On the perils of invoking neoliberalism in public health critique

Introduction

Read any issue of Critical Public Health and you’re more likely than not to see the concept of ‘neoliberalism’ invoked at some point. Inputting it as a keyword in the journal brings up 93 papers, and it features prominently in the title of three articles on our ‘most cited’ list: ‘Understanding health promotion in a neoliberal climate and the making of health conscious citizens’ (Ayo, 2012), ‘Neoliberalism, public health, and the moral perils of fatness’ (LeBesco, 2011) and ‘Aboriginal mothering, FAS prevention and the contestations of neoliberal citizenship’ (Salmon, 2011). The growing frequency with which the concept is invoked amongst authors publishing in CPH has led us to joke, on more than one occasion, that perhaps we should modify our name to Critical Public Health: the Negative Impacts of Neoliberalism.

In light of the growing prominence accorded to the concept of neoliberalism in (and of course beyond) the journal, it therefore seems like a good time to take stock of our conceptual equipment to ensure that it does what we think it does and want it do. Reminded of Latour’s (2004) injunction to think critically about critique, in this editorial we simply want to do ‘what every good military officer, at regular periods, would do: retest the linkages between the new threats he or she has to face and the equipment and training he or she should have in order to meet them’ (p. 231). Indeed, we can’t help but notice that much like the concept of ‘society’ before it, when the term neoliberalism is invoked it is often used to

jump straight ahead to connect vast arrays of life and history, to mobilize gigantic forces, to detect dramatic patterns emerging out of confusing interactions, to see everywhere in the cases at hand yet more examples of well-known types, to reveal behind the scenes some dark powers pulling the strings. (Latour, 2005, p. 22)

What is ‘neoliberalism’?

Broadly speaking, neoliberalism refers to the capitalist restructuring that has occurred around the globe since the 1970s in the name of a ‘post-Cold War, post-welfare state model of social order that celebrates unhindered markets as the most effective means of achieving economic growth and public welfare’ (Maskovsky & Kingfisher, 2001, p. 105). Thatcherism in the UK and Reaganism in the USA are often highlighted as prototypical manifestations of neoliberalism; however, policies informed by a similar market-centric logic were introduced in a more moderate form in a variety of social democracies (e.g. Canada, New Zealand, Australia, Sweden) (Brenner & Theodore, 2002; Maskovsky & Kingfisher, 2001; Ward & England, 2007). They were also exported to the Global South through the structural adjustment and fiscal austerity programmes enforced by institutions such as the World Bank and the International Monetary Fund (Brenner & Theodore, 2002).

In its strictest sense, neoliberalism refers to a macro-economic doctrine, but there is huge variation in the ways the term is employed in contemporary scholarship (Ferguson, 2010). Although its conceptual intelligibility is often taken for granted (Garland & Harper, 2012), neoliberalism is variously used as:

a sloppy synonym for capitalism itself, or as a kind of shorthand for the world economy and its inequalities … a kind of abstract causal force that comes in from outside to decimate local livelihoods … [or] a broad, global cultural formation characteristic of a new era of ‘millennial capitalism’ – a kind of global meta-culture, characteristic of our newly de-regulated, insecure, and speculative times. And finally, ‘neoliberalism’ can be indexed to a sort of ‘rationality’ in the Foucauldian sense, linked less to economic dogmas or class projects than to specific mechanisms of government, and recognizable modes of creating subjects. (Ferguson, 2010, p. 171)

Indeed, Ward and England (2007) have identified four distinct understandings of neoliberalism in the social sciences: (1) neoliberalism as an ideological hegemonic project; (2) neoliberalism as policy and programme (e.g. policies enacted under the banner of privatization, deregulation, liberalization, etc.); (3) neoliberalism as state form – i.e. the ‘rolling back’ and ‘rolling out’ of state formations in the name of reform; and (4) neoliberalism as governmentality – the ways in which the relations among and between peoples and things are reimagined, reinterpreted and reassembled to effect governing at a distance.

In light of this eclectic usage, scholars are now examining the relationships between neoliberalism and everything from ‘cities to citizenship, sexuality to subjectivity, and development to discourse to name but a few’ (Springer, 2012, p. 135). Although these versions of neoliberalism often intersect with each other, they can also lead to very different readings of the same phenomena. For example, taking a political economy perspective, Otero, Pechlaner, Liberman, and Gürcan (2015, p. 48) use the term ‘neoliberal diet’ to characterize the high levels of consumption of energy-dense, low-nutrition ‘pseudo foods’ amongst the working class; however, Foucauldian governmentality perspectives are more likely to characterize a neoliberal diet as precisely the opposite of this – as one that encourages the individual to take responsibility for his or her health by consuming more fruits and vegetables (e.g. Ayo, 2012). When a concept can be used to describe such an extraordinary – and even downright contradictory – array of phenomena, questions can clearly be asked about how useful it actually is.

Perhaps a larger issue is the reductive ways neoliberalism often tends to be used. As Phelan (2007) observes, in a number of accounts its effects are so totalizing and monolithic that it starts to assume causal properties in its own right; ‘that is, it becomes the “it” which does the explaining, rather than the political phenomenon that needs to be explained’ (Phelan, 2007, p. 328). Consider, for example, neoliberalism as governmentality – one of the more common ways the term is employed by CPH authors. As Kipnis (2008) observes, the key defining features of this variant of neoliberalism: governing from a distance; the emphasis on calculability; and the promotion of self-activating, disciplined, individuated subjects, can be found in a variety of contexts that are historically and culturally distant from Western neoliberal or liberal governing philosophies. In his words, ‘These three categories correspond to broad human potentialities that have been imagined in a wide variety of ways in a broad range of settings and that have become more prevalent in all state-governed and industrial societies’ (p. 284, emphasis added). Thus, characterizing such features exclusively in terms of neoliberalism runs the risk of exaggerating its scope by reifying it into a globally dominant force or stage of history (Kipnis, 2008). It also runs the risk of eliding other processes that deserve analytic attention in their own right. For such reasons, there have been growing calls to explore neoliberalism in terms of ‘concrete projects that account for specific people, institutions and places’ (Kingfisher & Maskovsky, 2008, p. 118) – what Brenner and Theodore (2002) refer to as ‘actually existing neoliberalism’.

Some suggestions for the way forward

Theoretical concepts such as neoliberalism clearly have their uses: they signal to readers the kind of argument a writer is making, and act as a shorthand to summarize complex configurations of economic, political and cultural change that do, arguably, have some commonalities across different contexts. It is the role of theory to provide abstracted explanations that hold across time and place, and the concept of neoliberalism has been a fruitful one for thinking about some general implications of contemporary social change. However, over-extension has its risks, and there are now diminishing returns in simply documenting how technologies, policies or products ‘illustrate’ neoliberalism. To advance our understanding of how, specifically, public health is imbricated in the various manifestations of neoliberalism requires a more critical, nuanced and reflexive approach.

First, we need far more clarity on how the term is being used, rather than taking its meaning for granted. With the over-extension of ‘neoliberal’ to describe everything from welfare cuts to wearable health monitors, scholars need to unpack more carefully the particular processes to which they are referring. Rather than assume a deterministic role for those processes, the nature of the links between, say, welfare change and the impact on subjectivities needs to be explicated. As Meershoek and Hortsman (2016) note in this issue, merely reporting how health promotion reflects or contributes to neoliberalism does little to untangle the ‘material, technical and practical dimensions’ of how what kinds of health, and whose, are prioritized. Taking the commodification of workplace health promotion technologies as their case, they unpack how policies emphasizing employee health become legitimated within networks that include knowledge institutes and private companies, but not the workers themselves. Importantly, this focus on the process itself enables their analysis to point to not only the potential negative effects for public health of such commodification, but also ways forward, in political mobilization through workers’ organizations to incorporate different frameworks of well-being.

Second, we need more nuance and specificity in accounts. The question is not so much ‘what forms do public health outputs or technologies take in neoliberal times?’ but ‘how, where and in what forms do the various processes of neoliberalism impact public health?’ Two papers in this issue illustrate the value of more specificity. Hervik and Thurston (2016), in their account of how Norwegian men discuss their responsibilities for health, note that the specificities of the welfare state in Norway configure assumptions embedded in talk about ‘responsibility’. Rather than simply reading off the espousal of ‘personal responsibility for health’ as another reflection of neoliberal hegemony, Hervik and Thurston note that in this context, responsibility for health is rooted in a participatory model of the welfare state, in which principles of egalitarianism and social democracy may have very different implications for public health than in welfare states where the focus is on individual choice and self-sufficiency. Similarly, Nourpanah and Martin (2016) delineate both parallels and divergences between the discursive framings of health promotion described in Western states and those they document in Iran, where there is an absence of focus on consumption, despite similar orientations towards individual choice.

In general, rather than reifying neoliberalism as a monolithic entity, it may be more productive to speak of ‘neoliberalization’ as an always partial and incomplete process (Ward & England, 2007). This raises potentially fruitful questions around when, where, and in what ways the economic, political and cultural intersect with health. We need also to be reflexive about claims to neoliberalism, in that of course our critique is inevitably embroiled in the very processes it seeks to analyze. Indeed, it may be productive to think of neoliberalism as a discourse as much as a reality (Springer, 2012). In sum, we are not calling for the abandonment of the concept – paraphrasing Clifford (1988) on yet another troubled notion (‘culture’), neoliberalism seems to be a deeply compromised idea we cannot yet do without. Thus, being more careful and mindful of how we use it seems a good place to start.

Kirsten Bell
Department of Anthropology, University of British Columbia, 6303 NW Marine Drive, Vancouver, BC V6T 1Z1, Canada
[email protected]
Judith Green
Faculty of Public Health & Policy, Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK