Abstract
The use of the category “race/ethnicity” intensified in the field of U.S. Public Health following the Clinton administration’s announcement of a budget increase for research focusing on ethnic and racial disparities in health. This article discusses the ways in which racialized difference is produced and represented as an object of knowledge and regulated by discursive practices in public health documents from U.S. federal government offices and a major public health journal published between 2001 and 2013. Races are approached, following Foucault’s proposition, as the product of racism, a technology of power of the modern State that consists of fragmenting humanity to permit colonizations. Thus, “race” has been established within the discourse to mark difference. Racism has developed concomitantly with the affirmation of power over life aimed at ruling out bodies and populations through public health practices, among others. The results suggest that the discourse on race varies throughout time. They indicate the relative permanence of a racialized regime of representation that consists of identifying, situating, and opposing subjects and groups based on standardized labels. This regime constitutes an ensemble of representational practices, which, together with disciplinary techniques and the use of culture as an idea, lead to the characterization and formation of racialized objects and stereotypes. These operations tend, together with medicalization and culturalization, to naturalize difference and constitute racial identities.
Introduction
In the late 1990s, the Clinton administration decided to finance public health research to eliminate the phenomenon identified as “racial and ethnic disparities in health” in the United States. In so doing, the administration proposed the improvement of the health of “minorities” by funding public health research and knowledge transfer activities, strengthening networks, and mobilizing the Surgeon General’s Office to develop awareness, education, and preventive programs (U.S. Department of Health & Human Services, 1998). At first sight, this political decision seems to mark a radical shift from earlier 20th century practices when, for example, public health officials in Los Angeles participated in producing Mexican, Chinese, and Japanese immigrants as racialized “Others” (Molina, 2006). Through media, policies, and guidelines, public health discourses contributed in shaping stereotypes of these racialized categories: Some were portrayed as “unclean,” “dirty,” “unhygienic,” or “germ-spreading.” These stereotypes could then legitimize other discourses and, as a result, many immigrants were excluded from full social participation. Similarly, U.S. colonial public health practices in the Philippines, in establishing rules of behavior for American soldiers, shaped the image of the “White” as opposed to the “Other” (Anderson, 2006). Principles and practices of Tropical Hygiene would gradually regulate the everyday life of American soldiers who were encouraged to dress and behave in ways such that sickness and madness would be avoided. Again, in the 1920s and 1930s, Fee (1993) reminds us that syphilis, which had originally been associated to vice and prostitution, was redefined as a “Black” disease given the links to stereotypes of Black individuals’ sexual promiscuousness.
In this article, I reflect on the racialization of contemporary U.S. public health in light of the concept of biopedagogy, which refers to institutional practices that offer individuals ways to understand and change themselves and others (Wright, 2009). My work is based on an ethnographic study of a corpus of public health documents from federal (U.S.) government offices (i.e., the websites of the Office of the Surgeon General and the Office of Minority Health [OMH]) as well as the American Journal of Public Health published between 2001 and 2013 (see Cloos, 2015). Following Foucault’s writings, postcolonial and cultural studies, I suggest that contemporary public health practices participate in reinforcing and reconfiguring racial difference. In addition, they propose and broadcast new racial meanings through knowledge-making processes and knowledge transfer (e.g., campaigns, education, prevention). In so doing, public health discourses continue to feed the debate about “human races” with scientific “truths”; a debate that started with modern colonialisms about three centuries ago. I also suggest that public health transmits very ambiguous if not paradoxical messages about the links between “race” and health/disease, and about the nature of racial difference. I discuss some of the ways in which public health discourses, through racialization, attempt to discipline bodies, and provide schemes by which individuals and groups have the possibility to represent themselves and “others.” As suggested by Wright (2009), the body can be seen as a political space, a space of application of biopedagogies. Moreover, I suggest that the body is also a political site that permits the production of difference that refers not only to the individuals but also to the group. I show how public health practices put into operation a process of racialization to inform and attempt to convince people how they should understand their bodies and how they should behave to experience a healthy life.
Public Health as Discourse: Between Power and Knowledge
From the 18th century, public health gradually became a field of knowledge, following the application of various disciplines to the health domain and the transition from an individual into a collective perspective (Fassin, 2005). Public health, together with medicine, also expresses a biopower, a political right “to make live and let die,” which was put in place by end of the 18th century to govern humans (Foucault, 1976, 1997). Foucault suggests this new political power is made up of two technologies: The first, which emerged in the 17th century, looked at disciplining individual bodies and, the second, which came to be added to the first in the following century, aimed at controlling life events (e.g., births, deaths, diseases). The mechanisms of disciplinary technology are to scrutinize, inspect, train, and use individual bodies for surveillance purposes and to improve work performance. Foucault referred to “biopolitics” as the other side of this power on life to control population phenomena by the establishment of mechanisms such as prediction, statistical estimations, and global measures to intervene, modify, or lower morbidity and prolong life. This biopolitic is carried out through institutions such as the medico-hygienist apparatus whose function consists in regulating public hygiene through the coordination of health care, centralization of information, normalization of knowledge, education, and the medicalization of population (Foucault, 1997).
Public health is viewed in this context as a “discourse” (Foucault, 1969), a notion that allows reflection and linkages between practices (i.e., representations, disciplinary techniques, and biopedagogies), objects of knowledge, and power. A discourse can be seen as an ensemble of heterogeneous devices (including institutions, norms, techniques, types of classification, and modes of characterization) that determines the way one names, analyzes, and explains an object, thus ensuring its formation at a moment of history (Foucault, 1969). The discourse shapes the object of knowledge (about health and disease)), the way to talk and think about it, and the way in which to behave in relation to it (Hall, 2003). The public health discourse engages practices that transform a situation into a “priority” or a “problem” that is perceived as pathological and that deserves intervention and change. The notion of “healthicization” allows the understanding of the emergence of a “public health problem” such as obesity or diabetes through practices that lead to both (scientific) knowledge and intervention. The operations associated with this process give a populational and collective dimension to a medical issue as a result of public health techniques and studies, media, and political fields. The medical language is progressively transformed into terms such as screening, frequency, risk, prevalence and incidence, and preventive measures—terms that address population and not individual cases. Healthicization allows connections between a group and the body, and between scientific knowledge and intervention.
As indicated on the U.S. Department of Health & Human Services (HHS) website (www.hhs.gov), federal health agencies are involved in the design and implementation of initiatives and strategies that look at informing, educating, and increasing awareness among the population on selected diseases and health-related practices and behaviors. Guidelines and information are provided to the public through various national health institutions with regard to physical activity and nutrition, healthy lifestyle, immunization, and health screenings. Governmental institutions fund projects and provide grants, collaborate with academic institutions in the knowledge-making process, and create regional partnerships. The Surgeon General, who is presented as the national reference for public health, is an officer of the U.S. army and is nominated by the President. In 2011, the Office of the Surgeon General released the National Prevention Strategy, a plan that aims at improving the health of citizens through various priorities such as tobacco control, preventing drug abuse, healthy eating, and active living. This plan is addressed to all segments of the nation therefore making all responsible (i.e., state and local policy makers, business people, health care providers, communities, families, and individuals) for improving the nation’s well-being. One of the proposed strategic directions to improve public health is to eliminate health disparities in focusing on “communities at greatest risk” such as “racial/ethnic minority groups” (U.S. Department of Health & Human Services, 2011).
Biopedagogies can be seen as discursive practices that are mobilized by such public health institutions and that take part in the healthicization process. In the framework of the “obesity epidemic,” Wright (2009) argues that both individuals and population are affected by normalizing and regulating practices that are disseminated through various social institutions such as schools, media, and government. Consequently, individuals are subjected to surveillance and self-monitoring based on knowledge and instruction on how to act to be “healthy” and protect themselves and others from such risks. Biopedagogies are viewed as practices that function as part of biopower, and, as such, can influence people’s beliefs and behaviors in relation to their bodies (Harwood, 2009; Wright, 2009). Furthermore, as Foucault (1997) has argued, with the emergence of biopower, another power came to be inscribed in the mechanisms of the modern state: racism.
The Racialization of U.S Public Health
The U.S. health domain is intimately associated with the idea of race (Afifi & Breslow, 1994; Meckel, 1997). The OMH was created in 1986 with the mission of improving and protecting the health of “racial and ethnic minorities” through policies and programs. Since 2000, the reduction of “racial and ethnic disparities in health” has been on the agenda of Healthy People, a national program that is redefined every 10 years. This initiative attempts to increase general awareness of the problem, and creates networks between governmental institutions, communities, and private and public sectors for individuals to make “informed decisions” based on “scientific knowledge.”
The Racialized Body: A Political Space Between Life and Death
“Race” can be seen as a form of differentiation that is used to produce differences and distinctions (Dorlin, 2009). Like sexuality, “racial difference” refers to bodies and populations, and this reason partly explains why it is attractive to the health domain (Foucault, 1997). Furthermore, as we will see, it allows the application of disciplinary and regulative practices. According to Foucault (1997), races emanate from racism, a technology of the modern state that is a power to death; a power that appeared with the emergence of biopower in modern states. The first function of racism, says Foucault, is the fragmentation of humanity into races while its second function is to establish a biological relationship between one’s own life and the death of an other. It is therefore essential to understand that the body became not only a disciplinary site for biopower but also a discursive site to create “difference” and produce racialized knowledge (Hall, 2003) as a form of knowledge that accompanied the concomitant development of nation states in Europe and North America (Loomba, 2005). It had become clear that the body had become a site that informs, establishes, and explains difference (Appiah, 1998).
Racialization can be understood as an operation that constructs in racial terms both the object of knowledge and the intervention. This process is made of practices that transform the population into groups according to “color tags” (Appiah, 1998). This operation, which consists of identifying and positioning subjects and groups in relation to each other according to body features, deletes individual subjectivities under the same label: In this sense, a person becomes racialized and “an object among other objects” (Fanon, 1952/1971). Racialization allows the inscription of difference in the process of sanitary problematization and, consequently, permits disease characterization (or behavior, life, and mortality) in fragmenting the population while catalyzing healthicization. An example of this is when it is suggested that “thirty-one percent of Hispanic children, 23% of Black children, 16% of White children, and 14% of Asian children [are] obese” (Thorpe et al., 2004, p. 1497). This process has a tendency to homogenize and fix groups and exclude those who do not respond to institutionalized norms nor to required statistical methods (Cloos, 2012). While identifying problems and elaborating interventions, public health practices and institutions produce an “other.” In so doing, public health gives racialized bodies more than a biological significance. Following Wright’s (2009) suggestions regarding biopedagogies, public health practices also give a social meaning that relates to identity or subjectivity. In this sense, biopedagogies are part of a discourse that shapes diseases and behavior-related knowledge and representations about the groups that are associated to it, and, by extension, individuals who are identified to these groups.
The Production of Stereotypes and the Making up of People
Do you think of yourself as (1) White; (2) Black or African American; (3) Hispanic or Latino; (4) Asian American; (5) Hawaiian or Pacific Islander; or (6) American Indian or Native American. (Neumark-Sztainer, Story, Hannan, & Croll, 2002, p. 845)
Since 1790, the United States always collected information with regard to the category of race in censuses although some categories change regularly (Oppenheimer, 2001; Richomme, 2007). At present, as indicated in the above quote, the “race/ethnicity” classification refers to six categories based on the norms of the Office of Management and Budget, a federal office. Therefore, this practice is agreed on at the political level. By using “race,” public health puts into operation a process of classification that aims not only at identifying people based on physical and/or cultural criteria but also at locating them in relation to each other. Reciprocally, people identify themselves to these labels in the absence of any rigorous kind of criteria that would define who has come to be considered as “White” or “Black” or “Asian.” It seems that racial identity became a convention in the United States despite its contextual (Oppenheimer, 2001), arbitrary (Krieger, 2003), and blurred (Appiah, 1998) aspects. Moreover, “no consistent racial groupings emerge when people are sorted by physical and biological characteristics” (U.S. Department of Health & Human Services, 2001, p. 7). It also has to be acknowledged that boundaries between “race,” “ethnicity,” and “culture” appear to be porous in public health studies and even interchangeable (Cloos, 2011, 2012, 2015).
Fassin (2005) indicates that public health puts into operation a process of culturalization through the production of statements about the culture of the subjects to which the intervention is directed. This process attempts to transform people’s representations, beliefs, and practices so they can be healthier or live longer. One consequence of such process is the characterization of both the disease and group (Hacking, 1992). Consider, as an example, the following excerpt from Guarnaccia et al. (1993) cited in the 2001 Report of the Office of the Surgeon General: “some Latino patients, especially women from the Caribbean, display ataque de nervios, a condition that includes screaming uncontrollably, attacks of crying, trembling, and verbal or physical aggression” (p. 11)). I agree with Hall (2003) that the creation of stereotypes plays a major role in the representation and the production of “racial difference.” This operation helps to reduce some groups to a few characteristic and simplistic images, which confirm the symbolic order.
Public health knowledge and recommendations that inform intervention are produced by practices that identify and target specific groups, their problems, and their needs. Racial categories are used to allow the identification of a public health problem and to design an intervention. Reciprocally, racial categories become part of the problem because of associations with specific diseases or certain behaviors or, alternatively, because of hypothesized biological differences, as in, “biologically, racial differences in insulin action have been documented” (Thorpe et al., 2004, p. 1499).
Racialized knowledge is often produced in an oppositional manner, reproducing binaries such as “White/non-White” or “Whites/minorities.” For example, Needle et al. (2003) suggest that there is a “disproportionate ongoing HIV/AIDS crisis in racial/ethnic minority populations” (p. 970). As a result, millions of people are potentially associated with a “crisis.” Despite the fact that, among them, the vast majority is not and will never be affected by HIV, such discursive practice brings together, in the same bag, millions of very different people in terms of language, socio-economic status, practice, and occupation. Another example from the National Prevention Strategy (National Prevention Council, 2011) illustrates these practices of opposition and difference: As compared with non-Hispanic Whites, African Americans show high rates of homicide and sexually transmitted infections (STIs), while American Indians have a particular problem of alcohol-related death, and Hispanics, of STIs and childbearing. The U.S. public health carries out a process of racialization: It produces racialized groups that are characterized in terms of behaviors and diseases, and reciprocally, it gives racial meanings and a social dimension to disease. These practices are well illustrated in the OMH and the 2001 Report of the Surgeon General. Each “minority population” is described according to demographics (population number, age, sex), history, geography, socio-economic characteristics (education, income, mean family size), behaviors (alcohol, tobacco, obesity), causes of mortality, and risk factors for some diseases (cancer, diabetes, cardiovascular diseases, HIV/AIDS, etc.). The characterization of American Indians and Alaska Natives (AI/ANs) is made through statistics for selected indicators and diseases, and comparison is made with the “non-Hispanic Whites” who are the reference:
American Indians and Alaska Natives have an infant death rate 60 percent higher than the rate for Caucasians. AI/ANs are twice as likely to have diabetes as Caucasians. AI/ANs also have disproportionately high death rates from unintentional injuries and suicide. In 2010, the tuberculosis rate for AI/NAs was 5.8, as compared to 2.0 for the White population. (OMH, n.p.)
Based on the profile presented by the OMH, we come to know racialized groups through very schematic pictures made of both spatialization and statistics. This form of knowledge is about practices made by comparison, inclusion–exclusion, generalization, diagrams, rates, norms, diseases, behaviors, average, life, mortality, and prediction. In this way, we come to know “Black” and “White” people through obesity rates. “Black” people are represented in a way that suggests that they are generally fatter than “Whites.” Similarly, we come to know “White” people somehow by default and in comparison with the “Other,” as in this excerpt, “in comparison with White women in this sample, African American women were somewhat less educated, younger, much less likely to be married, more likely to be obese, and more likely to be living in poverty” (Dole et al., 2004, p. 1359) or this other one, “[the] African American race was found to be the stronger risk factor for HIV infection” (Clements-Nolle et al., 2001, p. 917). The racialization of public health practices allows for the creation of knowledge and the production of stereotypes that serve the purpose of the intervention into specific segments of the population.
The Racialization of Biopedagogies
Federal agencies broadcast information, messages, and recommendations about health issues through radio networks, private and public sectors, community-based organizations, nutrition and recreational programs, press releases, and, more recently, health information technologies (websites, tweets, Facebook, SMS messages). Wright (2009) suggests that the meanings associated with the body are constituted in various “pedagogical sites” and that such sites have the power to influence learners and how they come to see and act on themselves and others. As such a site, the OMH supports several initiatives that are tailored to each “minority” group and that promote what is referred to as “healthy behaviors.” For example, the OMH promoted “9 A Day,” a national campaign to “encourage African American men to eat 9 servings of fruits and vegetables a day. African American men are among the most seriously affected by diet-related chronic diseases, and have the lowest overall consumption of fruits and vegetables” (HHS, 2003). In collaboration with other federal health agencies, the OMH (http://minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlID=50) also aimed at
preventing, treating and controlling Hepatitis B viral infections in Asian Americans, Native Hawaiian and Pacific Islanders. More specifically, this plan will aim at educating the community about risk factors and encourage testing through community based organizations, culturally based interventions, educational materials, and the training of health care providers.
The notion of “culture” can be located at the intersection of knowledge and intervention. Like the idea of race, “culture” can be seen not only as the explanation for but also the solution to the problem. Earp et al. (2002) reported on a “culturally appropriate” intervention to promote mammography among African American women living in rural settings. This meant that the intervention had to be sensitive to the “culture” of the targeted (racialized) population. In other words, some kind of “cultural knowledge” about the group had to be acquired with regard to, for example, language, histories, beliefs, values, and cultural identity (U.S. Department of Health & Human Services, 2001); coping response styles (Whaley, 2004); social norms regarding body shape, eating, and physical activity patterns (Neumark-Sztainer et al., 2002); and cultural factors that could explain disparities and could therefore be relevant for the design of an intervention dedicated to eliminate disparities. In short, while shaping the intervention, cultural and behavioral factors both describe and produce the group.
The Native Diabetes Wellness Program is another example that illustrates the racialization of public health practices and the mobilization of the notion of culture within recommendations to be healthy. In this context, the meaning given to healthy bodies and communities encompasses racial and cultural identification. To think about one’s self as healthy requires to think about one’s self as racialized and culturalized subject, to identify as part of a racial and cultural group. This program is part of the Centers for Disease Control and Prevention (CDC) (http://www.cdc.gov/diabetes/projects/ndwp/about_ndwp.htm) and aims at promoting health among AI/AN communities through the re-appropriation of traditional knowledge, practices, and food while reclaiming cultures and identity. Based on this program, high prevalence of diabetes among AI/ANs stems from historical and social changes in relationships with the land, which affect ways of living. Therefore, the solution for better health resides in the return to cultural traditions such as harvesting traditional food, dancing, playing games, and listening to elders. For that purpose, the CDC offers grants for “Traditional food projects” that look at “restoring traditional ways of living.” According to this perspective, tradition is the way for AI/ANs to think about themselves as healthy and their body, as free of diabetes. “Culture” as “tradition” becomes the solution to rediscover health and identity among AI/ANs, and the notion of sovereignty is reduced to traditional food recipes, as suggested by the CDC (2013). A return to a mythical past, food tradition, and group cohesion seems to be the solution, keeping in mind that health is the responsibility of AI/ANs.
Everhealthier Women is a third concrete example that illustrates the operationalization and the racialization of biopedagogies. This project is a “mobile web app” that aims at helping “minority women take control of their health” in managing health tasks (e.g., screening and prevention behaviors) for themselves and others through new technologies (mobile web and SMS text messaging). This project won first prize in the Reducing Cancer Among Women of Color Challenge from the OMH, in partnership with a Health Information Technology national agency (http://www.hhs.gov/news/press/2013pres/05/20130515b.html). The message used by this technology is racialized in providing the following information: “African American women are more likely to die from cancers; Latina women are more likely to get cervical cancer; Asian women are less likely to access regular cancer screenings.” The technology recommends some actions to individual users, according to age and gender (e.g., “protect your skin,” “breastfeed your baby,” “eat healthy,” “get active,” “manage stress,” “use condoms,” “get tested for HIV,” “get important shots,” “talk with your doctor about depression”). The user can have more information about each “action” and can be reminded of an action to be taken by providing a date, a telephone number, or email address, and the person can share information with her network.
The racialization of biopedagogies allows the reaching of specific targets, (racialized) bodies and groups, according to identified problems and priorities although basic health instructions remain universal. This means that if biopedagogies, through the ideas of race and culture, tend to oppose and reproduce difference, health as an ideal (often represented by the image of the “healthy White”) and related behaviors remain the same for all. However, it seems that some barriers impede this quest. Racism (and not only racialization) continues to affect health care practices in the sense that some would benefit from some services while others not (van Ryn & Fu, 2003). In brief, in the United States, the governmental public health’s cultural approach to disease tends to ignore the political and social contexts from which diseases emerge.
Conclusion
In this article, my attempt was to show that in U.S. public health, the process of racialization comes to be added to healthicization to shape knowledge and intervention. In other words, public health practices, including biopedagogies, are racialized. This means that people are instructed on how to live and behave with reference to physical (and/or cultural) attributes. In so doing, public health still participates in the reproduction of difference and otherness. Furthermore, in contemporary U.S. public health studies, some authors still see “race” as a risk factor that is only partly modifiable. Today, cultural, behavioral, and biological factors are part of the explanations of racial disparities in health although some authors point to racism and socio-economic factors as the main reasons for such inequalities (Dressler, Oths, & Gravlee, 2005). Health practices therefore participate in reinforcing the biological and/or cultural dimension of the idea of “race.” According to Appiah (1996), racial labels can have negative consequences because they are associated with historical and social attributes that mark people and groups. The public health discourses produce social identities in constructing the “other” while shaping the “self.” Public health practices are part of a discourse that both produces and gives meaning to racial difference: The “White” is globally presented as the reference and the norm, the one who has the better health, the wealthier. In so doing, public health and other health institutions participate in shaping identities based on an idea of difference that was invented centuries ago within the framework of modern colonization.
Much remains to be said about the way public health and biopedagogies are or are not effective in the determination of identities and people’s health-related practices, especially in a context of power relationships still shaped by colonialism and racism. Azzarito (2007) refers to The Autobiography of a Brown Buffalo to discuss the tensions and paradoxes created by health education messages (i.e., within the framework of the fitness movement in the 1950s-70s United States) and expressed by Acosta, a Mexican immigrant. According to Azzarito, Acosta associated fitness with “Whiteness,” American identity, social success, and citizenship—an image that created a feeling of identity loss that lead to practices of resistance to assimilation. In the end, we must agree with Hacking (1992) that types of persons are created with the labels and corresponding descriptions created by the “experts.” In limiting the number of categories, it seems that public health limits the possibilities of being. The “imaginary world” (Appadurai, 1996) of U.S. public health is often presented as static, binary, and in which the norm is racialized. De Boeck and Plissart (2005) reminds us that, while looking for homogenization, the state has continually produced difference allowing for exclusion and stigmatization.
Footnotes
Declaration of Conflicting Interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The author thanks the Social Sciences and Humanities Research Council of Canada for its PhD scholarship leading to his reflection on the racialization of U.S. Public Health.