohol consumption or smoking.
The ethnography in this thesis, however, only speaks at first glance to the analytical framework of bio-power. While one may imagine institutionalised programmes to monitor the Turkish migrant population’s burden of diabetes and to “discipline” their bodies in health education, there was, at the time of this research, no epidemiological data on the diabetes prevalence of any minority groups in Germany, no interventions targeted at this patient group or official education offered in another language than German. That said, Turkish-origin doctors devised their own healthcare plans to care for their Turkish migrant clientele and Foucault (1998 ) indeed conceptualised bio-power as dispersed in institutions and their representatives rather than centralised.
Power/knowledge Foucault (1998 ) did not envision a “top-down” central power of direct rule, but a power that is local, diffuse and dispersed in various institutions, and that is represented in and reproduced through people. In this case of diabetes, bio-power would be asserted by the family doctor, the diabetes nurse, the newspaper health correspondent. Power, for Foucault (1980, 2000), is always intrinsically linked to knowledge; in fact, this link between systems of knowledge and power is so inevitable that he coined the term power/knowledge. Biomedicine, for example, is such a pervasive system of thought because it is represented in its various institutions of clinical spaces and by the medical profession that occupies such spaces and
teaches patients how they should understand and treat their bodies (Lupton 1997:
99). In his essay The government of the body (ibid. 177-195), Turner parallels Weber’s sociologically more established concept of rationalisation and ascetic practices with Foucault’s power/knowledge relationship. Tracing the “subtle connections between the body, knowledge and power”, he unpacks medical regimes of diet and “anxieties about obesity and dieting, slimming and anorexia, eating and allergy” (ibid. 192). Such social, political practices of food are embedded in a knowledge system that regards the body as a machine that requires surveillance and management and that employs “science in the apparatus of social control” (ibid.
This thesis will present ethnographic accounts on how knowledge on diabetes is negotiated by the research participants (Chapter 4). It will explore how diabetes self-management requires detailed knowledge on diabetes itself and strategies on how to conduct everyday lives in order to control diabetes well. In accordance to Foucault’s (1980) notion of power/knowledge, this diabetes knowledge is intrinsically linked to power relations. Many Turkish Berliners have no access to diabetes education that acknowledges their needs, for example in regard to language or diet. The Turkish-language education sessions offered by some Turkish-origin doctors guard knowledge in different ways, providing only very basic education for the alleged un-educated. Even within the self-help group power relations shape how knowledge is negotiated. Knowledge is, nonetheless, actively sought and challenged;
knowledge is indeed “practice” rather than an abstract entity (Foucault (1990 ).
Self-care In his last volume of the History of Sexuality, The Care of the Self (1990 ), Foucault shifted his attention from the disciplining of docile bodies to agency of committed self-disciplining selves. Again exploring history, he investigated ancient Greco-Roman moral economies of self-care. He found that body maintenance is not necessarily subject to disciplinary biopolitical governing but could be “technologies of the self” (Foucault 1997). In the classical age the notion of self-care was a conscious, voluntary, personal and ethical/normative exercise. This “self-mastery” was about the exercise of freedom, rather than being constrained by power/knowledge (Foucault 1990 : 34). Freedom, in his view, was not considered a given, but would be individually achieved through practices (Foucault 1997). These ancient notions of “self-reliance” (Foucault 1990 : 100), as he quotes Celsus, on knowing about healthy living practices such as diets and physical activity, cultivating the self for a better life quality, seem very contemporary values.
This later work started, although only as an emergent and unfinished new line of inquiry, to allow for a more complex understanding of body-politics and opened the floor for numerous contemporary readings of Foucault’s work that included active selves in their bio-studies.
On self-care, the volume of Petersen and Bunton (1997) that was mentioned earlier includes an ethnographic study on self-starvation that Eckermann (1997) describes as a technology of the self. To mention a contribution on diabetes, Ferzacca’s Actually, I don’t feel so bad (2000) is a study on diabetes selfmanagement in a U.S. veteran clinic. Ferzacca suggests that strict diabetes management regimes should not be considered as bio-power. While doctors and patients share a normative idea of the cultivated self that leads a productive life, the veterans engaged in idiosyncratic technologies of the self in order to fulfil such expectation.
A study on Russian immigrants with diabetes in the U.S. argues that these patients were non-compliant patients, not because they rejected the proposed selfcare recommendations but because they did not share the normative, neo-liberal ethics of productive, disciplined selves (Borovoy and Hine 2008). Here, there is no reference to Foucault’s self-care that describes ancient body ethics as the effort towards a more philosophically better person. Instead, ethics are believed to be rooted in neo-liberalism, that means that capitalism has produced ethical norms of discipline and productivity. There is a whole range of literature that finds explanation in neo-liberalism and a capitalist logic of productivity. Ritenbaugh’s study Obesity as a Culture-bound Syndrome (1982) explored American middle-class ideas about body control – mostly visible as a slim body shape – through physical exercise and certain dietary regimens. She argues that these are intrinsically Western concepts. A healthy lifestyle and a slim body has become a moral postulate in Western society and obesity, cardiovascular diseases and diabetes – all regarded as due to excessive calorie intake – are blamed on the patient’s own bodily ill-management. I am, however, suspicious of a too limited focus on neo-liberal mechanisms in health and lifestyle practice, for one, as Foucault suggests with his history of ancient self-care that such practices can have nothing to do with modern neo-liberal capitalist morals of productivity (cf. Nehamas 2005, The Art of Living).
The ethnography in this thesis that looks at self-care practices resonates is some ways with a Foucauldian framework. Rather than subjects of bio-power, the Turkish Berliner’s with diabetes engage in their own practices of disciplining their bodies. As official healthcare services do not acknowledge their special needs, they actively seek and negotiate education, knowledge and support in order to achieve better control over their illness (Chapter 4). Foucault offers us a scope of work that can help to understand contemporary examples of self-care. It enables us to ask as to whether the clinical ideal of an expert patient and diabetes self-management practices should be understood as bio-power, or whether patients step outside biomedical power/knowledge and achieve autonomous techniques of self-care. While the Turkish-speaking self-help group rehearse text book answers and follow clinical recommendations, they have to negotiate access to such knowledge and amend clinical recommendations in order to make them relevant to their social lives that are not envisioned in such standardised advice.
This leads to another question. Would Foucault grant his criminals, mad and sick of his earlier work, which he mentions no longer in his later work, such individual, active assertion of freedom? I am raising this question because, unlike Foucault’s previous work that mainly featured the controlled lives and bodies of marginalised people, the ill or criminal, the ethical quest of self-care was one of people from privileged backgrounds. By that I mean that the ancient texts he drew on featured men in ancient Greek and Roman society not women or slaves. Foucault did not address this himself (although this personal quest for freedom is deeply embedded in a society that tolerates slavery; Foucault 1990 ). This present ethnography sits uncomfortably between Foucault’s concept of bio-power that exerts an inescapable control over sick, marginal bodies and his notion of privileged bodily self-care that represents an ethical exercise towards a more perfect, “philosophic life” (ibid. 57). In this thesis I will not only argue that the marginalised can indeed engage in deliberate practices of self-care, mainly as bio-power seems to be largely uninterested in this population group. Moreover, such self-care is not based on ethical motivations but is a far more practical exercise, and concentrating the analytical perspective only on Foucauldian philosophical enquiry on freedom fails to address more immediate and thus relevant questions of bodily suffering.
Lupton (1995) scrutinised Foucault’s idea of self-care and suggested that healthy living and sports can be personal and deliberate practice. But rather than understanding such practices as Foucault’s ethical “technologies of the self” (1997), Lupton argued that such practices do not necessarily derive from an individual health awareness but simply create emotional, sensual pleasure (also in Lupton 1997). Such sensual experience can also be derived from resistance and non-compliance, for example from deliberate transgressions such as smoking (citing Klein 1993). Finally, Lupton alerted us to the possibility that health choices can be based on ideas of fate rather than hegemonic health imperatives (Davison et al. 1992) and that factors such as social class should be taken into consideration when dissecting Foucault’s docile bodies.
Contributions such as Lupton’s (1995, 1997) stress the importance to move beyond Foucault’s concepts of bio-power and self-care. As much as the concepts of bio-power and ethical self-care serve well to describe the systems of power/knowledge, institutions that patients seem to be at the mercy of, or personal standards they aspire to, such framework nonetheless limits possible avenues of understanding. While Foucault’s later work moved towards a history of self-care, active selves and their technologies, everyday lived experience remained at the margin of his ideas. I agree with Lupton (1997) that health and illness is inevitably about emotions and embodied experience, which is something Foucault was not interested in despite his insistence of bringing the body into the equation.