“Becoming More Mortal”: governing through “risk”, “vulnerability” and “underlying health conditions”
I apologize for breaking the flow of promised Research Hub entries, but such is the nature of the times. I felt compelled to say something about modes of governing COVID-19 that are currently (Jan – Feb 2022) being practised. Specifically, I wish to reflect on dominant people categories and their governing effects, including lived and subjectification effects (see WPR question 5; Bacchi and Goodwin 2016: 20). The categories I wish to target are interconnected: “underlying health conditions”, “at-risk populations”, “vulnerable groups”, “hospitalization [or death] with COVID as distinct from hospitalization [or death] from COVID”. I intend to consider these issues alongside a narrative of my own experiences to indicate the power and influence of governing categories.
I have a chronic health condition. It leaves me immunocompromised (immunosuppressed). Notice how I’ve already taken on two categories, and I have only just begun!
Allow me to digress briefly. In my 2003 memoir, entitled Fear of Food: A Diary of Mothering (Spinifex Press), I reflected on the repercussions of being classified as an “elderly primigravida” when I became pregnant at age forty-four:
“Being of a certain age for your first child means that you are automatically considered a high-risk pregnancy. … I tried to deny the implications of being labelled ‘high risk’, but we shouldn’t ignore the impact of medical diagnoses on our psyche. In fact, you could say that being called ‘high risk’ was not a way to make you feel relaxed about your pregnancy” (Bacchi 2003: 3).
This sensitivity to the impact of governing categories was reflected in my 1996 book, The Politics of Affirmative Action, which developed the notion of “category politics”. This concept (which germinated in my pre-Foucauldian days) incorporates the political uses of both conceptual and identity categories.
With this background, unsurprisingly, I pay close attention to the categories of analysis deployed in responses to COVID-19. Hence, I began to dwell on a category that was receiving almost daily mention in the numerous press conferences by the Prime Minister, State Premiers, Health Ministers and Public Health Officers in Australia. Allow me to note in passing the impact of the pandemic on the status and influence of public health, at least in certain settings, indicated in Australia and overseas in the “rock star” status accorded certain Public Health Officers (see Anders Tegnell in Sweden, https://onlinelibrary.wiley.com/doi/full/10.1111/apm.13112).
The category that drew my attention and my ire was “underlying health conditions”. It started to appear in daily reports of deaths “associated with COVID-19” in November 2021. With my chronic health condition, I recognized myself in the category and wondered about the possible objective in its use. Perhaps the intent was to make “regular” people feel less worried about their possible sickness and death (Laterza & Romer 2020). Or, just perhaps, the category diverted attention from COVID-19 itself and its (mis)management to “underlying” conditions that would probably/possibly do you in.
And then serendipity! I was reading Louise Erdrich’s wonderful novel The Sentence at the time of these increasingly disturbed concerns about my chronic condition and COVID-19. She writes:
“The Reports kept saying that those who died had underlying health issues. That was probably supposed to reassure some people – the super-healthy, the vibrant, the young. A pandemic is supposed to blow through distinctions and level all before it. This one did the opposite. Some of us instantly became more mortal. We began to keep mental lists. One morning we started figuring the odds.”
“You get an automatic point for being a woman”, said Pollux, “plus ten years younger. That’s two points.”
“I think we both get a point for having blood type O. I’ve heard type A is more susceptible”.
“Really? I’m not sure. I’d question that”.
“We have to subtract those points anyway for being a teeny bit overweight”.
“Okay, let’s cancel those two factors out”.
“I lose a point for having asthma”, said Pollux. “You get a point for not having it”.
“Although now they’re saying it might not make a difference. But I’ll give you the point”. (Erdrich 2021: 183-184; emphasis added).
But that is me, I decided! Was I keeping score? Not intentionally, but perhaps under the radar I thought – you may have a chronic condition but at least you are not obese, and you don’t have sleep apnoea. Queensland’s Public Health Officer, Dr. Kerry Chant, recently reported that a coroner’s review of deaths of 28 people under the age of 65 infected with COVID-19 identified both obesity and sleep apnoea as “related” conditions (https://www.dailymail.co.uk/news/article-10474947/Covid-19-Australia-Kerry-Chant-reveals-sleep-apnea-health-conditions-coronavirus-deaths.html).
It was time to put on my Foucauldian hat before I threw up my hands in despair and surrendered completely to the practices of categorization dominating public debate.
Governing through risk technologies
Dr. Chant drew a connection between “underlying health conditions” and “risk”: “… those who are elderly and those that have underlying health conditions are most at risk of severe disease, hospitalization and death” (https://www.9news.com.au/national/coronavirus-nsw-updates-new-case-numbers-deaths-dance-floor-restrictions-to-end/622c9287-3676-4efb-aa49-0dc4bad2478a
This reference to “risk” is an uncontroversial statement in public health terms. However, that does not mean that it is uncontroversial.
A great deal has been written about “risk”, “risk categories” and “risk technologies” by critical scholars, including those interested in governmentality. The notion of “risk technology”, associated with those researchers, highlights the role of “risk” categories as mechanisms of governing. In a subsequent entry on “data”, I illustrate this point with references to the role of risk categories in welfare governing, in statistical risk assessments in criminal justice, and in predictive risk modelling.
The governmentality scholar, Mitchell Dean, provides us with a way to think about “risk” and its role as a governing technology. He reminds us:
“There is no such thing as risk in reality …Risk is a way, or rather a set of different ways, of ordering reality, of rendering it into a calculable form. It is a way of representing events in a certain form so they might be made governable in particular ways, with particular techniques and particular goals”. (Dean 1999: 177)
To come to understand how “risk” functions as a governing mechanism, Dean advises that researchers tease out “the forms of knowledge that make it thinkable”, and “the political rationalities and programs that deploy it” (Dean 1999: 178).
This approach to “risk” indicates how a WPR analysis can be useful in this context. Instead of generalizing about the notion of “risk” as if it has a set and obvious meaning, we need to identify the knowledges relied upon to give it meaning, and to examine how the concept represents the “problem” in specific circumstances.
How then does the creation of “the elderly” and those with “underlying health conditions” as “at risk” of disease and death shape governing practices? It could, of course, translate into increased resource allocation or more targeted health services. Or, it could serve to “explain” and explain away higher than usual death rates (see https://www.youtube.com/watch?v=iJA8f0BAI4k).
Governments at both the federal and state levels in Australia decided that the practices of relaxing restrictions and opening borders (international and state) in December 2021 needed to be accompanied by a shift in focus from COVID-19 case numbers to the numbers of those hospitalized and of deaths. As the numbers in hospitals rose, Prime Minister Morrison sought a new definition for hospital cases, distinguishing those admitted due to Covid from those admitted for “unrelated reasons” and testing “positive during routine inspections” (Day 2022). As the death toll rose, it became important to offer plausible explanations for this rise that did not draw attention to poor pandemic management practices or to COVID-19 itself, as these deaths could be anticipated (Herrick 2020). “Underlying health conditions” proved to be a useful public health intervention in this regard.
A J P Morgan economist defended the practice of recording the deaths of people who died with COVID-19 separate from those people who died because of COVID-19 – a difficult distinction to make (Trabsky 2020) – lowering the CFR (case fatality rate) in Denmark from 0.045 per cent to 0.027 per cent (https://www.abc.net.au/news/2022-02-09/denmark-covid-19-pandemic-becomes-endemic/100814004). In Australia Morrison continues to defend the distinction between “passing away with Covid” and “passing away because of Covid” (Daily Mail 16 Feb 2022; https://www.dailymail.co.uk/news/article-10517671/Scott-Morrison-says-dying-Covid-not-dying-Covid.html).
I am not suggesting deliberate manipulation in this usage. Rather, I wish to draw attention to the way in which public health knowledge served to make a case about the need to “open up”, a case that would resonate with many in the general population – since we have been told for decades that if we don’t keep the weight off and exercise regularly, we will develop “underlying health conditions”.
Governing through vulnerability
At the same time, targeted groups – and these usually include the elderly, people with disabilities, Indigenous peoples, and those with chronic health conditions – are frequently described as “vulnerable”. Indeed, the main riposte to perceived government mismanagement of the pandemic, at least in Australia, is that our “most vulnerable citizens” have been ignored. In this situation it becomes difficult to suggest the need to rethink the category of “vulnerability”, but I believe it is necessary to do so.
In a previous entry (Research Hub 31 Aug 2020) I described how, in work with Chris Beasley, we challenged a dominant conceptualization in Australian public policy that sets “vulnerable” bodies against other healthy bodies. Vulnerable bodies are seen to reflect a view that people are controlled by their biology, that they are (so to speak) at the mercy of their bodies (Bacchi and Beasley 2002). This view is contrasted to a preferred default position, in which perceived autonomous rational actors keep their bodies in line or “under control”.
There are downsides to both positions – the citizens who are deemed to have control over their bodies become “responsibilized”, and are held responsible for their health outcomes. Petersen and Lupton (1996) argue that public health constructions of risk are premised on the expectation that individuals will govern their own risk-taking practices (see also Nettleton 1997). This perspective is currently endorsed in the federal government’s refrain that, in relation to the pandemic, it is time for Australians to demonstrate “self-responsibility” (SBS News 21 Dec. 2021; https://www.sbs.com.au/news/scott-morrison-urges-personal-responsibility-instead-of-mask-mandates-and-lockdown/1097f6bc-831f-47a8-8970-1b87634d5bca) (on this theme in Sweden see NyGren & Olofsson 2020). Australian government websites offer guidance on “what you can do to reduce your risk or that of someone you care for.”
On the other hand, those characterized as controlled by their bodies – i.e., the “vulnerable” – are constituted as lesser citizens (Bacchi and Beasley 2002). In these cases, Beasley and I highlight the often, inadvertent acceptance of a hierarchical relationship between those who can care versus those who need care. We further characterize this relationship as displaying “the residues of noblesse oblige”, effectively denying the socio-political relations that constitute this hierarchy (Beasley and Bacchi 2007: 293).
It is important also to note that health promotion programs that target “at risk” populations can be stigmatizing (Bacchi and Goodwin 2016: 74), singling them out as wanting or weak. Shani (2020) adds that the fact that the most “vulnerable” people are also those of retirement age is significant “for they are deemed surplus to the requirements of a functioning capitalist economy”. They are “disposable” populations (Duffield 2007), expendable, exerting “additional pressures” on government budgets (Australian Government 2013).
At some level this willingness to accept the deaths of specific groups of elderly people, Indigenous peoples, those with disabilities and those with co-morbidities raises disturbing reminders of eugenic theories and the notion of survival of the fittest (Laterza & Romer 2020). Connections have been drawn between the defence of “herd immunity” as a pandemic strategy and Malthusian population theories (Malinverni 2020). “The ‘herd’ will survive, but for that to happen, other ‘weaker’ members of society need to be sacrificed” (Laterza & Romer 2020). At the same time the “herd” will build up its immunity to SARS viruses.
I don’t have space here to sort through the competing ideas about the role of heredity in evolution in the 19th and 20th centuries (Bacchi 1980), or the distinctions between “negative” eugenics, with its endorsement of compulsory sterilization of the “unfit”, and “positive” eugenics, looking to environmental and hygienic reforms to improve “the race” (Dean 2015: 25). Rather, I’m suggesting that it is useful to take a broader perspective and to think about how policy decisions create the “problem” of “population” – here in terms of “the people” versus “the expendables”.
Of course, the language of “herd immunity” is less popular today, at least in Australia. Rather, there are suggestions that we should “let it rip” or, more commonly, that we have to learn to “live with the virus” (https://thewest.com.au/news/coronavirus/the-ashes-scott-morrison-blasted-over-stint-in-commentary-box-c-5221620).
In any event, the lived effects for members of the disability community, Indigenous peoples, and residents in aged care homes frequently involve severe illness and, all too often, death.
Beasley and I (2007) suggested that there is a need to develop new frameworks of meaning to rethink the ways in which governmental practices conceptualize bodies. To this end we offer the concept of “social flesh” to bypass the constructed dichotomy between those characterized as controlling their bodies and those deemed to be controlled by their bodies, between the “marketable” and the “disposable” (Shani 2012).
Our hope is that “social flesh” might serve to disrupt the current dominant neoliberal ethic that privileges autonomous, rational actors who are held responsible for their lives and health, and to highlight the unequal burden of infectious diseases (Research Hub 31 July 2020). “Social flesh” does this by drawing attention to shared embodied reliance, mutual reliance, of people across the globe on social space, infrastructure and resources (Beasley and Bacchi 2007).
The call by Dr Tedros Adhanom Ghebreyesus, Director-General, World Health Organization, to get “all countries to work together to reach the global target of vaccinating 70% of people in all countries by the middle of 2022” indicates recognition of that embodied reliance. In the place of “narrow nationalism and vaccine hoarding by some countries”, he argues, there is a need to negotiate “a global pandemic accord to strengthen the governance, financing, and systems and tools the world needs to prevent, prepare for, detect and respond rapidly to epidemics and pandemics”. https://www.who.int/news-room/commentaries/detail/2021-has-been-tumultuous-but-we-know-how-to-end-the-pandemic-and-promote-health-for-all-in-2022
The goal, put simply, is for all of us to become more mortal rather than scapegoating those with “underlying health conditions”.
Australian Government 2013. An Ageing Australia: Preparing for the Future. Productivity Commission. Available at: https://www.pc.gov.au/research/completed/ageing-australia
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Trabsky, M. 2020. “Died from” or “died with” COVID-19? We need a transparent approach to counting coronavirus deaths. The Conversation, 9 September.
My sincere thanks to Anne Wilson, Jennifer Bonham and Angie Bletsas for comments on an earlier draft.