Original Article on the Politics of Self-care

HEALTHISM AND THE MEDICALIZATION

OF EVERYDAY LIFE

Robert Crawford
This article considers some implications of the new health consciousness and
movements-holistic health and self-care-for the definition of and solution to
problems related to “health.” Healthism represents a particular way of viewing the
health problem, and is characteristic of the new health consciousness and movements.
It can best be understood as a form of medicalization, meaning that it still retains
key medical notions. Like medicine, healthism situates the problem of health and
disease at the level of the individual. Solutions are formulated at that level as well.
T o the extent that healthism shapes popular beliefs, we will continue to have a
non-political, and therefore, ultimately ineffective conception and strategy of health
promotion. Further, by elevating health to a super value, a metaphor for all that
is good in life, healthism reinforces the privatization of the struggle for generalized
well-being.

The social effort to gain control over that part of the human experience captured
by the concept of health remains elusive. This paper is a tentative assessment of some
such efforts made in the late 1970s in the United States. A new popular health con-
sciousness pervades our culture. The concern with personal health has become a
national preoccupation. Ever increasing personal effort, political attention, and
consumer dollars are being expended in the name of health. The past few years have
witnessed an exercise and running explosion, the emergence of a vocal and often
aggressive anti-smoking ethic, the proliferation of popular health magazines, and the
appearance with amazing frequency of health themes in newspapers, magazines, and
advertisements for even the most remotely related products. Vitamins and other
health aids are being consumed more and other items consumed less-all for health
reasons. On numerous social occasions, and in spite of much professed rejection of
concern or derisive amusement, personal health has become a favorite topic of
conversation.
Certainly not for everyone. The health enthusiasts, those proclaiming by example
and advocacy a healthy life style, appear to be overwhelmingly middle class. While
working class struggles to shorten the work week, abolish child labor, and change
working conditions have historically been in part focused on health, and although
occupational health and safety has also generated a new interest in recent years, the

This paper was supported, in part, by the Kaiser Family Foundation through a grant to the
Institute of Society, Ethics and the Life Sciences for its Health Policy Research Group.

International Journal of Health Services, Volume 10, Number 3,1980

0 1980,Baywood Publishing Co., Inc.

365

doi: 10.2190/3H2H-3XJN-3KAY-G9NY
http://baywood.com
366 1 Crawford

current preoccupation with personal health displays a distinctive-although not exclu-

sive-middle-class stamp. This is particularly true of two new popular health move-
ments which have attained considerable attention and popular participation: holistic
health and self-care.
The holistic health movement, from which most of the examples in this paper are
drawn, is a rema:kably diverse challenge to orthodox medicine (1-6). It includes an
array of non-allopathic healers and their clients and an even larger assemblage of
adherents who have adopted many of its principles into a health and life philosophy.
Some of the healing methods utilized are various stress-reduction therapies such as
meditation and biofeedback, polarity therapy (“balancing life energy”), iridology
(“interprets the neural-optic reflexes in the sensitive tissue of the iris”), guided
imagery, nutritional therapies, movement or dance therapy, rolfing (“a technique
for reordering the body”), massage, and various healing methods adopted from
naturapathy ,homeopathy, and Native American and Eastern traditions (7,8). Holistic
health sees illness and health as not simply a physical matter, but also as emotional,
mental, and spiritual. Interested in the whole individual, holistic healers talk of
treating the person, not the disease. Oriented toward health promotion or disease
prevention, they (1):
. . . want to know how the people who come to them live and feel, what they eat
and smoke and how much they exercise, what kind of stress they have at work and
at home, whether they are satisfied with their achievements and their relationships
to other people.. . . Much of their therapeutic work consists of helping people to
see how their habits, attitudes, and expectations, the way they live and work, think,
and feel, are affecting their physical and emotional health, and of assisting them in
taking steps not only to prevent disease but to feel better.

In its broader philosophic orientation, holistic health is portrayed as “a way of being,”

an interrelation or balance of body, mind, and spirit, a concern with “high-level
wellness,” “super health,” or the “joy of life.” Often holistic health incorporates a
religious view, and both Western and Eastern religious practitioners and organizations
have promoted holistic health services. In all its manifestations, holistic health encour-
ages clients to become active participants in the healing process and to exert self-
responsibility. In this last regard, the holistic health movement has much in common
with another health movement of the 1970s.
Self-care and self-help, like holistic health, are also kaleidoscopic in their approach
to health and illness concerns (9-16). Unlike holistic health, there is little attention to
developing alternative healing methods or new professional healers. But like holistic
health, these movements often challenge professional medicine. They seek to reduce
the reliance of individuals on medical practitioners and substitute individual and group
activities aimed at improving health, coping with chronic disease, acquiring diagnostic
and therapeutic skills, and adopting disease prevention practices. Self-care is oriented
more to the transfer of medical competence to the individual. Ozonoff and Ozonoff
(1 6) describe the medical self-care literature as falling into several categories: “first
aid,” “triage,” “doctor substitute,” “self-improvement ,” and “consumer guidebooks.”
As defined by Levin (17, p. 206), one of its major proponents, self-care is “a process
whereby a lay person can function on his/her own behalf in health promotion and
 Healthism / 367

prevention and in disease detection and treatment at the level of the primary health
resource in the health care system.” Self-help, while doing many of the same things,
does them in groups. It evolves more from a tradition of mutual aid and a larger
self-help movement. In the case of women’s self-help, it is clearly a strategy within
the context of a political movement (18). In many concrete examples, however,
self-help and self-care become almost indistinguishable.’
This paper is a discussion of some of the implications of a particular way of viewing
the “health” problem. A previous paper (19) analyzing the ideology of individual
responsibility for health related that ideology to developments in the political
economy of the medical sector and American society at large. It focused on the
policy implications and symbolic functions of that ideology in resolving emerging
issues in favor of dominant political and economic interests. Without intending to
minimize these concerns, the present effort is a more in-depth and broader examina-
tion of the structure of that ideology. While the former was aimed more at elaborating
the instrumental or functional uses of the ideology, this is an attempt to identify
some of the concepts and suppositions of the new health consciousness. As a discus-
sion of ideology, by which I mean a socially and culturally constructed way of seeing,
interpreting, and evaluating some aspect of the physical and social world and the
relation of self to those worlds, it addresses the following questions: What explains
how the problem of “health” is understood at a particular historical moment? What
is the process by which cultures define certain activities, individual and collective,
as essential for health? Why are other activities excluded or neglected? These are
some of the most essential and complex questions for a political analysis of how
societies attempt to resolve problems related to the concept of health.
The ideas presented here are exploratory and heuristic. The paper is not a descrip-
tive account of these movements or other concrete manifestations of the new health
consciousness. It must be followed by ethnographic research (“the descriptive recon-
struction of common-sense knowing in everyday activity and social interaction” [20,
p. 4461). Further, even though the following remarks take the form of a critique, I
particularly hope they will be considered by the proponents of the new health con-
sciousness and not simply their critics. If, in our enthusiasm for changes oriented
toward creating new individual and social capacities freed from domination, we fail
to identify aspects which may contradict those objectives, we risk repetitive disable-
ment. Even the most radical challenges to orthodoxy are at best partial and always
contain within their conceptions and structure the very elements against which the
challenges are aimed. In the process, dominant ideologies and social structures are
reproduced. Whether from external manipulation or internal conception (in some
ways a false dichotomization), movements contain ideological contradictions from
their inception. After all, they develop within an ideological space which is already
constructed. Such contradictions cannot be grounds for dismissal, but neither should
they be ignored.

‘The following discussion is more relevant to self-care than to self-help, and more relevant to
those aspects of self-care concerned with health promotion or prevention of disease.
368 / Crawford

HEALTHISM AND THE NEW HEALTH CONSCIOUSNESS

I have chosen the word healthism as a way to crystallize some important contradic-
tions in the new health consciousness and movements (for a previous use, see reference
21). Briefly, healthism is defined here as the preoccupation with personal health as a
primary-often the primary-focus for the definition and achievement of well-being;
a goal which is to be attained primarily through the modification of life styles, with
or without therapeutic help. The etiology of disease may be seen as complex, but
healthism treats individual behavior, attitudes, and emotions as the relevant symptoms
needing attention. Healthists will acknowledge, in other words, that health problems
may originate outside the individual, e g . in the American diet, but since these
problems are also behavioral, solutions are seen to lie within the realm of individual
choice. Hence, they require above all else the assumption of individual responsibility.
For the healthist, solution rests within the individual’s determination to resist culture,
advertising, institutional and environmental constraints, disease agents, or, simply,
lazy or poor personal habits. In essence, then, cause becomes proximate and solution
is constructed within the same narrow space.
The new health consciousness is more inclusive than what is described here as
healthism. The more general heightened awareness and interest in health often includes
environmental and occupational health concerns as well as a concern for personal
health enhancement. Environmental awareness has been especially significant for what
is sometimes called the natural health movement. One can also find among the health
conscious, people with variously developed political understandings of how social
forces and processes systematically encourage unhealthy individual behavior, often
for private advantage. Tobacco and food-producing agribusiness have been the objects
of much adverse attention. The new health consciousness, in other words, is a complex
fabric and cannot be reduced to the thread of healthism or anything else. The ways
we think about and act upon our anxieties and hopes for health, our understanding of
what is to be done to promote or maintain health, and our notions of accountability
and responsibility are all in flux. Thus, a focus on personal health and individual life
style modifications may co-exist with and even act to stimulate attempts to change
social conditions detrimental to everyone’s health. As Katz and Levin (22) and
Gartner and Riessman (10) point out with respect to self-care and self-help, there
are numerous examples of politically activated groups which identify with these
movements.
Thus, even though healthism may not completely dominate the ideologies and
activities of the gamut of groups and individuals who consider themselves part of
this new health consciousness, the argument here is that to some degree this ideologi-
cal tendency is present in all of them. I will argue that the ideology of healthism
fosters a continued depoliticization and therefore undermining of the social effort
to improve health and well-being. As an ideology which promotes heightened health
awareness, along with personal control and change, it may prove beneficial for those
who adopt a more health-promoting life style (23). But it may in the process also
serve the illusion that we can as individuals control our own existence, and that taking
personal action to improve health will somehow satisfy the longing for a much more
 Healthism / 369

varied complex of needs. As such, healthism functions as dominant ideology, con-

tributing to the protection of the social order from the examination, critique, and
restructuring which would threaten those who benefit from the malaise, misery, and
deaths of others.
How health is popularly understood is in large part reflected in a society’s thera-
peutics. In turn, those therapeutics further structure cultural understandings (24).
Popular notions about health, in other words, help produce and are partially repro-
duced by the therapeutic mode. We live in a medical age. American culture has been
undergoing a progressive medicalization which partly can be understood by the fact
that medicine embodies some of the most fundamental propositions and characteris-
tics of this culture. Unless these propositions are understood, it will be possible to
combat medicine as an institution but leave intact (or reinforce) the cultural world it
“represents .”
The profound impact of medicine on the beliefs and activities of our society has
captured the attention of numerous observers of American social life (25-29). Con-
trary to claims and first impressions, the new health consciousness (in its healthiest
manifestations) entails a further medicalization of our culture, and, in particular, a
medicalization of how the problem of health is understood. While modifications of
dominant medical paradigms and practices are being adopted, some of the most
fundamental and disabling medical and other dominant cultural conceptions have
remained untouched.

MEDICALIZATION AS IDEOLOGY

Medicalization, a concept developed by sociologist Irving Zola (30), can be under-

stood as having two broad meanings. The first links an increasing range of social
phenomena with the institution of medicine-the profession of medicine, therapeutic
practice, and medical diagnosis. In this usage, medicalization is usually described as
an expansion of professional power over wider spheres of life, especially deviant
behaviors, replacing religious and legal actors and their modes of social control. As
medical professionals continually enlarge their jurisdiction, societal resources devoted
to activities assumed by physicians also increase and physicians become gatekeepers
for an ever-expanding number of social functions-functions which bestow both
benefits and penalties, privileges and exclusions (31). Zola argues (21, p. 42) that
medicalization in this sense is connected with two attributes of the profession: “their
control of their work and their tendency to generalize their expertise beyond technical
matters.” Indeed, such is the characteristic, according to Hughes (quoted in 21, p. 42),
which describes all professionals:
Not merely do the practitioners, by virtue of gaining admission to the charmed
circle of colleagues, individually exercise to do things others do not, but collectively
they presume to tell society what is good and right for the individual and for society
at large in some aspect of life. Indeed they set the very terms in which people may
think about this aspect of life.

The second meaning of medicalization refers to the extension of the range of social
phenomena mediated by the concepts of health and illness, often focusing on the
370 Crawford

importance of that process for understanding the social control of deviance. As Illich
notes (26, p. 118):
By naming the spirit that underlies deviance, authority places the deviant under
the control of language and custom and turns him from a threat into a support of the
social system. ttiology is socially self-fulfilling.

Social existence is increasingly circumscribed by the medical naming of that spirit.

More deviant behavior is defined in terms of sickness, and normalcy in terms of
health. Alcoholism, child abuse, opiate addiction, obesity, problems with sexual
functioning, and violence have all become matters for medical diagnosis, and the label
of illness has been attached to them (32). Also important is that as our society
becomes increasingly concerned with disease prevention and health promotion, more
social activity is thought about in relation to its effect on health. In other words,
prevention of illness becomes a more pervasive standard by which behaviors-eating,
drinking, working, leisure activities-are judged.
Of course, the two broad meanings are linked. The health/illness category has been
promoted by professionals and either directly or indirectly enhances professional
power. That is, medicalization in the first sense fosters medicalization in the second,
and vice versa. Freidson captures the essence of the interconnection (25, pp. 253-254):
The medical profehsion has first claim t o jurisdiction over the label of illness and
anything t o which i t may be attached, irrespective of its capacity to deal with it
effectively. In such a fashion d o we see the rise to social prominence of a social value
such as health is inseparable from the rise of a vehicle for the value-an organized
body of workers who claim jurisdiction over the value. Once official jurisdiction is
gained, the profession ih then prone to create its own specialized notions of what it
is that shall be called illness. While medicine is hardly independent of the society
in which it exists, by becoming a vehicle for society’s values it comes to play a major
role in the forming and shaping of the social meanings imbued with such value.

A strong case can be made that the new health movements and consciousness may
ultimately extend medical jurisdiction, even though they are presently developing in
relative autonomy from it (16, 33). This is secondary, however, to my principal
theme. Suffice it to say that the power of the medical profession and the extension
of professional jurisdiction should be distinguished from the power of a way of
thinking which is linked to but also detached from the medical profession-the cultural
dissemination of medical perception or ideology. The focus here is on the influence
of a medical way of seeing, with the impact of an already medicalized social under-
standing on the conceptions and practices emerging within self-care, holistic health,
and the new health consciousness. The intent is to follow Hughes when he said of the
professions that “they set the very terms in which people may think about this aspect
of life.”
What is being suggested is that in contemporary American culture the notions of
health and illness, in whatever context used, in large measure retain a medicalized
meaning. It is on the level of daily living, external to medical institutions and relation-
ships, that experiences, activities, and ideologies about health are being elaborated.
The impact of medicine must be examined on this level, for there are profound impli-
cations for how our society attempts to solve the problems of health and well-being
generally. The question of medicalization is important because, like any other mode
 Healthism / 371
of symbolization, medicalized perception sets boundaries on ways of thinking and
channels consciousness and behavior. To the extent that the new health movements
and consciousness incorporate medical ideology, they risk reproducing many of the
social problems engendered by that therapeutic form.

SOME ASPECTS OF MEDICAL PERCEPTION

Medicine as a therapeutic or clinical science locates the problem of disease in the

individual body. (Disease locates itself in the individual body and thus creates the need
for a healing response to that individual experience. It is this fact which underlies the
ideological problems being discussed. See pp. 372-373 and 383-385 below and refer-
ence 34, pp. 119-151 .) The individual is both the locus of perception and intervention,
more firmly so since the end of the 19th century when, as Foucault (35) traces the
transformations (the beginning of which he dates t o the close of the 18th century),
the very foundation of medical knowledge becomes lodged in the “sovereignty of the
gaze” fixed on individual signs and symptoms and then in deep anatomical structure.
It is through the observation of individual signs and symptons that it became “possible
to designate a pathological state . . . a morbid essence . . . and an immediate cause.”
(35, p. 90) And with the development of anatomy, the medical understanding of
disease turned even more fully toward “the deep, visible, solid, enclosed, but accessible
space of the human body.” (35, p. 195) Thus, what is known about disease is now a
matter of positive knowledge of the individual. What is seen is what is known, and
what is known becomes the space for intervention. Locked into a particular way of
seeing, an imprisonment reinforced by institutional structures, medicine knows and
acts upon disease bounded by an immediacy of perception which is physical (mechani-
cal, biochemical, visual). In escaping from a nosology of morbid essences, it built its
science and clinical practice on the closed grounds of what becomes, in principle, an
observed occurrence within the individual body.
Notions of causation are compressed as well, limited to the boundaries of the
individual in which disease takes on its only meaningful existence. Anything which
cannot be shown to interact with the organism to produce a morbid state is increasing-
ly excluded. “The local space of the disease is also, immediately, a causal space.” (35,
p. 189) Solution to the problem of disease is directed toward breaking the most
immediate causal link. Thus, medical perception pushes causal understanding toward
the immediate and local, and solution toward the elimination of symptoms and the
restoration of normal signs. As Foucault states (35, p. 191), “the space of the disease
is, without remainder or shift, the very space of the organism.” Medicine has become
“a science of the individual.” Foucault contrasts medical thought with an epidemio-
logical tradition and perception (35, pp. 22-36) which sees the problem of disease as
“a nucleus of circumstances,” a “complex set of intersections,” in which the only
individuality is a “historical individuality.”2
A closely linked and much discussed medical notion is that of specific etiology (28,
pp. 91-97). It is a reductionistic concept of causation suggesting that disease can be

’See also reference 28, pp. 113-143, and reference 36.

372 I Crawford

understood in terms of pathogenic agents. Specific etiology has worked to reinforce

medical individualism, an individualism which has progressively demolished competing
explanations grounded in the understanding of a multiplicity of causes. Aided by
new research technology, late 19th-century scientists were able to isolate the active
microorganisms of infectious diseases. Powerful explanatory models were built on
such discoveries. Scientific medicine came of age. Swept aside were vaguer and more
metaphysical conceptions, but also discredited were the theories of “social medicine.”
As proclaimed by one prominent German medical researcher in the late 19th century,
“the study of infectious diseases could now be pursued unswervingly without being
sidetracked by social considerations and reflections on social policy.” (36, p. 34)
Successful laboratory experiments based on the specific etiologic model were
mistakenly offered as proof of the supremacy of that particular theory of causation.
Scientific medicine had succeeded in throwing a bright light on a key element in
the causation of disease, but that light served to concentrate the search for causation
where scientific medicine now claimed to be the proper field of investigation.
It has been only recently that the medical approach to health maintenance and
promotion has been widely questioned in academic and policy circles (37-39). No one
argues that medicine is an unimportant therapeutic tool. It does save lives and it does
relieve pain, enable active lives, and perform important “caring” functions (clinical
iatrogenesis aside). However, the well-known inability of medicine to find a cure for
many of the chronic and degenerative diseases, especially heart disease, stroke, and
cancer, combined with the cost crisis in medicine and the accumulation of data which
even question the contribution of medicine to the decline of mortality from infectious
disease (37,40), have all pushed policy discussions toward the consideration of more
effective strategies of disease prevention.

THE IMPACT OF MEDICAL PRACTICE

Medical concepts are reinforced by a therapeutic practice which isolates the

individual from the social context in which disease is acquired. Of course, modes of
healing, therapeutic institutions, and practices are intimately connected with dominant
notions of precisely what is to be cured. Cross-culturally, they assume radically
different forms (41). The impact of institutionalized therapeutic practice is to
reinforce dominant ways of seeing. Medical practice in 20th-century America provides
a good example.
Reams have been written about the social construction and experience of thera-
peutic practice. Only a few points need to be stressed here. First, it should be clear
from decades of sociological research that the therapeutic encounter is a restructuring
or socializing experience, and because of several features of the doctor-patient
interaction and the psychological state in which therapy is experienced, an extremely
powerful one. As Dewar (42) and McKnight (43) have noted, the person becomes a
client and patient in a one-to-one contractual arrangement, requiring of the client-
patient, among other things, the presentation of “a condition whose pathology closely
 Healthism / 373

matches the specific quality of the mode of treatment where delivery is being
offered.” (42, p . 5) This matching is achieved through a reordering of the patient’s
understanding of the problem. In the therapeutic relationship, the task of the patient
is to understand the signs and symptoms of the problem as the physician reads them
and thus to accept the medical definition of both problem and solution. Taussig (44,
p. 2) calls this process the creation of a “phantom-objectivity” with regard to disease,
a process of “denying the human relations embodied in symptoms, signs, and
therapy,” a process by which “we not only mystify social relations, but we also
reproduce a political ideology in the guise of a science of (apparently) ‘real things’
-biological and physical thinghood.” Following Lukacs, he concludes (44, p. 8):

Medical practice is a singularly important way of maintaining the denial as to the

social facticity of facts. Things thereby take on a life of their own, sundered from
the social nexus that really gives them life, and remain locked in their own self-
constitution.

The understandings which are restructured in the medical encounter should not be
understood as previously autonomous ones, which are only then manipulated in
therapy. Past therapeutic experiences and notions derived from diffused medical ideas,
as well as reinforcing ideological premises of the society acquired by other means, pre-
structure the encounter. The client is already, in a sense, “professionalized.” In other
words, “persons being helped take on as their own some of their helpers’ theories,
assumptions, and explanations.” (42, p. 4) These attitudes are perpetually reinforced
in a therapeutic setting divorced from family, friends, home, and neighborhood, by
hierarchically structured relationships in which non-medical experience and assump-
tions are either declared illegitimate or effectively ignored. That non-therapeutically
derived notions persist, understandings which place the cause of misfortune in
concrete social experience, is a remarkable testimony both to the strength of the
need for a socially meaningful explanation and to the poverty of a medical practice
incapable of providing one.
In sum, medical practice is an individualized treatment mode, a mode which defines
the client as deficient and which reconstructs the individual’s understanding of the
problem for which help is being sought. That reconstruction individualizes and com-
partmentalizes the problem, transforming it into its most immediate property: the
biological and physical manifestations of the individual, diseased, human body. The
answer to the problem is then logically held to be found in the same professionalized
and individualized treatment, not in the reordering of the social, political, and environ-
mental circumstances in which the individual exists. The need for a therapeutic
response to individual disease experience, not denied here, thus becomes the field
upon which selective explanations are authoritatively communicated and dominant
social relations thereby reproduced. The specter of a medicalized and medicated
society, where already psychoactive drugs, sleeping aids, and common pain relievers
have become the standard response to almost every conceivable malaise, must at least
raise questions about the wisdom of such heavy reliance upon medical problem
solving. Such questions are, in fact, being asked in the new health movements.
374 I Crawford

HEALTHISM AND MEDICALIZATION

Holistic health and self-care adherents are critical of and reject many of these
medical conceptions and practices. Self-care grounds much of its philosophy in a
critique of the disabling qualities of our pan-therapeutic culture .3 Despite some
professionalization or the movement, self-care seeks to reduce dependency on
physicians and other professionals and enhance medical self-competence, and, in its
self-help forms, t o stimulate mutual aid and support. At least in the latter instance,
self-help is an important step toward re-integrating the experience of disease into a
meaningful social context. In acknowledging the loneliness of pain, disability, and
dying, self-help provides a viable alternative to isolating medical experiences.
Similarly, enthusiasm for holistic health can in large part be understood as a
response to the alienation experienced in the medical encounter, to the structural
inability of medicine t o provide satisfactory explanations for the questions “Why
me‘?’’ and “Why now?” Holism rejects the medical destruction of socially grounded
interpretation and offers instead an overtly experiential understanding of disease.
It replaces the sterile world of biologic facts with a readily understood moral system:
a system of right attitudes and behaviors, in which “the connection between ourselves
and our experience” is made explicit. In the process, social meaning is reconstituted.
“What is the message of these symptoms‘?” asks the holistic therapist (46, p. 9);
“What is a headache t o me‘?’’The emphasis of the new healing, it is argued (46, p. 70),
“must be away from the clinical and into the personal.” Holistic healing takes serious-
ly the need of the sufferer t o understand his or her suffering in terms of the events
and experiences of everyday life.
Nonetheless holistic health appears to be burdened by the ideology of healthism.
Even though whole persons and their experience regain a new attention and multiple
causation replaces the medical theory of specific etiology, and even though the mind-
body dualism is renounced-all significant modifications which may open the way
for even broader conceptions4 --the healthist formulation still situates the problem
at the level of the individual niirid and body (48, p. 20):
I n the emerging holistic perspcctivc, nature is a n intcractivc friend, and discase is
a feedback proccss within the choo9ing system of the individual, a process which
informs the individual that some life process is off-course. The individual is thc only
person who can discovcr that feedback messagc and act upon it, perhaps with thc
help of providers.

As an ideology which subscribes t o the medical definition of the problem of health

and illness, in which the individual is the locus of perception and intervention, health-

3.
l h e distinction between therapeutic and non-therapeutic is bcconiing more difficult to draw.
In practice, the therapeutic, understood as the provision of d service by a “hcalcr,” is diffused
throughout society via a deluge of professional and “lay expert” advice found in popular health
publications, health food atores, and advertisements for mass-conaumed product\. We have become
what Rieff (45) describes as a “thcrapzutic culture.”
4 0 n e recent article (47, p. 9) clainis that “in thc iiolistic health model, the locus of causation
and cure is enlarged to include the society at large ” ‘I‘he authors ?tress the importance of healing
not only the individual but also “the society which crt’atos the sick individual.” While promising,
this conception does not represent the dircction taken in tlie overwhelming majority of the
literature.
 Healthism / 375

ism remains locked in a prison of reductionism, despite its apparent broadening.

Healthism bends the modifications of medical notions of causality in one direction
only: toward psychobiologism, toward host resistance and adaptation. Whether
through the concepts of disharmony, unbalance, stress, host-resistance, immunity
systems, at-risk behaviors, unfitness, life style, wholeness, “low-level worseness” and
“high-level wellness,” “ways of being and perceiving,” and so on, healthism is an
ideology which requires either the self-restructuring of attitudes, emotions, and
behaviors, or the intervention of healers to help accomplish the same. “Illness is a
message from within,” goes the refrain; both cause and cure can be found there.
According to one adherent (49, pp. 26,24):

If we are to help individuals reappraise certain important beliefs about themselves

and their self images, then we are coming to the heart of the basic cuuses of illness.

Different reactions to the same stress factors . . . are obviously determined by our
mental programming. They are a product of how we see the world and how we think
we are threatened by it. T o me, therefore, it would make far more sense to examine
and reverse the negative ways we perceive the world than to spend time and money
concocting new pills for the relief of distress. Pills give relief, but they only postpone
cure. Cure comes from reversing our perceptions, from discovering how we create
our own “realities.” (emphasis added)

The point is not that such a focus is unimportant, just as the biomedical model
must be appreciated for what it has contributed to healing and prevention. As a
therapeutic model, holistic health may prove to be as effective as medicine (and
perhaps more effective for many conditions). After all, health and illness, however
else they may be viewed, are also individual matters. Whatever the level of social
construction to which causality may ultimately be attributed, that construction
appears in forms which are uniquely individual. At least they are experienced as such.
It is both possible and important to unmask the meaning of health and illness in the
most personal terms. Moreover, one can always posit a moment of choice, acts and
attitudes of complicity, a level of individual responsibility and control. Ignoring the
psychic and behavioral part of health and illness would itself be reductionistic. It
would probably also preclude a vast range of preventive and therapeutic possibilities.
But if the “meaning” of health and illness remains divorced from the society in
which meaning is constructed, the resolution of the problem must be partial, doomed
to ameliorative or adaptive efforts-even though the illusion of autonomy can be more
easily nourished. Illustrative is an introduction to a holistic health handbook in which
the author counsels (50, p. 19) against the “negativity” of blaming the environment
and proclaims that “health and happiness can be ours if we desire; we can create our
personal reality, down to the finest detail.” When such private efforts become the
model for social practice, let alone public policy, they reinforce a medicalization of
life which leaves us powerless to control our own fate. They incapacitate precisely
because, in both conception and practice, those who adopt such efforts as a model
tend to deny or choose to ignore the structural conditions which produce in our
society the behaviors, attitudes, and emotions upon which so much attention is now
focused.
Also illustrative is a popular self-help guide to overcoming cancer (51). After
376 I Crawford

offering pitifully few remarks on the reality of carcinogens, the authors immediately
proceed to a discussion of how few people exposed to carcinogens actually contract
cancer. Departing from this observation, the rest of the book is devoted to topics
like “personality, stress, and cancer,” “a mind/body model of cancer development ,”
“participating in your health,” “accepting the responsibility for your health,” “the
benefits of illness,” “the value of positive mental images,” “finding your inner guide
to health,” and so forth. Only the vaguest references are made to the dominant social
and cultural factors which promote the “cancer-prone personality.”
As in the above example, social origins are not entirely denied. In fact, holistic
health repudiates “the study of the individual abstracted from the context of other
human beings.” But, as Jacoby has written of much of contemporary psychology, the
social context is most often reduced to the immediate context of interpersonal
relations and “psychological atmospheres.” He notes (34, p. 136):
A social constellation is banalized to an immediate human network. It is forgotten
that the relation between “you and me” or “you and the family” is not exhausted
in the immediate: all of society seeps in.

Thus, Ardell devotes a chapter in his High Level Wellness (52) to “Environmental
Sensitivity.” After briefly noting the physical and social aspects of environment, about
which he warns “there are severe limits to what most of us can do to change,” he
devotes practically the entire chapter to what he calls the “personal” aspects of
environment (52, p. 163):
The manner in which you organize your bedroom or work space, the kinds of
friendship networks you create and sustain, and the nature of the feedback about
yourself which you invite by your actions, are all examples of the personal environ-
ment, or spaces you consciously or unknowingly set up for yourself.

In the reduction of “social relations to immediate human ones,” the society in which
experience is lodged remains hidden; the part is isolated from the whole.
Central to the holistic health and self-care models is the concept of individual
responsibility. This notion appears in virtually everything that has been written on
these subjects. Ardell summarizes its importance (52, p. 94):
All dimensions of high level wellness are equally important, but self-responsibility
seems more equal than all the rest. It is the philosopher’s stone, the mariner’s
compass, and the ring of power to a high level wellness lifestyle. Without an active
sense of accountability for your own well-being, you won’t have the necessary
motivation to lead a health-enhancing lifestyle.

Self or individual responsibility is the mechanism believed to propel the transition

from a medically dominated experience to one more meaningful, autonomous, and
effective for health maintenance and promotion. As such, it can be understood as
political language. It implores individuals to reclaim the power they have given to
physicians. (More cynically, it can also be understood as a convenient device whereby
one set of healers captures the clientele of another, while obscuring that primary
objective.) In a medicalized and “reified” society in which we experience ourselves as
mere objects and the forces which envelop us as active subjects, the decision to take
personal responsibility can mean a revitalization of the attempt to control those
 Healthism / 377

forces, to become ourselves active subjects. Moreover, it forces us to examine how we

have become complicitous in our own oppression. If we do not believe that we can
control our own fate, how can any consciously chosen change take place? Thus,
asserting a claim to individual responsibility partially delegitimizes existing authorities
and throws open a new political terrain. To the extent that individual responsibility
and related terms like self-help are experienced as symbols of empowerment, they may
become one of the few ways that people conceive of themselves as actively political
at all (10).
However, as political language, individual responsibility is highly problematic. Most
obviously, it risks all the myopia of classical individualism which I have been discuss-
ing. It risks fostering the illusion that individual responsibility is sufficient. It leaves
unexamined the “voluntary” assumption about human behavior, through which it is
taken for granted that because individuals can and do choose to act differently, it
simply remains for them to make such choices. In other words, it promotes a concep-
tion which overlooks the social constraints against “choosing.” Further, it may also
exacerbate an already prevalent sense of powerlessness about controlling the forces
which impinge on individuals by promoting a concept of control which may be viewed
as an alternative to political efficacy: “I can’t change the world, but at least I can
change myself.” Faced with an “everything causes cancer” hopelessness, personal
protection is offered as the best route to health (53, p. 38):
We have evidence that cancer may be provoked by the air we breathe, the foods
we eat, or by the pajamas our children wear to bed. Since it is clearly almost impos-
sible to avoid contact with known cancer causes, the most important questions
become: How do we stimulate and strengthen our resistance? How do we activate
the immune system?

Moreover, for a generation which experienced the political motion and excitement of
the 1960s, the turn inward toward self-cultivation can be partly understood as a
reaction to the disappointment and political impotence experienced in the 1970s.
Redefining the problem as self-change and preoccupying oneself with keeping healthy
is one way to cope with that disillusionment.
In possible acknowledgment of some of these problems, the argument has been
made that personal responsibility is the necessary first step toward a more political
stage when people will act collectively to change social conditions. “Heightened
individual consciousness,” Katz and Levin assert (22, p. 333), “is a precondition for,
not an antagonist of, social action.” They offer the hypothesis that “people alert to
personal hazards and active in their own self-protection are the people most likely
to be concerned with economic and political etiologies”; and that the
, . . potential for increasing the competence and confidence of citizens in tackling

established powers is great; small and local successes will lead to others; coalitions
for broader political and social ends will occur. . . (22, p. 335).

But if individual responsibility is understood as actions taken on the individual level

to enhance or alleviate a particular condition, there is no evidence that a more political
conception or behavior will follow. Of course, neither is there evidence for my more
skeptical view. There is statistically a positive correlation between an individual’s sense
378 I Crawford

of personal efficacy, self-confidence, self-esteem, and so forth, and the level of social
and political participation (54). But the relationship is far more complex than the
stage theory-from individual responsibility to political action-suggests. I am not
denying that, for many, a more political conception may coexist or follow (nor am I
questioning the value of individual protective measures); I am only questioning the
unexamined assumption. After all, individual responsibility as ideology has often
functioned historically as a substitute for collective political commitments. Might not
such possibilities of mutual exclusion exist in the present case? Given the prevalence
of privatized notions of the path to well-being, and the current ideological campaign
to place full responsibility for health on the individual (19), a stage theory of politici-
zation is questionable. In fact, the failure to adopt an explicitly political understanding
of the health problem amounts to a refusal to confront the massive, ideological de-
politicization being promoted. It is practically to guarantee that dominant ideology
will prevail.
Finally, as currently employed, the notion of individual responsibility promotes an
assumption of individual blame as well. The intersection of morality and blame with
illness and health is one of the most complex subjects facing medical sociologists and
social historians (24, 25, 27, 44, 55-59). Health and disease have always been moral
concepts and cannot be understood independently of the moral principles of the time
nor the particular social relations within which they are placed, including the doctor-
patient relationship. Ehrenreich and English (60), and others (61), have attempted to
show, for example, how patriarchal structures and values are reproduced through the
medical structuring of illness as a kind of deviance. What is clear is that the classical
Parsonian sick role cannot suffice as an adequate explanation. Parsons (62) believed
that the sick role was a social process by which the individual sick person would not
be blamed or punished for deviating from normal role obligations so long as he or she
did not give in to illness but agreed to work with medical practitioners in order to be
able to return as quickly as possible to those obligations. He thought the “exemption”
contained within the sick role was an ideal conventional form. In contrast to illness
seen primarily as punishment or as evidence of Satanic designs, medicine (while still
accomplishing important social control objectives) offers a more benign interpretation.
In some respects, the medical doctrine of specific etiology-the identification of an
external, natural, biological cause-does promote an apparent de-moralization of
disease and illness. It proffers an exemption, even though submerged moral judgments,
in both the doctor-patient relationship and within popular culture, persist.
Healthism, however, adopts a more strident moralism. Accompanying the focus
on what we can do for ourselves as individuals, blame is brought front-stage.’ Self-
responsibility does not necessarily equal blame. As an ideology, however, which
focuses so exclusively on behavior, motivation, and emotional state, and as an ideology
of self-improvement which insists that change and health derive from individual
choices, poor health is most likely to be seen as deriving from individual failings.

’Here, healthism also reflects (and lends additional support to) recent changes in the medical
model. The development of psychosomatic medicine has already set the stage, as well as the
scientific legitimation, for the new moralism.
 Healthism / 379
“We choose our sickness when, through neglect or ignorance, we allow it to spread
within us” (63, p. 116); or “We should not fool ourselves into thinking that disease
is caused by an enemy from without. We are responsible for our disease.” (63, p. 4)
As stress becomes a dominant paradigm, “clients are aided in understanding how they
are responsible for the pressures and tensions in their lives.” (52, p. 15) Warned against
thinking about stress as an “outside pathogen,” we are told instead that stress is up to
us (49, p. 25):
We talk about the stress produced by our jobs, our home, our family, our
business, the weather, the government, world conditions, and so on. Once again, we
are led to believe that we are victims of some outside force that is imposing its will
on us and causing us distress. . . . We choose our own psychological pathogens of
stress by the way we choose to perceive and interpret events in our lives.

And as health becomes a super-value, those who fail to seek it become near pariahs
(46, p. 10):
The gift of health is the gift of life, which raises the value of the whole idea
exponentially. The gift of health, then, is the gift of happiness, of completeness, of
love and of being. To abuse it, or to fail to seek it out with all our power is a denial
of the value of self. Anyone who disregards the magnificence of life deserves only
pity.

Thus, the failure to maintain health is ascribed to some kind of unwillingness to be

well or an unconscious desire to be sick, or simply a failure of will. As stated by Ardell
(52, p. 2):
The only tyrant you face is your own inertia and absence of will-your belief
that you are too busy to take your own well-being into your own hands and that the
pursuit of self-health through a wellness-promotive lifestyle is too hard, complicated,
or inconvenient.

Sometimes it is explained by ignorance or the failure to insure immediate social

support for individual change.
In other words, the no-fault principle contained in the classical sick role formula-
tion, itself a forgery, is being withdrawn. It is being replaced by a “your fault” dogma.
In the words of one adherent (64, p. 72): “As a prerequisite to Wholistic Healing we
mus: stoF blaming others for our condition or expecting others to bail us out of
trouble.” Healthism joins other social forces currently attacking what they see as the
“overuse” or “abuse” of illness as an excuse to avoid “obligations,” unnecessarily
visit a physician, or collect government or negotiated benefits.
Healthists have thus helped to create a potential-sick role through which the obliga-
tion to stay healthy is more strongly asserted. In the potential-sick role, societal
expectations are imposed on behalf of prevention. As potentially sick, individuals
are experiencing more intense social pressures to act in ways to minimize that poten-
tial. Failure to act preventively becomes a sign of a social, not just individual, irrespon-
sibility. According to Knowles (65, p. 59):
The idea of individual responsibility has been submerged to individual rights-
rights, or demands to be guaranteed by government and delivered by public and
private institutions. The cost of sloth, gluttony, alcoholic intemperance, reckless driv-
ing, sexual frenzy and smoking is now a national, and not an individual responsibility.
380 1 Crawford

This is justified as individual freedom-but one man’s freedom in health is another

man’s shackle in taxes and insurance premiums. I believe the idea of a “right” to
health should be replaced by the idea of an individual moral obligation to preserve
one’s own health-a public duty if you will.

The notion of deviancy is therefore extended from the sick person to the poten-
tially sick person, from manifest illness to what is considered unhealthy behavior.
We all become deviants in our everyday lives-when we light up a cigarette, when we
consume eggs at breakfast, and when we are unable to express fully our emotions.
Persons who act in such a way as to predispose themselves to sickness are now con-
sidered actually to be sick (66, p. 6):
Positive wellness, not just the absence of disease, is the goal. The conventional
physician considers a person well if he has no symptoms and falls within the normal
range in a series of diagnostic tests. Yet this “well” person might smoke heavily,
take no exercise, eat a bland, sweet, starchy diet, and impress all who meet him as
glum, antisocial, and emotionally repressed. To a New Medicine practitioner, such a
person is quite sick, the carrier of what biologist Ren6 Dubos calls “submerged
potential illness.’’

Thus, all behaviors, attitudes, and emotions considered to put the individual “at
risk” are medicalized-the labels health and illness become attached to them. Like the
sick role, the potential-sick role mandates a moral duty: the obligation to correct
unhealthy habits. Conversely, it condemns illness as an individual moral failing. The
partial exemption contained within the sick role is further compromised. Notions of
good motivation and morality regain explicit status. Illness, again, becomes the
individual’s fault. In the process, victim-blaming ideology wins a powerful ally in
popular culture.

THE ONE-DIMENSIONALIZATION OF WELL-BEING

Wellness is Fun, Romantic and Hip-Sexy and Free

Holistic health T-shirt slogan

In healthism, healthy behavior has become the paradigm for good living. Healthy
men and women become model men and women. A kind of reductionism or one-
dimensionalization seems to occur among healthists: more and more experiences are
collapsed into health experience, more and more values into health values. Health,
or its supreme-“super health”-subsumes a panoply of values: “a sense of happiness -
and purpose,” “a high level of self-esteem,” “work satisfaction,” “ability to engage
in creative expression,” “capacity to function effectively under stress,” “having
confidence in the future,” “a commitment to living in the world,” the ability “to
celebrate one’s life,” or even “cosmic affirmation.” “Health is more than the absence
of disease . . . ,” writes one of the new pulpiteers (49, p. x), “it includes a fully pro-
ductive, self-realized, expanded life of joy, happiness, and love in and for whatever
one is doing.” In the “high level wellness” ethic, “health is freedom in the truest
sense-freedom from aimlessness, being able to express a range of emotions freely, a
zest for living.” (67) In short, health has become not only a preoccupation; it has
also become a pan-value or standard by which an expanding number of behaviors
 Healthism / 381

and social phenomena are judged. Less a means toward the achievement of other
fundamental values, health takes on the quality of an end in itself. Good living is
reduced to a health problem, just as health is expanded to include all that is good in
life.
In the process of acquiring a health-governed identity, the world is restructured
metaphysically and politically. As the symbolic of health expands to include more
and more experience, experiences of other kinds, alternative symbolizations by which
people define their malaise and goals, along with implied strategies for alleviation or
fulfillment, are affected. Other perceptions are reordered in relation to the symbol
of health and become subordinate to it. Such perceptions become more remote, less
a part of conscious understanding and concern, or alternatively, more immediate but
only in relation to the culturally defined notions of what it means to be healthy.
More values are incorporated under the rubric of health and thereby lose the clarity
of distinctiveness.
Health has periodically been prominent in the utopian imagination. Three decades
ago, the World Health Organization adopted a definition of health which stands as
a forerunner of the contemporary attachment of meaning to the concept: “Health
is a state of complete physical, mental, and social well-being and not merely the
absence of disease or infirmity.” One critic, Daniel Callahan, wrote of the definition
(68, pp. 8081), “it turns the problem of human happiness into one more medical
problem, to be dealt with by scientific means. . . . It makes the medical profession the
gate-keeper for happiness and social well-being . . . the final magic-healer of human
misery.” The problem remains, but now the healers are holistic and the quest for
health is an everyday concern. Callahan states the problem clearly in elaborating his
objections to the WHO definition (68, pp. 82-83):
Such an ideology has the practical effect of blurring the lines of appropriate
responsibility. If all problems-political, economic and social-reduce to matters of
“health” then thereceases to be any way to determine who should be responsible for
what. . . . For as soon as one treats all human disorders-war, crime, social unrest-as
forms of illness, then . . . health is no longer an optional matter, but the golden key
to the relief of human misery.

It is here that the medically constructed notion of health as a personal or individual

matter-as a problem which arises from factors within or at the boundaries of the
individual body-must again be considered. Under such a symbolic, the struggle for
generalized well-being, defined as health, becomes more firmly locked into the
confines of personal effort. Whereas medicine individualizes “disease ,” healthism
individualizes “disease .” Either one goes for therapeutic repair or armoring, or one
adopts an independent strategy for personal enhancement against the external forces
and internal weaknesses which assault well-being. In the healthists’ world, the pursuit
of health substitutes for, or may become defined as, doing politics. Where blue-collar
workers are likely to talk of speed-ups or long hours, middle-class healthists are more
prone to discuss their internal balance, stress, or adaptive mechanisms. Stress is in you;
exploitation is in others.
A number of factors contributing to this development can be suggested. As a
pan-value, healthism is a form of medicalization. Medical propaganda has been
382 / Crawford

bombarding our culture with the message that health is the most important of values,
offering its magic bullets as the key t o longer and disease-free lives. Doctors have
offered themselves and are elevated to the status of cultural heroes. Medical commodi-
ties inundate the media. It should be no surprise that the failure of medicine to deliver
the goods does not diminish the dream. Just the opposite. Health has become even
more of an absorption, consuming not only the therapeutic products, activities, and
imaginations of an expanding phalanx of new therapists but also the everyday concern
and attention of the middle class.
Further, the enhancement and control of personal health finds fertile ground in a
middle-class population which in the 1970s was forced t o adjust to a world of
increased insecurity and uncertainty-in health, in economic life, and in personal
relationships. When life is experienced as eluding control, particularly when people
begin to wonder whether a standard of living t o which they have become accustomed
can be sustained, the need for personal control is intensified. Personal health has
become one such area into which people can throw their energies and reassert the
sense that they can act on their own behalf.
Moreover, as we are increasingly defined as deviant (as potentially sick) in our
everyday behaviors, attitudes, and feelings, we come t o see ourselves as lacking. Not
only do we experience the insecurity of imagined, future illness, the anxiety of worri-
some prognosis, but also the insecurity of the deviant, the anxiety of not fitting in.
Adopting health as a preoccupying value may act as a sort of prop against that insecur-
ity. The healthist is in essence saying, “See, I am not deviant. I am not lacking. I
control my condition. I am in the process of being healthy and whole.” What is impor-
tant is the adoption of a symbol as a personal identity which matches dominant social
expectations and stands in opposition t o the identity of deviant. Healthism, in other
words, becomes self-perpetuating. It extends deviance and then provides an answer
t o its own problem. Additionally, despite the apparent individualism, by making
health a super value and then defining health as a distinct set of behaviors, attitudes,
and emotions, a further social structuring of experience is promoted. Healthism may
thus be a response not only t o its own extension of deviance but also t o isolation in
a broader sense: “If we’re going t o be alone, let’s at least be alone in the same ways;
do the same things, etc.” Thus, the individualism of healthism may in fact be a highly
elaborated affirmation of belonging.
Ironically, however, the healthist is forced into a deeper contradiction. On the one
hand, he adopts as his own the symbol of health. On the other, as he delves more
deeply into a limitless definition of health as total well-being, disease becomes more
of a conscious everyday experience. Total well-being engenders total disease. Health-
ism may thus reinforce the individual’s experience as a deviant and the anxiety of a
sense of lacking for which ever-more compensating behavior is required. It probably
extends apprehensiveness about future illness as well. Despite the shared rituals of
healthist pursuits, how much is isolation overcome under these circumstances?
More portentously, when good living is defined as eliminating the personal symp-
toms believed contrary t o health, will there emerge a kind of individualistic protection-
ism in which a steady-state, psychobiological system is believed t o be derivative of a
steady-state life-in which rocking the boat will produce conflict, upset, and added
 Healthism I 383

stress, all of which are believed to lead to one of the dread diseases forty years hence?
What will healthists do, for example, with data (69, p. 81) which suggest “a relation
between rapid social change and accompanying personal changes, including disordered
situations, leading eventually to disease”? Will, at its extreme, alienation and its
attendant behaviors become illness (understood as potentially sick) and integration
and its attendant behaviors (happy acquiescence) be celebrated on the altar of health?
Will healthism become the perfect ideology for a depoliticized and cacoon-like
cultureP
Worst fears aside, the argument here is that healthism serves to mystify and channel
discontent, and perhaps deviance itself (71), into forms which are basically nonthreat-
ening to the existing order. Medicine has always performed this social control func-
tion, and now medicalized ideology does the same. If ideological conflict can be
thought of as a struggle over symbol systems by which people define their malaise
and which imply certain solutions, the symbol of health in the emerging healthist
ideology is most compatible with a system of domination based on the therapeutic
and personal achievement of well-being. Just as the language of caring or help obscures
the unequal power relationships of a growing therapeutic state (72), so the language
of self-care, individual responsibility, and holism obscures the power relations under-
lying the social production of dis-ease and discontent.

HEALTH AND SUBJECTIVITY

My thesis has been that the new health consciousness and movements stand in
danger of being captured by a symbolic and practice of pure subjectivity. It’s not that
social change is completely ignored, only that it is seen as an outcome of subjective
practice multiplied. Change will occur, it is believed, as in the market, when enough
people are recognized by power centers as wanting and choosing healthy life styles.
Often a pessimistic appraisal of the opportunity for political change reinforces utopian
ideas of long-term change based on individual choices.
Considering the difficulty of changing life styles (e.g. the habit or addiction of
smoking, or the investment of time and money necessary to find healthier products),
it is remarkable that there is so much interest in doing so. The behavioral focus
becomes more understandable, however, in a context in which personal health protec-
tion and promotion appears to be the only possible alternative to a health-denying
environment which eludes control. Faced with such limited choices, the most difficult,
individual adjustments will be attempted. In the absence of a clear societal responsi-
bility for (commitment to) health promotion, individual responsibility comes to be
seen as a necessity. As individuals, we all face the same dilemma: we cannot afford
to wait for a political solution, so those of us who are able adopt health practices
which we believe will reduce our risk. The loss of control over health is “eased by its
endless pursuit .”
‘The supreme individualist-opposed in depth to earlier modes of self-salvation: through
identification with communal purpose,” is in Rieff‘s terms (45, p. 5) “psychological man,” a new
modal personality which holds the conviction that “the new center, which can be held even as
communities disintegrate, is the self.’’ The triumph of the therapeutic has meant, for Rieff, the
vanquishment of politics. See also Lasch (70).
384 / Crawford

Those most able to make individual adjustments are more likely to be middle class.
Middle-class people not only possess more personal resources for changing life style,
doing holistic therapy, and so forth, but also have acquired fundamental notions
about themselves as social actors from work situations (and all the supporting socializ-
ing patterns) which are individually competitive. They are already predisposed toward
seeing their achievements as a result of personal effort alone. A healthist formulation,
while still plausible, is less likely to be the response of blue-collar workers and lower-
class people who would be more prone to see at least some health problems in “we-
they” terms.7
The various health movements have taken vastly different directions. Political
activists in the occupational and environmental health movements are most often
singular in their focus on factors external to the individual-objective factors, like the
corporate production of carcinogens that pose concrete health threats-while healthists
in the holistic health and self-care movements are preoccupied with the subjective,
behavioral arena. Both take fundamental truths and turn them into half truths through
an exclusive attention. One takes the individual as the problem; the other takes the
society as the problem. Both fail to understand what Marx understood (quoted in 34,
pp. 104-105): “Above all we must avoid postulating ‘Society,’ again, as an abstraction
vis-a-vis the individual. The individual is the social being.”
The ideas of Russell Jacoby (34, p. xxii) are germane to this point:
The prevailing subjectivity is no oasis in a barren and dehumanized society; rather
it is structured down to its core by the very society it fantasizes it left behind. To
accept subjectivity as it exists today, or better, as it does not exist today, is implicitly
to accept the social order that mutilates it. The point, however, is not merely to
reject subjectivity, . . . it is to delve into subjectivity seriously. This seriousness entails
understanding to what extent the prevailing subjectivity is wounded and maimed;
such understanding means sinking into subjectivity not so as to praise its depths and
profundity, but to appraise the damage; it means searching out the objective social
configurations that suppress and oppress the subject. Only in this way can subjectiv-
ity ever be realized: by understanding to what extent today it is objectively stunted.

The failure of the occupational and environmental health movements, as well as much
of the political left, to develop a critique and practice which take seriously the predica-
ment of the individual (for example, the needs for viable coping options, or for
immediate strategies for reducing vulnerability to disease, or for a more viable and
meaningful healing mode) undermines the realization of their objectives. At least
healthism attempts to respond to these needs. It is manifestly therapeutic.
Pure subjectivity, however, cannot help but to promote a misunderstanding of both
the subjective and objective conditions of health and disease. It misses the dialectical
essence of social existence. The isolation imposed on the two realms-subjective and
objective-is a political and ideological one. It serves the interests of domination.
The failure of healthist ideology to treat individual behavior, attitudes, and emotions

7Ehrenreich discusses one sense in which healthism may itself be an expression of a “we-they”
mentality. She suggests that healthism has become an important means for the middle class to
structure its own class identity. Conspicuous, health-promotion behaviors (e.g. non-smoking) may
act as “recognition signals,” for purposes of both differentiation and mutal affirmation (7 3).
 Healthism / 385

as socially constructed reproduces the disablement fostered by medical ideology and

the ideology of individualism in general. Instead of approaching the complex inter-
relationship of individual characteristics, choices, and larger social structure, healthism
promotes a new moralism.
Everyone needs t o cope. Faced with seemingly unchangeable or hopeless situations,
we invent ways to adapt to them, despite the often disabling consequences of many
of the coping mechanisms we “choose.” Without such mechanisms, plentifully
supplied in the interest of social control, this society would explode with discontent.
For those of us seeking political and personal change, patterns of coping pose often
overwhelming obstacles. But it would be pure romanticism, as well as elitist moraliz-
ing, to insist that we give up our ways of coping, stop adapting, and get on with the
business of changing ourselves and the world. Such moralizing will not overturn
political quiescence. Most people will make those choices for change in situations in
which it makes sense for them to do so.
Healthism is a kind of elitist moralizing about what are believed to be unhealthy
coping behaviors. It is ironic that healthists should be such prudes. For even though
they oppose one kind of coping, they adopt another kind of coping philosophy which
also disables. In its exclusive focus on subjective practice, it reproduces the Same
dynamic of response as the at-risk behaviors they are criticizing. My critique of
healthism is not aimed at questioning whether it has any therapeutic value. Anything
that works for the individual cannot be dismissed. Thus, even though healthists
advocate behavior changes which, like cessation of smoking or reduction of alcohol
consumption, are likely to improve individual health, in the long run, such an exclusive
preoccupation is likely to be health denying. It reinforces the illusion that individual
coping is enough. Certainly it is possible to cope and change self and society at the
same time. But because it further undermines a political conception of the health
problem, healthism reinforces the tendency toward wholly private, individual
solutions.
An at-risk society will produce at-risk individuals and behaviors. Healthism leaves
people at risk. A genuine holistic health demands a holistic society. A movement
which hopes to transform human behavior must go beyond coping. An ideology and
practice is needed which, unlike healthism, seeks to enhance our social capacity to
control the conditions of our existence. Similarly, political movements aiming to
change unhealthy social conditions would be more successful if they took seriously
individual needs for coping, for finding partial solutions for the self. The ideologically
imposed and disabling separation between private, personal, coping actions and
political movements designed to change society must be overcome if a viable health
strategy and, indeed, a viable society are to be achieved. Healthism disables because
human capacity cannot be advanced in the subjective sphere alone.

Acknowledgments-For me, writing is truly a collective as well as an individual

process. Too many people have responded to drafts and personal presentations for me
to cite them individually. Thank you each and every one. This paper would have been
better had I taken more of your suggestions.
386 / Crawford

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Dr. Robert Crawford

Box 4348
Department of Political Science
University of Illinois at Chicago Circle
Chicago, Illinois 60680