Carol Bacchi

The Social Determinants of Health (SDH, or sometimes SDoH) have been on the health agenda for over two decades. The World Health Organization (WHO) describes them as “the non-medical factors that influence health outcomes”: “They are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (WHO 2023). The literature in the area is extensive. There have been numerous WHO Commissions on the topic. The 2009 Commission expanded the definition of SDH: 

“The social determinants of health are defined as the structural determinants and conditions of daily life responsible for a major part of health inequities between and within countries. They include the distribution of power, income, goods and services, and the circumstances of people’s lives, such as their access to health care, schools and education; their conditions of work and leisure; and the state of their housing and environment. The term ‘social determinants’ is thus shorthand for the social, political, economic, environmental and cultural factors that greatly affect health status.” (WHO 2009)

These “social determinants” do not immediately come to mind when one mentions a death certificate. Rather, the tendency is to think about death certificates simply as administrative forms that must be filled in to track deaths in the community. Death rates clearly make a link more feasible – illustrating, for example, the high numbers of deaths proportionately among certain social groups, for example in suburbs with lower socioeconomic status (Glover et al. 1999; AIHW 2022). However, death certificates precede death rates. In fact, they constitute death rates. According to Swain et al. (2005: 652), “the primary tool for measuring mortality rates is the death certificate”. Hence, I suggest that analytically they deserve a closer look. 

In this analysis, death certificates are treated as governmental mechanisms or technologies that have effects “in the real” (Bacchi and Goodwin 2016: 44). Specifically, how COD (cause of death) is problematized in these administrative documents/forms shapes lives and living conditions in particular ways that need to be traced. Death certificates rely upon deep-seated ontological presuppositions about how bodies work (or don’t work) and the kind of subject that “inhabits” these bodies (see Jewson 2009). The individual is regarded as an “essentially biophysiological and neurophysiological system, which can be broken down into an unlimited number of subsystems (anatomical, cells, molecules, genes) that are functional parts of the whole” (Yadavendu 2003: 5180). Disease is considered as a malfunction of one or more subsystems. The study of disease is called pathology.

At the most obvious level the focus on pathological system failure in death certification practices completely precludes attention to SDH. There is certainly no space on the standardized international death certificate that explicitly invites the listing of the “the conditions in which people are born, grow, work, live, and age” (from above). While many articles report on errors in recording COD, this entry is not strictly concerned with coding errors (but see below for further discussion) (Adeyinka and Bailey, 2022; Morgan et al., 2022). Rather, it focusses on what is invisible on death certificates – on what is NOT counted, on what is silenced and hence on what is deemed to be irrelevant or insignificant. 

The repercussions of the lack of space for SDH on death certificates are stark, given that governments collect mortality data from these forms to plan and implement health care policy, and to allocate health and research funding (Brooks and Reed 2015: 74). Indeed, the lack of space for SDH on standardized international death certificates may help explain why health promotion and public health measures are the “Cinderella” areas of the health sector (Lewis 2005: 171). In a challenge to the limitations of US COD figures, the epidemiologists Michael McGinnis and William Foege (1993: 2211) note that the preponderance of health care expenditure “will be devoted to treatment of conditions ultimately recorded on death certificates as the nation’s leading killers”. On this topic it is relevant to acknowledge the well-established overreporting of cardiovascular deaths on death certificates (Pagidipati and Gaziano 2013; Lakkireddy et al. 2004). Attempts to create space for SDH within the parameters of current death certificates are canvassed and assessed later in the entry. There we will look at Z codes, what they facilitate in terms of reporting SDH, and what limitations they face. 

In this discussion it is important to keep an eye on the larger context and whether it is deemed to be desirable to encourage the “State” to acquire more and more information about its “citizens” and “others” (Foucault 1991). Bowker (1996:55) points out that “the ultimate cause of death” is “state-defined”:

“It was made explicit in 1932 that when there were two equal underlying causes of death (e.g., cholera and leukemia) then the cause that would be most useful to the state (in this case cholera, which was a matter of public health concern) would be taken statistically as the underlying cause.”

We appear to be caught in something of a cleft stick here – we either demand that social conditions be factored into COD decision-making processes and accept state-sanctioned surveillance, or we face exclusion from important research dollars and decision-making sites.

COVID-19, SDH and COD

The pandemic has driven home the association between SDH and COD. It has opened the floodgates on research highlighting the importance of socioeconomic conditions in COVID-19 death rates. Indeed, it has become commonplace to report that the pandemic has revealed ruptures and fractures in existing social arrangements – by class, age, disability, mental illness, gender, race, etc.

McGowan and Bambra (2022) provide a useful example. They produce a scoping review to identify and synthesise published evidence on geographical inequalities in COVID-19 mortality rates globally. A large majority (n=86) of the reported studies found that COVID-19 mortality rates were higher in areas of socioeconomic disadvantage than in affluent areas. McGowan and Bambra concluded that “COVID-19 has exacerbated endemic health inequalities resulting in a syndemic pandemic of higher mortality and morbidity rates among the most socially disadvantaged”.  Social disadvantage is captured in the concept of “deprivation” – “which is an area measure of poverty, low income, and a reflection of the wider social determinants of health (such as housing, working conditions, unemployment, health-care access, etc.) (McGowan and Bambra 2022: e968; emphasis added). This connection between SDH and COD via COVID-19 is well-established (Chávez-Almazán et al.2022; Dalsania et al. 2022; Figueiredo et al. 2020; Samuel et al. 2021; WHO 2021; Singu et al. 2020).

The question becomes – what follows from all this research? Where are the health policy interventions that attest to the impact of these comprehensive and well-supported analyses? Historically the track record on delivering on SDH is poor. Proponents seek to find explanations for what is commonly called the “know-do” gap, referring to the gap between what we know about broad social and economic patterns in population health (SDH) and what is being done – which is very little! Explanations for this inaction tend to target the apparent “lack of will” of those with institutional authority to implement SDH insights (Harvey 2006) and their possible ideological aversion to those insights (Raphael 2006; Bambra et al. 2005). 

Alongside these explanations, I suggest the need to pay more attention to structures of governance, including funding arrangements, because of the ways these practices shape social relations, subjectivities and policy outcomes (Bacchi 2008). In the particular case at hand, I argue that the operation of death certificates as governmental mechanisms helps to explain the invisibilization or silencing of SDH. In an earlier entry (30 May 2023) I apply the WPR questions to the standardized death certificate as “practical” text. There the case is made that current death certificates leave little to no room for reflecting on the social determinants of health (SDH). This theme of “silencing” is pursued in this entry. 

What else is missing from death certificates?

While this analysis is not specifically concerned with reporting errors, as already mentioned, it wishes to highlight the absences on death certificates (WPR question 4). It is a moot point whether these should be described simply as “errors” or whether they reflect systemic political imbalances.

Importantly, in some settings, the certificates themselves are missing. For example, higher income countries record all deaths, noting the causes on the death certificates. This is not the case worldwide. The problem of unrecorded deaths is particularly acute in low- and middle-income countries (Lang 2022). As Bowker (1995: 52) describes, the international classification of diseases (ICD), developed in 1893 and with ICD-11 as the latest update (WHO 2022a), imposes an imperialist reading of disease on the rest of the world.

In terms of specific “pathologies”, while mental illness is a factor in many deaths, it is almost never listed on death certificates. Psychiatric disorders are sometimes certified on death certificates, but they are seldom selected as the underlying cause of death. Goldacre et al. (2006) report that “The majority of deaths with a certified psychiatric cause are usually omitted from official mortality statistics, which are typically based on the underlying cause alone”. As a result, explain Vigo et al.(2016), 

“mental disorders appear to only account for 0·5% of total years of life lost, because GBD (Global Burden of Disease) estimates only reflect deaths directly attributed to mental disorders recorded in death certificates (mostly due to schizophrenia and substance abuse), which leads to zero global deaths attributed to bipolar disorder, depression, and other mental illnesses”.

Stirton and Heslop (2018) raise concerns about the accuracy and reliability of MCCD (Medical Certificates of Cause of Death) for people with intellectual disability, while Rockett et al. (2011) identify a grave need to improve the sensitivity of suicide certification in most countries. 

Manoeuvring within the system

A range of interventions in the COD field indicate both disquiet with the current certification process and suggestions for how to improve it. Introduced in 1954, “multiple causes” analysis is one such development. It targets all the causes of death on the death certificate, including the underlying cause and associated causes. The Australian Institute of Health and Welfare (AIHW) signalled in 2012 that “the use of multiple causes of death data to describe patterns of mortality is becoming more prominent”. Despite widening the parameters for diagnosis of disease entities, “multiple causes” analysis does not dislodge the primacy accorded the UCOD. It also clearly stays within the biophysiological paradigm. As Armstrong (2021: 1623) points out, while medicine has opened for inspection the chain of events leading to a death, in so doing it “has affirmed its own explanatory framework around death”.

Verbal autopsy and psychological autopsy aim to compensate for the inadequacies of death certificates in certain situations (thank you to Peter Mayer for this lead). In populations lacking medical certification, the WHO (2022b) recommends the use of verbal autopsy: 

“Verbal autopsy is an interview carried out with family members or caregivers of the deceased using a structured questionnaire to elicit signs and symptoms and other pertinent information that can later be used to assign a probable underlying cause of death.”

For equivocal suicide cases Rockett et al. (2011) suggest adopting psychological autopsy methods: 

“A psychological autopsy involves in-depth review of medicolegal records and follow-back interviews with family, friends and acquaintances of a decedent to look specifically for possible antecedents of his or her suicide or possible suicide.” 

Zhu et al. (2022) draw on a registry from the Korea Psychological Autopsy Center to show connections between suicide and social determinants of health in South Korea.

As with “multiple causes” analysis, verbal and psychological autopsy aim to assist in identifying COD. They remain within the biophysiological paradigm in which a notion of causality “singles out a pathological factor” (Timmermans and Almeling 2009: 23). 

Z codes: possibilities and concerns

The most explicit attempt to bring awareness of SDH to COD analysis is the introduction in 2015 of Z codes, which form part of the ICD’s (International Classification of Diseases) classificatory schema. In Australia the ABS (Australian Bureau of Statistics 2020) receives files from hospital Registrars with information about the deaths that were registered each month. The ABS then amalgamates and checks the records, assigns “cause of death” codes to each record, validates the dataset and produces statistical output. To put it bluntly, if a “condition” does not have a code, it does not get counted. The creation of Z codes is therefore a significant development and deserves attention.

The items available as Z codes are highly variable. They appear in a summary table produced by the CDC (Centers for Disease Control and Prevention 2021). Jacobs (2021) provides a useful introduction to Z codes and his concerns about their limitations. He argues that many of the existing codes are far too generic, such as Z59.8 (low income), “which encompasses a wide array of financial issues, each requiring a distinct solution”. He also points out that, in the US, Z codes are rarely used. This lack of uptake is linked to the reluctant adoption of Z codes by health care providers (True 2021). It seems that, if a coded item isn’t funded, it isn’t used – understandably! At the same time, the American Medical Association, UnitedHealthCare, and the American Hospital Association have petitioned to expand Z codes to capture a broader range of SDH and with greater specificity (Jacobs 2021: 3206), suggesting a brighter future for Z codes.

Below I have produced two sample lists (1 & 2) to indicate the range and nature of specific Z codes. Sample list 1 points to the ways in which some Z codes appear to target “structural determinants” of health. The items on this list indicate support for a critical SDH that emphasises the role governments play in creating specific social, economic and environmental contexts that help to make people either “ill” or “well” (Bacchi 2009: 135). 

Sample list 2 contains items where the target for change is the individual (or their parents) rather than living and working conditions. By contrast with Sample list 1, it identifies social factors that work through individual behaviours, commonly referred to as “risk factors”. This variability in Z codes signals the diversity of positions within SDH, identified by Yadavendu (2013) as a shift from “holism” to “individualism”:

“The older, philosophical approach in public health involved a holistic, population-based understanding that emphasized historicity and interrelatedness to study health and disease in their larger socio-economic and political moorings. A newer tradition, which developed in the late 19th century following the acceptance of the germ theory in medicine, created positivist transitions in epidemiology. In the form of risk factors, a reductionist model of health and disease became pervasive in clinical and molecular epidemiology.”

Z codes: Sample list 1 

Z55.1 Schooling unavailable and unattainable

Z56.3 Stressful work schedule

Z56.81 Sexual harassment on the job

Z57.0 Occupational exposure to noise

Z58.6 Inadequate drinking-water supply

Z59.1 Inadequate housing

Z60.5 Social exclusion and rejection

 

Z codes: Sample list 2

Z55.3 Underachievement in school 

Z59.2 Discord with neighbors, lodgers and landlord

Z60.0 Problems of adjustment to life-cycle transitions

Z62.1 Parental overprotection

Z62.891 Sibling rivalry

Z63.5 Disruption of family by separation and divorce

Z72.3 Lack of physical exercise 

Z72.51 High risk heterosexual behavior

Z72.52 High risk homosexual behavior

To deal with this plurality of perspectives, I suggest treating each Z-coded item as a proposal, in the WPR sense of the term, and submitting it to a WPR analysis ( KEYNOTE ADDRESS – CAROL BACCHI – 17 August 2022). Collectively, the sample lists also signal the need for concern about the accumulation of highly personal information for the purposes of governmental administration.

Finally, to repeat a theme running through this entry, to the extent that Z codes aim to offer causes of disease entities, they remain within what Armstrong (2021) calls “the pathological explanation”. The focus remains on disease entities rather than on the conditions a person lives in and with – the social and environment conditions that shape their lives, not just their deaths. The task becomes shifting from a conception of health as absence of disease to health as a “state of complete physical, mental and social wellbeing” (WHO 1946). 

Returning to the pandemic

I opened this entry by highlighting the extensive research attesting to the impact of socioeconomic conditions on COVID-19 death rates and queried the policy interventions that might usefully follow. Here I consider the extent to which a governmental response adopted in many countries, testing and contract tracing, pays heed (or not) to SDH.  

I draw on the work of Richard et al. (2023) who set out to evaluate the space for a focus on SIH (social inequalities in health; a proxy for SDH) in the design of testing and contact tracing (CoviTCT) protocols in France. Health inequalities, such as differences in life expectancy by social groupings, are seen to be the outcome of SIH (Marmot 2005).

Richard et al. (2023: 8) explicitly invite readers to approach the testing and contract tracing response as a problematization. They point out that, as a proposal, CoviTCT centres on the virus and contaminants. The primary goal is to break chains of transmission. 

Such a representation of the problem, they argue, participates “in (re)producing a predominant clinical framing (Benford and Snow, 2000) of the pandemic situation” (Richard et al. 2023: 8; see Townley et al., 2023). 

While the “key informants” interviewed by Richard et al. (2023: 5) adopted positions on a continuum ranging from a biomedical to a health promotion vision, a SIH perspective emerged only as a complement to the clinical epidemiological strategy of the CoviTCT intervention.  As a political response Richard et al. (2023: 9) stress the need to elevate the importance of SIH reduction approaches:

“From a dual perspective of social justice and epidemiological coherence, the COVID-19 pandemic has highlighted that SIH need to be considered as the basis of infectious diseases response, regardless of the emergency context.” 

In terms of effects (WPR question 5), interventions that aim to control the transmission of the virus tend to produce a focus on what Waleed Aly (2020) calls the “symptoms” of COVID-19. We are encouraged to see “technologies” such as CoviTCT as “solving” (albeit in a piecemeal fashion) the “problem” of contagion. There is no space in this reactive approach to consider how we have got here – how pandemics, for example, are an increasing likelihood due to a range of practices such as deforestation (Zimmer 2011). 

None of these comments suggests that we do not need testing and contact tracing. The point is to see how such a proposal/intervention creates the “problem”, what it assumes and what it leaves out. This approach could profitably be applied to other public health interventions, such as social distancing, mask wearing, working from home and “hard” lockdown (Kelaita et al. 2023). 

Tasks for another day

To argue, as I have done, that death certificates need redesigning to acknowledge explicitly the place of SDH does not on its own indicate what ought to be included on, or dropped from, the form. Rather, it highlights the need to encourage conversations on the design, assumptions and effects of this governmental mechanism. On the one hand there is a need to reflect on the limitations of a death certification process that “forces the use of a chain of linear, single diagnoses to describe the complex process by which people live and die” (Merlin et al. 2022: S37). On the other hand, there is an opportunity to engage with those who argue that this decontextualizing of death may be “an inevitable way of getting things done in medicine” (Timmermans and Almeling 2009: 23). 

In the short term, it is interesting to consider what might follow from encouraging doctors to use Z code categories carefully when they fill in death certificates. I say carefully, of course, due to the possibility of lapsing into individual behavioural categories of analysis and the possibility of extracting personal information that has no business being included on administrative forms of any kind (discussion above). Navigating the edges of the cleft stick I mentioned earlier is doubtless a challenging task for all of us.

I would be keen to hear reactions to the last three Research Hub entries on COD (Cause of Death). Have they managed to pique your interest in the political implications of standard administrative forms such as death certificates? Please contact me at: carol.bacchi@adelaide.edu.au or subscribe to the WPR list (see this link:  Welcome to the WPR Network! | Karlstad University (kau.se)

In the next entry I intend to deliver on my promise to examine what happens when WPR is applied to WPR. 

References

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Yadavendu, V. K. 2003. Changing Perspectives in Public Health: From Population to an Individual. Economic and Political Weekly, 38(49): 5180-5188.

Yadavendu, V. K. 2013. Shifting Paradigms in Public Health: From Holism to Individualism. NY: Springer.

Zhu, Y., Nam, S., Quan, L., Baek, J., Jeon, H., and Tang, B. 2022. Linking suicide and social determinants of health in South Korea: An investigation of structural determinants. Frontiers in Public Health, DOI 10.3389/fpubh.2022.1022790 Zimmer, C. 2011. A Planet of Viruses. University of Chicago Press.

In the recent elaboration of key premises in WPR ( KEYNOTE ADDRESS – CAROL BACCHI – 17 August 2022) I emphasize the importance of cultivating a genealogical sensibility. The argument supporting this proposition is that we need to consider how we have got “here” from “there” because such a focus makes it possible to question the present. Foucault (1990) calls this approach “a history of the present”. Importantly, a genealogical sensibility resists the temptation to offer a strict chronology of developments, which can lead to a sense of inevitability. For Foucault (1977), relying on Nietzsche, genealogies are records of discontinuity, of twists and turns, of skeletons in the closet (if you will). A genealogical sensibility therefore keeps a sharp eye open for tensions and debates around crucial issues. To those who find this detail dull, I apologize. My training as a historian means I love this stuff!

The history of the current standardized death certificate is long and complicated, and way beyond the purview of a Research Hub entry. Some of the research in this entry is original, but mostly I draw on secondary sources. I bring particular attention to contestatory frames of reference. As a uniting theme, I highlight debates about the countervailing influences of biology and environment on human development. To undertake this task, following Dean (1999: 178), I identify the forms of knowledge that make COD thinkable, the techniques that discover it, the technologies that seek to govern it and the political rationalities and programs that deploy it.  Keep your eye open for these knowledge and other practices, and for resonances with (not replicas of) contemporary developments!

Bills of Mortality, John Graunt and “Shop-Arithmetique”

Bills of Mortality were produced in late 16^th century London, primarily to monitor cases of the plague and to institute quarantine where needed. Parish clerks kept the statistics. Causes of death other than plague were recorded from about 1604 (Connor 2022: 2). 

A London draper, John Graunt (1620-74), produced a systematic study of the Bills of Mortality in 1662. He applied what he described as “the Mathematiques of my Shop-Arithmetique” – his book-keeping skills – to the data. His tables indicate sharp differences in annual death rates between what Graunt called “Acute” or “Epidemical” diseases and those which he described as “Chronical”, a distinction that can be traced to the time of Hippocrates. 

Graunt drew attention to the poor health and reduced longevity of those living in large geographical regions, a phenomenon that became known as the “Urban Penalty”. In his words, 

I considered, whether a City, as it becomes more populous, doth not, for that very cause, become more unhealthfull, I inclined to believe, that London now is more unhealthfull, then heretofore, partly for that it is more populous, but chiefly, because I have heard, that 60 years ago few Sea-Coals were burnt in London, which now are universally used. For I have heard, that Newcastle is more unhealthfull than other places, and that many People cannot at all endure the smoak of London, not onely for its unpleasantness, but for the suffocations which it causes.  (Graunt 1662 in Connor 2022: 5)

(I feel tempted to say: “plus ça change, plus c’est la même chose”.)

Graunt tied the importance of demographic and epidemiological data to the need to keep Government and Trade “certain and regular”, with consequent benefits for peace and prosperity (Connor 2022: 6). He expressed misgivings about the effectiveness of quarantine against contagion: “That the troublesome seclusions in the Plague-time is not a remedy to be purchased at vast inconveniences” (Connor 2022: 6), a view that may sound familiar. 

Graunt’s friend and colleague, William Petty, coined the term “Political Arithmetic” to describe the connection between demography and government. Defined by Charles Davenant (1656-1714) as “the art of reasoning by figures, upon things relating to government”, this thinking is considered the forerunner of economics as a discipline (Hoppit 1996 in Connor 2022).

The Power of Statistics

The other form of knowledge implicated in the evolving enthusiasm for COD accounting is statistics. Moriyama (2011: 10) traces the “triggering event leading to the first ICD [International Classification of Diseases]” to “the unlikely Great Exhibition of 1851 held at the Crystal Palace in London”. At that event numerous nations displayed their industrial products. Visiting statisticians pursued the idea of comparing national statistics, which led to the First International Statistical Congress at Brussels in 1853. Moriyama reports: “By this time, a systematic review seems to have occurred of subjects that could be candidates for international statistical comparison”, including “Causes of Death”. 

Following a proposal at the 1853 Congress to produce a uniform nomenclature of diseases, which was needed to tabulate “causes of death”, William Farr and Jacob Marc D’Espine were charged with developing classifications. Farr (1807-1883) was a physician employed as a British government statistician (Alharbi et al. 2021: 4). D’Espine was a Swiss statistician. D’Espine’s list grouped causes according to their nature, that is, as “gouty, herpetic, hematic”, etc. Farr divided diseases into three classes:

the first for those that occur endemically or epidemically, in other words, the communicable diseases, which provided an index of salubrity [health or well-being]. The second class was for those diseases that arise sporadically—these he subdivided anatomically into diseases of the nervous system, respiratory organs, etc., ending with a group for those of uncertain location such as tumors, malformations, debility, sudden death, and old age.  (Moriyama 2011: 10)

According to the president of the committee overseeing the project, classification of groups of the diseases had only secondary importance: “the main point was to produce a list of morbid entities frequent enough to merit the attention of the statistician, enabling comparison of data on known morbid entities” (Moriyama 2011: 11; emphasis added). In the event, Farr’s list, which included the principle of classifying diseases by etiology followed by anatomic site, survives in the present classification. As Armstong (2021: 1621) points out, the nineteenth century decision to separate epidemic, sporadic/pathological and violence as causes of death has continued to underpin the classification of death into the 21^st century.

In this classification model, epidemics supersede deaths from pathological causes as “underlying cause of death”. At the First Revision Conference on the International List of Causes of Death in 1890, Jacques Bertillon, Chief of Statistics for the City of Paris, prepared a guide for medical officers responsible for determining COD. His third rule stipulated: 

When among the two causes of death there is a transmittable disease, it is preferable to assign the death to it, for statistics of infectious diseases are particularly interesting to the sanitarian [whom we shall meet shortly CB], and it is important that they shall be as complete as possible. (in Moriyama 2011: 30)

This privileging of epidemic disease as underlying cause of death continued into the twentieth century. In 1958 Carl Erhardt, Director of the Bureau of Records and Statistics, Department of Health, New York, endorsed this thinking: “In populations with high mortality and short life expectancy, death is most often caused by infectious or communicable disease. Under such circumstances, the cause of death can often be expressed as a single term” (Erhardt 1958: 163). This convention explains the WHO (2020: 3) directive to doctors and coroners to list COVID-19 as the “underlying cause of death” (see previous entry 30 May 2023).

Sanitation and COD

The mid-19^th century proved to be a pivotal time for discussions around COD. In 1837 the Registration Act was passed in England. It included provisions for inquiry into causes of death. In 1839 William Farr, whom we have already met, became compiler of abstracts in the Registrar-General’s office. He developed and analyzed mortality statistics to do with the conditions of sanitation and health in England (Moriyama 2011: 2). Farr drew direct links between environmental factors and health/death. Registration districts were characterized by “degrees of insalubrity”, depending on whether they exceeded the established standard of 17/1000 deaths. Mortality in excess of this rate was “assumed to be due to defects in the environment” (Eyler 1987: 343). 

Farr’s 1837 mortality report included a comment on 63 deaths resulting from “starvation”: “Hunger destroys a much higher proportion than is indicated by the registers in this and every country, but its effects, like the effects of excess, are generally manifested in the production of diseases of various kinds” (in Whitehead 2000: 87). “Natural death”, in his account, could be accelerated by “want and privations” (in Armstrong 2021: 1621). 

Eyler (1976) notes that health reformers and sanitarians accepted a view that health, disease, death, and physical and moral conditions were joined in an indissoluble link. In Farr’s (1875 in Eyler 1976: 336) explanation:

There is a relation betwixt death and sickness. … There is a relation betwixt death, health, and energy of body and mind. There is a relation betwixt death, birth, and marriage. There is a relation betwixt death and national primacy. … There is a relation betwixt the forms of death and moral excellence or infamy. 

The Medical Officer to the Privy Council, John Simon (1857-58 in Eyler 1975: 336), added to Farr’s list a supposed relation between infant mortality and the causes leading to racial degeneration. In this ordered world where everything linked up so neatly, statistics promised to provide an effective tool to “elucidate the complex dependency of health on manner of life”. A driving force in this discussion was Florence Nightingale, who aimed to demonstrate statistically how improved sanitary conditions and better schooling reduced mortality, illness, and even criminal behaviour (Moriyama 2011: 11).

There were tensions among the sanitation campaigners. The well-known first secretary to the Poor Law Board and later Commissioner of the General Board of Health, Edwin Chadwick, objected to Farr’s inclusion of the category “starvation” in the Bills of Mortality. Chadwick argued that it was impossible for a person to starve to death in London. “The notion that poverty itself was the cause of illness was, for Chadwick, unthinkable” (Corbett 1999). Chadwick had served as private secretary to Jeremy Bentham, the utilitarian philosopher. The Benthamite prescription for pauperism was deterrence: “The pain of the workhouse was to be greater than the pain of poverty and poor relief” (Corbett 1999).

It is too simple to paint Farr as a proponent of the social determinants of health and Chadwick as the defender of the evil workhouse. As Armstrong (2021: 1621) points out, Farr’s focus on “external agents”, such as “intemperance, cold, want, and effluvial poisons”, did not disrupt the dominant biomedical or pathological explanation of death with its focus on “disease entities”. All that Farr accomplished, and it is no mean accomplishment, was to highlight the range of influences in people’s environments that cause disease. This theme – whether it is possible to disrupt “the pathological explanation” in death certificates – is taken up in the next Research Hub entry.

In addition, it is useful to consider how Farr’s statistical frame of reference placed limitations on his social analysis.  He wanted to make statistical inferences and believed this could not be done with the small numbers that would be produced in a detailed classification. Hence, he did not provide specific rubrics for diseases that were rare in England (Moriyama 2011: 10), imposing an Anglo-Celtic analytic lens.

Challenges to “salubrity” 

The opposition to our sanitarians, which developed later in the century, came from several quarters. On one side were the anti-vaxxers (yes, indeed). The Reverend and Mrs William Hume-Rothery led the National Anti-Compulsory Vaccination League. Their targets were the Compulsory Vaccination Acts of 1867, 1871 and 1874 (we are talking about smallpox here). Mrs Hume-Rothery questioned male domination of medicine, especially male tyranny over female patients. She strongly objected to the proposal to give qualified practitioners the sole right of signing death registers. State medicine, she claimed, threatened personal liberty and morality: “It seemed a conspiracy of a greedy profession against the public”. Her National Anti-Compulsory-Vaccination Reporter carried the following articles: 

“The Swedish Small-Pox Statistics Fraud: The Real Truth of the Matter,” 1882, 5:25-29 

“How Pro-Vaccinators Manipulate Statistics,” 1883, 7:195-97, 214-16

 (see Eyler 1976: 347-348)

Other opponents of the sanitary reformers, clearly with very different arguments, were local medical authorities. They voiced no objections to the role of physicians in public policy but, based on their experience, they expressed doubts that death rates were a good test of the healthiness of their respective districts. According to Eyler (1976: 348), this opposition signalled “the growing medical domination of the public health movement”. The president of the Society of Medical Officers of Health asked the Statistical Society of London in 1874 if death rates could be lowered with sanitary reform: “Would it do away with the overcrowding that was one of the necessary conditions of the existence of people in large towns?” (Eyler 1976: 348).

The chief challenge to mortality rates as measures of community health was that “Implicit in the program of these social pathologists is the belief that length of life reveals quality of life” (Eyler 1976: 354). In reaction, a demand for compulsory registration of sickness became common, led by the International Statistical Society, the Epidemiological Society, and a joint committee of the Social Science and the British Medical association (Eyler 1976: 354). It was 1911 before national compulsory registration of contagious diseases was enacted. 

“National primacy”, COD and eugenics

The identified relation Farr makes “betwixt death and national primacy” (see above), and Simon’s reference to “racial degeneration”, noted earlier, suggest links between the development of COD accounting and the eugenics movement. In previous work – actually in my previous life as a historian – I explored the complex variations in Australian eugenic thought between 1900 and 1914 (Bacchi 1980). Of some interest to the topic at hand is the distinction I identified between so-called positive eugenicists and negative eugenicists. The former put their faith for improving the “race” (and they did speak in these terms) in environmental change and the latter in biological interventions, including compulsory sterilization of the so-called “feeble minded”. At first glance, there appears to be a clear dispute between those who promoted environmental and those who offered biological explanations for human development. However, the two groups shared a belief in the prominent place of biology but, according to our “positives”, there remained some room to move. While the priority placed on national/racial improvement needs to be recognized, it is important to keep an eye open to divergence and contradiction, and just plain messiness, “to show that things ‘weren’t as necessary as all that’” (Foucault 1991: 76). 

As an example, Professor Raymond Pearl (1879-1940) from Johns Hopkins University, was an avid supporter of the eugenics movement in the early 1900s. But in 1925 he wrote a book condemning the movement as unscientific. Professor of the Blomberg School of Public Health, he was a founder of biometry, the application of statistics to biology and medicine. He used his statistical studies to demonstrate the connection between smoking and death, and to trace the varying times of death for body organs, useful in current transplantation. He was highly critical of the International Classification of Causes of Death, describing it as “not primarily a biological classification”. He proposed modifying the list to group all causes of death under the heads of the several organ systems of the body:

We are now looking at the question of death from the standpoint of the pure biologist, who concerns himself not with what causes a cessation of function, but rather with what part of the organism ceases to function, and therefore causes death. (Pearl 1921: 491) 

As a “pure biologist”, Pearl endorsed a view of the body as machine, though he was far from impressed by the nature of evolution: “The workmanship of evolution, from a mechanical point of view, is extraordinarily like that of the average automobile repair man” (Pearl 1921: 516). Hence, he questioned some of the strategies of the eugenicists. Since a brown-eyed man and a brown-eyed woman might have blue-eyed children, he could see no “guarantee that a wealthy, intelligent, tall, and handsome couple would not have children who grew up to be poor, stupid, short, and ugly” (Hendricks 2006). However, while on occasion he questioned the class bias of eugenics, he continued to express racist and anti-Semitic views.

Pearl supported birth control as a public health measure, targeting what eugenicists referred to as the “differential birth rate” (Bacchi 1980: 208). His expressed goal was to reduce the high birth rate in many non-industrialized countries and in lower income groups within the industrialized world, indicating a continuing class-based prejudice. He held out hope that child welfare might provide a useful direction to reduce the general death rate, with his focus primarily on education:

Ignorant and stupid people must be taught, gently if possible, forcibly if necessary, how to take care of a baby, both before and after it is born. It seems at present unlikely, that mundane law will regard feeding cucumber to a two months’ old baby, or dispensing milk reeking with deadly poison makers, as activities accessory to first-degree murder. (Pearl 1921: 494). 

At the same time Pearl endorsed public hygiene initiatives:

… if that final Judgment Seat, before which so many believe we must all eventually appear, dispenses the even-handed justice which in decency it must, many of our most prominent citizens who in the financial interests of themselves or their class block every move towards better sewage disposal, water and milk supply, and the like, or force pregnant women to slave over a washtub and sewing bench that they may live, will find themselves irrevocably indicted for the wanton and willful slaughter of innocent babies. (Pearl 1921: 495). 

With all this, he finally concludes that biology trumps environment: 

It furthermore seems to me that the results presented in this paper add one more link to the already strong chain of evidence which indicates the highly important part played by innate constitutional biological factors as contrasted with environmental factors in the determination of the observed rates of human mortality. (Pearl 1921: 516)

I have offered Pearl, not as a confused and bombastic biologist, but to illustrate that, when it comes to causes of death, the picture is complicated. At the same time Pearl’s work illustrates the primary focus in death certificates on biology in one form or another – a focus either on disease entities, or on organ systems. Efforts to bring factors from outside that framework to bear on conceptions of death causation (COD) fight an up-hill battle. In the last entry in the series (next entry), I concentrate on interventions designed to bring awareness of the social determinants of health to the discussion of COD. 

References

Alharbi, M. A., Isoudard, G. and Tolchard, B. 2021. Historical development of the statistical classification of causes of death and disease. Cogent Medicine, 8:1, 1893422, DOI: 10.1080/2331205X.2021.1893422 

Armstrong, D. 2021. The COVID-19 pandemic and cause of death. Sociology of Health & Illness, DOI: 10.1111/1467-9566.13347

Bacchi, C. 1980. The nature-nurture debate in Australia, 1900-1914. Historical Studies, 19(75): 199-202. 

Bowker, G. C. 1996. The History of Information Infrastructures: The Case of the International Classification of Diseases. Information Processing & Management, 32(1): 49-61.  

Connor, H. 2022. John Graunt F. R. S. (1620-74): The founding father of human demography, epidemiology and vital statistics. Journal of Medical Biography, DOI: 10.1177/09677720221079826. 

Corbett, S. 1999. Review: C. Hamlin, Public Health and Social Justice in the Age of Chadwick Britain 1800-1854.  Health Promotion International, 14(4): 381-382. 

Dean, M. (1999). Governmentality: Power and rule in modern society. London: Sage.

Erhardt, C. L. 1958. What is “The Cause of Death”?  Journal of the American Medical Association (JAMA), 168(2): 161-168.

Eyler, J. M. 1976. Mortality Statistics and Victorian Health Policy: Program and Criticism. Bulletin of the History of Medicine, 50(3): 335-355. 

Farr, W. 1875. Letter to The Registrar-General on the Mortality in the Registration Districts of England during the Years 1861-70, Supplement to the Thirty-fifth Annual Report of the Registrar-General of Births, Deaths, and Marriages in England, 1875 [C. 1 155-1]. XVIII, pt. 2] 

Foucault, M. 1977. Nietzsche, genealogy, history. In D.F. Bouchard, (Ed.), Language, counter-memory, practice: Selected essays and interviews. 

Ithaca: Cornell University Press.  

Foucault, M. 1990. The concern for truth. In L.D. Kritzman (Ed.), Michel Foucault: Politics, philosophy, culture. Interviews and other writings, 1977–1984, 1st edition 1988, A. Sheridan, (trans.). New York: Routledge.

Foucault, M. 1991. Questions of method. In G. Burchell, C. Gordon, P. Miller (Eds.), The Foucault effect: Studies in governmentality. Chicago: University of Chicago Press.   

Graunt, J. Natural and political observations mentioned in a following index, and made upon the bills of mortality. London: John Martin, 1662.

Hendricks, M. 2006.  Raymond Pearl’s “Mingled Mess”, Johns Hopkins Magazine. Available at: https://pages.jh.edu/jhumag/0406web/pearl.html

Hoppit J. 1996. Political arithmetic in eighteenth-century England. The Economic History Review New Series, 49: 516–540.

Moriyama, I. M. 2011. History of the Statistical Classification of Diseases and Causes of Death. Centers for Disease Control and Prevention, National Center for Health Statistics.

Pearl, R. 1921. The Biology of Death – IV. The Causes of Death. The Scientific Monthly, June. 

Simon, J. 1857-58. Introductory Report by the Medical Officer of the [General] Board of [of Health], Papers Relating to the Sanitary State of the People of England, [2415]. XXIII, xxvii. 

Whitehead, M. 2000. William Farr’s legacy to the study 

of inequalities in health. Bulletin of the World Health 

Organization, 78(1): 86–87.

World Health Organization (WHO) 2020. International guidelines for certification and classification (coding) of COVID–19 as cause of death. https://www.who.int/publications/m/item/international-guidelines-for-certification-and-classification-%28coding%29-of-covid-19-as-cause-of-death

You may recall the adage that there’s nothing certain in life except death and taxes (notice the “uncertainty” trope at work; see previous Research Hub entry 29 April 2023). Well, you can scrap the first of these. It seems that in the time of COVID-19 you are dead for some purposes but not for others, or dead for some jurisdictions but not for others (Harries 2020; Trabsky & Hempton 2020). Or, I’ve heard it said that in the time of COVID-19 death does not count at all. 

My interest in this topic was sparked by the marshalling of the phrase “underlying health conditions” in reports by public health officials in Australia in their daily briefings on COVID-19 case numbers and mortality figures during 2021 and early 2022. I couldn’t help thinking at the time that some people were identified in this way, as having “underlying health conditions”, to divert attention from the rising death toll. After all, if people who died had “underlying health conditions”, their deaths appeared to have less to do with COVID-19. An implied lower death count could then serve to reduce the seriousness of the pandemic and, subsequently, allow more “freedoms” from public health restrictions.

Research on the topic led to several discoveries. First, the phrase, “underlying health conditions” or “pre-existing health conditions”, was being used in similar ways elsewhere. In a Research Hub entry entitled “Becoming More Mortal” (22 Feb. 2022) I referred to the work of the Native American novelist, Louise Erdrich (2021), who was clearly as bemused as I was by the operation of the term.  Further research led me to discover, with my colleague Anne Wilson, that the phrase played a key role in one of the longest running policy disputes in American history, the design of a health care system that covered the health of the population (Bacchi and Wilson 2022). Alongside these topics, I began to ask how such a phrase came to be (possible) and how it related to conceptions of health and illness more generally – recognizable as WPR questions 2 and 3 (see Chart in Bacchi and Goodwin 2016: 20). This search took me to the topic of death certification, the topic I introduce in this entry and pursue in two subsequent entries. 

As you shall see, in this series of three entries, I make the case that there is a good deal at stake in the form and content of the current internationally standardized death certificate (WHO 2022). Specifically, applying the WPR questions, I develop the argument that the death certificate, in its design and use, functions as a governmental mechanism to undermine the social determinants of health (SDH). There is no suggestion here of deliberate intent.

 To support this claim, this entry reviews how COVID-19 deaths are recorded and counted. In the second entry, in a month’s time, I offer a brief genealogy of how the international death certificate came to be adopted worldwide, with a particular focus on contestation. In the third entry of the series, I show how death certificates can undermine SDH, and review the possibilities and limitations of attempts to redress this situation (e.g., through Z codes).  

My governmentality background leads me to approach this topic in a specific way. Death certificates are described as “inscription devices”, to use the language of Actor-Network theory. Like graphs and maps, they are technologies or governmental mechanisms that, because of their appealing perceptual simplicity, “make it increasingly difficult to disagree with the matter at hand” (Latour, 1987: 64–70 in de Boer et al. 2021: 400). “Government” in this usage has a broader meaning than conventional uses of the term that target specific state institutions. It involves the regulation and oversight of the behaviours (or conduct) of the population by a wide range of agencies, authorities, experts and professionals (Bacchi 2023).  

As an example of a governmental mechanism, Rowse (2009) shows how the current Australian census problematizes Indigenous peoples as part of a population binary, Indigenous and non-Indigenous. Such a problematization, says Rowse, provokes consideration of the sort of political claims such a statistical distinction facilitates or blocks. In the European context, Walters (2002) explores how the apparently innocuous policy affecting signposts at airports, in which passengers are directed to EU and non-EU queues, serves to designate and firm up both “Europe” as a “place” and the category of “the European”. Importantly, in these studies the interest is not in rhetorical framing of the “problem” but in the governmental practices that produce certain problematizations and their political implications. 

Following in this tradition of exploring the political implications of commonly endorsed governmental mechanisms – e.g., censuses, signposts – I want to open reflections on how current standardized death certificates play significant roles in how lives are lived and how social relations are organized. Following Koopman et al.’s (2018) work on birth certificates, I see the need to pay more attention to death certificates as governmental technologies that shape worlds. 

Applying WPR (“What’s the Problem Represented to be?”) to death certification

In the language of WPR, death certificates become “practical texts” “which are themselves objects of a ‘practice’ in that … they were intended to constitute the eventual framework of everyday conduct” (Foucault 1986: 12-13; Bacchi 2009: 34). As practical texts they are problematizations with all sorts of repercussions for government funding and the design of public health interventions. How, then, I want to ask, do current practices of death certification affect governing? What specific effects can be associated with the patterns in death certification practices? Are their grounds for rethinking the conventions surrounding death certification practices and death certificates? 

These questions can be addressed through applying a WPR analysis. I start from the death certificate as a practical text and consider how it produces “cause of death” (COD) as a particular sort of problem.

I ask: what is the “problem” of “cause of death” (COD) represented to be in current death certification practices? One terminological issue needs to be sorted out at this point. The focus in death certificates is on “cause of death” and, more specifically, on the “underlying cause of death” (UCOD). This term needs to be kept distinct from “underlying health conditions”, which are not considered to be the “underlying cause of death”. Indeed, “underlying health conditions” are set apart from the “underlying cause of death”, both literally and figuratively, as explained in due course. To avoid confusion, I refer to “underlying health conditions” as “pre-existing health conditions”, which is often used as a synonym. 

As “practical texts”, death certificates provide the starting point for analysis. Recall that WPR examines proposals (proposed solutions, recommendations, etc.) in texts because they indicate what is identified as needing to change and hence what is produced as “the problem” (Research Hub 30 Jan 2023).

At one level, you could argue that the simple creation of a death certificate produces the “problem” as lack of certification, opening up consideration of the manifold reasons put forward for the usefulness of such certification. Historically, the practice of death certification dates to the 12^th century and is considered to be a legal obligation of the attending doctor prior to the disposal of the decedent’s remains (Swift and West 2002). With the rise of nation states, emphasis is placed on standardized classifications so that information can travel across boundaries/borders (Bowker 1996: 50).

Going further, it becomes possible to examine the specific form of the death certificate – how it is designed, which items are deemed to be relevant – to understand what is being problematized. Here it becomes relevant to examine the changes made to the standardized death certificate over time. Such changes reveal shifts in approaches to health and illness. 

The current standardized international death certificate has gone through several iterations (Erhardt 1956; Alharbi et al. 2021). It follows the model recommended by the World Health Organization (WHO) in 1927 (see Stirton and Heslop 2018), and finally accepted in 1940 (Armstrong 1986: 219). Called the Medical Certificate of Cause of Death (MCCD), it consists of two parts directly targeting “cause of death”. Part 1 offers spaces for a doctor or a coroner to fill in the immediate cause of death on the first line and the “chain of events” leading to this outcome on subsequent lines. On the last line in this sequence (of usually three items) appears the “underlying cause of death” (UCOD), defined by the WHO as “a) the disease or injury which initiated the train of morbid events leading directly to death, or b) the circumstances of the accident or violence which produced the fatal injury” (WHO, 2010: 31 in Stirton and Heslop 2018: 659). Part 2 of the form is used to list “other significant conditions, diseases or injuries that contributed to the death, but were not part of the direct sequence leading to death” (Stirton and Heslop 2018: 660). It is here, in Part 2, that our “underlying [or pre-existing] health conditions” are placed – a location clearly distinct from the “underlying cause of death” and the “chain of morbid events”. 

Question 2 in WPR targets deep-seated assumptions and presuppositions in the design of death certificates. This question opens a plethora of themes that require elaboration. Let me run through two key themes: first, the conception of disease and hence the conception of the body in the death certificate; and second, the place of causation in the design of the form.  

On the first theme, Jewson’s (2009) notion of “medical cosmology” proves useful. Described as a “parallel idea” to Foucault’s discursive formations, medical cosmologies “are conceptual structures which constitute the frame of reference within which all questions are posed and all answers are offered”. Jewson describes the cosmological system of Hospital Medicine in these terms:

“At the centre of the new medical problematic was the concept of disease. Interest in the unique qualities of the whole person evaporated to be replaced by studies of specific organic lesions and malfunctions. Diseases became a precise and objectively identifiable event occurring within the tissues, of which the patient might be unaware. The fundamental realities of pathological analysis shifted from the total body system to the specialized anatomical structures. The experiential manifestations of disease, which had previously been the very stuff of illness, now were demoted to the role of secondary signs. The patient’s interest in prognosis and therapy was eclipsed by the clinician’s concern with diagnosis and pathology. The special qualities of the individual case were swallowed up in vast statistical surveys.” (Jewson 2009: 628)

This analysis indicates that the targeting of specific “organ systems” in death certificates needs to be historicized (WPR Question 3) and questioned rather than simply taken for granted. 

Second, we need to reflect on the conception of causation at work in death certificates. The focus is on a single underlying cause that operates through a “chain of events”, with causal links all the way up the chain to the final, “immediate” cause of death. The “causal chain” was introduced to deal with the tendency among doctors to list more than one underlying cause of death. The “chain” allowed a more complex understanding of the death process, without removing the focus from the “underlying cause”, which was deemed to be useful for epidemiological purposes (see next Research Hub entry). 

I have written elsewhere about the contested space around conceptions of causality, specifically about how causality is treated in Critical Realism (Bacchi 2016: 6). In this tradition, Pawson et al. (2005) describe how, to make a “causal inference” between “two events (X and Y),” “one needs to understand the underlying mechanism (M) that connects them and the context (C) in which the relationship occurs” (p. S1:21- 22). Mechanisms, in Critical Realism, refer to hypotheses about individuals’ behaviours, illustrating a basic methodological individualism. 

By contrast, a Foucault-influenced poststructural analytic strategy challenges conventional views of causality, in which one thing (or a few things) causes another. Instead, Foucault effects “a sort of multiplication or pluralization of causes” (Foucault 1991: 76), a proliferation of “events” as the random results of “the interweaving of relations of power and domination” (Tamboukou 1999: 207). “Everything depends on everything else” (Veyne 1997: 170). This perspective dramatically opens the understanding of the death “event” (Ariès 1982: 587), with implications for policy design – as we shall see when I address the space or lack of space for SDH in death certificates.  

Question 3 in WPR asks how we have arrived at this point in our conceptualization of COD. I pursue this question in the next entry with a particular focus on contestation. As a genealogy the task is to indicate that the death certificate might have developed differently, “to show that things ‘weren’t as necessary as all that’” (Foucault 1991: 76). 

Question 4 in WPR asks what is silenced through death certification practices. This question usually attracts the most attention among researchers. It is the question that encourages us to think “outside the square”, to imagine things differently. There are overlaps between this question and Question 5 on effects (Bacchi and Goodwin 2016: 20-24). Specifically, the category of “discursive effects” in Question 5 encourages us to reflect on how the current frame of reference for COD – the focus on diseases and organic “malfunctions” (Jewson 2009: 628) – makes it difficult to raise other “matters of concern” (Latour 2004), e.g., social determinants of health (SDH). I pursue this theme through the next two Research Hub entries, highlighting how the current international death certificate produces little to no room for reflecting on the social determinants of health (SDH).

Question 6 in WPR creates space to examine closely the specific practices involved in the development and use of standardized death certificates. Step 7 meanwhile confronts researchers (in this instance, me) with the need to consider the assumptions that underpin their (my) proposals for revising death certificates. For example, as someone who has needed numerous biomedical interventions, I find myself shifting between a questioning of the biomedical paradigm and sheer wonder at its successes. How to manage this tension becomes an important theoretical consideration.   

A good deal of contemporary discussion about death certificates focuses on how they are filled in. That is, concern is raised about the poor training offered medical residents and how they frequently get the COD “wrong” (Morgan 2022; McGivern et al. 2017). Without diminishing the significance of this lapse in protocol, a WPR approach directs criticism at another level. Schultz (2014) puts it this way: more important than the errors in reporting is “what we are looking for” and, by implication, what we are NOT looking for – what we fail to recognize as significant. In this and the subsequent two entries, I develop the argument that standardized death certificates do NOT look for the social and environmental causes of death. SDH is missing from death certificates and missing from consideration. The implications (effects as in Question 5 of WPR) are considerable. Again, Schultz (2014) pointedly states that “we count what we care about and more disturbing we care about what we count”. It’s time therefore to return to COVID-19 to see what we count.

COVID-19 deaths: What do we count? 

Historically and today, as I explain in more detail in the next entry, epidemics are treated as a separate category of disease. Consistently, they are described as underlying causes of death, pure and simple. However, as the concern about pandemic infections declined over the last century more and more attention has been directed to the “sequence of events” or “chain of morbid events” leading to death – the goal here to better understand the complex interplay of diseases, the “multiple causes”, that lead to death. The Australian biometrician, Treloar (1956: 1378), called for a “deeper study of the endemiology of chronic disease” due to the “passing of the era of acute communicable disease” (see also Moriyama 2011). And then COVID-19 arrived! 

The WHO responded as expected, given the historical treatment of epidemics as exceptional diseases. It lay down the rule to list COVID-19 as the “underlying cause of death”: 

“A death due to COVID-19 may not be attributed to another disease (e.g., cancer) and should be counted independently of pre-existing conditions that are suspected of triggering a severe course of COVID-19.” (WHO 2020: 3; emphasis added) 

A “causal sequence leading to death” is still required: “For example, in cases when COVID-19 causes pneumonia and fatal respiratory distress, both pneumonia and respiratory distress should be included, along with COVID-19, in Part 1”. However, COVID-19 is listed last in the “chain of events” as the “underlying cause”. If the person who dies had “existing chronic conditions”, also described as “comorbidities” or “underlying health conditions”, these are to be reported in Part 2 of the MCCD (Medical Certificate of Cause of Death).

These guidelines are applied in many countries (Australian Bureau of Statistics (ABS) 2020; Veeranna and Rani 2020). In Australia the ABS stresses the need to specify the “causal pathway leading to death in Part I of the certificate”, noting that “all conditions and symptoms should be included”. In the United States initially COVID-19 was treated like pneumonia, the final endpoint, or immediate cause, in the train of events leading to death. From April 2020 the new rules required COVID-19 to be listed last as the underlying cause. Therefore, the train of events was reorganised: “any long-term conditions, no matter how serious, were then relegated to Part II of the Death Certificate as ‘contributing’ causes” (Kiang et al. 2020).

The listing of a “sequence of events” leading to death from COVID-19 and the inclusion of “underlying [pre-existing] health conditions” in Part 2 of the death certificate led to a debate about whether people died “with” COVID-19 or “from” (“of”) COVID-19. The Queensland Government (2022) uses this distinction – a distinction not found in the WHO Guidelines – in their information for health professionals about recording and reporting COVID-19 deaths:

         “Recording a death “from” COVID-19

If the underlying cause of the death is COVID-19, then “COVID-19” should be recorded in Part 1 of the Medical Certificate of Cause of Death and be included on the lowest line as the underlying cause with all antecedent conditions and symptoms (including duration) that led to the disease or condition resulting in death. Other significant considerations contributing to the death but not related to the diseases or conditions causing the death are recorded in Part 2

Recording a death “with” COVID-19

If a person had COVID-19 but the virus was not part of the chain of events leading to death, COVID-19 should be included in Part 2 “other significant conditions contributing to death”, with the main condition [sic] disease or condition in Part 1 followed by the underlying causes below.”

A recent report from the Australian Actuaries COVID-19 Mortality Working Group (Actuaries Digital 2023) noted that deaths previously referred to as “with COVID-19”, are now described as “COVID-19 related”, meaning that COVID-19 “contributed to the death”. 

This distinction between dying “with” COVID-19 and dying “from” COVID-19, which is difficult to make, can be used to reduce the case fatality rate (CFR) and, hence, the significance accorded the pandemic (Trabsky 2020; Amoretti and Lalumera 2020). It prompted some to make the case that the appearance of other “causes” on the death certificate means that you cannot attribute the death to COVID-19.  This reasoning explains Trump’s figure of 6% for the percentage of deaths due to COVID-19 (Aschwanden 2020). These were the 6% of doctors or coroners who listed COVID-19 as the underlying and only cause of death, not mentioning the “chain of events” and “contributing” conditions. There are reports of undercounting of COVID-19 cases in the ACT and NSW due to the failure to count those where COVID-19 was not listed as a “contributing factor or cause of death” (Ferguson 2022). 

In reaction to this confusion, there has been increasing reliance on the calculation of “excess deaths” in estimating the impact of COVID-19. These figures are estimated by comparing observed death versus expected mortality rates based on prior years. Examining the “excess mortality” in Australia – i.e., the deaths above those that would have been expected had there been no pandemic – the Actuaries’ Report noted that: there were over 20,000 more deaths in 2022 than expected; just over half of these (10,300) were “due to deaths from COVID-19″ (identified as the “underlying cause” on death certificates); another +2,900 were “COVID-19 related deaths”, while 7,000 made no mention of COVID-19. The Report noted that COVID-19 was a likely catalyst in COVID-19 related deaths, and that it is difficult to know “how much ‘blurring’ there may be between deaths from COVID-19 and COVID-19 related deaths” (emphases in original). 

The Actuaries’ Report links the 7,000 excess deaths that did not mention COVID-19, in part, to an association between COVID-19 and subsequent higher mortality risk from heart disease: “certifying doctors would generally not identify a causative link several months after recovery from COVID-19”. Some of these excess deaths are also attributed to pandemic-related delays in emergency care and delays in routine care (Actuaries’ Institute 2023). These deaths are not considered to be due to COVID-19 since they do not involve medical mechanisms. 

CONCLUSION

I suggest that it is time to shift the focus of analysis from what we count in terms of COD to what we don’t count, putting into question the central parameters of the death certificate. Building on Schultz (2014), if we care about what we count, then it’s time to start counting more things as causing death – e.g., pandemic-related delays in emergency care and delays in routine care. 

This proposition operates at several levels, as will become clear in the next two entries. On one level I raise questions about the focus in death certificates on “disease entities” and what this focus precludes from analysis (i.e., the social determinants of health). At another, and perhaps more practical level, I consider whether it is feasible to bring the social determinants of health into death certification practices. I ask: do “multiple causes” approaches offer a possible way forward? And what about Z codes?

Before I broach these questions, I trace, in the next entry, some of the strands of influence that have brought us to the current situation in delineating causes of death. I identify a biology/environment tension in approaches to population health and suggest the difficulties the environmental option continues to face. 

References

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Kiang, M. V., Irizarry, R. A., Buckee, C. O., and Balsari, S. 2020. Every Body Counts: Measuring Mortality From the COVID-19 Pandemic. Annals of Internal Medicine, 173, 1004–1007. https://doi.org/10.7326/M20-3100.

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Morgan, A., Andrew, T., Guerra, S., Luna, V., Davies, L. and Rees, J. 2022. Provider reported challenges with completing death certificates: A focus group study demonstrating potential sources of error. PLOS ONE | https://doi.org/10.1371/journal.pone.0268566

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It seems to be a truism that, in the throes and anguish of a pandemic, we are living in a time of “crisis”. The term certainly appears often enough in the titles of published articles and could be designated a trope of our times. Applying WPR thinking, I suggest the need to stand back from the automatic adoption of such tropes to examine them as governing or governmental mechanisms. To develop this argument, I consider the primacy accorded “crisis” in Koselleck’s Begriffsgeschichte, the links between “crisis” and “risk” as governing technologies, and the invocation of “uncertainty” as a new model for doing politics. 

Categorizing approaches to “crisis”

To begin, it is useful to offer examples of the most common ways in which “crisis” operates as a concept in current academic debates. I identify three conceptualizations: first, the scientific conception of “crisis” as “truth”; second, the identification of “crisis talk” as rhetorical manipulation; and third, the production of “crisis” as social construction. The poststructuralist option I proceed to develop evades these three options and engages “crises” as governmental problematizations. First, let us look briefly at the three more common uses of the term. 

•  The psychologist Dev Roychowdhury (2020) makes the scientific case for “a comprehensive understanding or consensus on a definition of crisis”. He argues that such an understanding “is not only a part of sound academic approach, but also paves the ways for scientific investigation to be undertaken with the aim of explaining, predicting, and managing crisis successfully”. A firm definition of crisis, in this view, is necessary for science to be accredited as a guide to managing present and future challenges. It follows that to achieve this goal requires “access to up-to-date evidence-based guidance” (Odium et al. 2021: Abstract).

•  Molla and Cuthbert (2022) direct attention to “crisis exploitation” (Boin et al. 2008) as a form of rhetorical manipulation. They describe how the Australian Government “framed the COVID-19 pandemic and the associated fear of an economic downturn as a crisis to sell old policy packages and imaginaries” (Molla and Cuthbert 2022: Conclusions). Here we have a clear example of the argument that concepts can be marshalled for political ends. 

•  Aligned to this view a crisis can be treated as if it were socially constructed through narrative (Hay 1996) or “discourse” (Walby 2022: 499). For example, Agamben (2020) is concerned that “the crisis has been exaggerated, if not invented, for the purpose of legitimating the concentration of power in the hands of the executive branch of government” (in Walby 2022: 507). 

Walby (2022: 501) usefully points out that “crisis” is commonly treated as “real” – i.e., the scientific option – in fields of risk (Beck 1992, 2009; discussed below) whereas the notion that a “crisis” is socially constructed is common in the field of security, “especially when the issue is centred on a threat rather than physical harm”. She interprets this usage to mean that “a crisis is both real and its meaning is contested” (Walby 2022: 501). Approached through WPR thinking, a crisis is neither real nor “unreal”, and acknowledging disputes about its meaning does not advance us very far theoretically (see Hall 1998: 80). Rather, attention turns to the ways in which the concept “crisis” influences “the evolution of ongoing practices” (Tanesini 1994: 207).

. 

Conceptual traditions and “crisis” 

Where do the conceptual traditions introduced in the first two entries in this series (27 Feb 2023; 30 March 2023) fit within this schema of scientific, rhetorical or social constructionist approaches to “crisis”? As mentioned in the previous entry and developed below there is some blurring of the boundaries between the Cambridge School and Begriffsgeschichte on the treatment of “crisis” as “speech act”. At the same time, the attention Koselleck, and others associated with Begriffsgeschichte (Jordheim and Wigen 2018), direct towards what they call the “conceptual work” performed by concepts suggests some possible overlap with a poststructural performative perspective. The task, as I see it, is to clarify the relationship between “conceptual work”, as described in Begriffsgeschichte, and WPR, which I proceed to do below. To forecast the argument, Begriffsgeschichte focuses primarily on political actors who marshal concepts, such as “crisis”, for political purposes, whereas WPR examines the operation of such concepts within governmental directives, read broadly. 

The term “crisis” is central to Koselleck’s work, introduced in the first entry in this series on WPR and concepts (27 Feb. 2023).  Koselleck’s doctoral thesis from 1959, later published under the title Kritik und Krise (Criticism and Crisis), offers a critique of Enlightenment philosophers (Voltaire, Diderot, Rousseau, Schiller, and Kant) for evoking “crisis” to avoid “direct political confrontation with the absolutist state”. Instead, in his view, they submitted the absolutist state to a form of moral criticism “deemed to bring about its collapse”. In this way, argues Koselleck, “to talk of crisis is to bring crisis about” (in Jordheim and Wigen 2018: 438).

Jordheim and Wigen (2018: Abstract) build on Koselleck’s ideas to develop an argument about the ways in which concepts – with their targets being “progress” and “crisis” – are used to order events, objects and polities. They argue that, since the late 18^th century, “the key concept for structuring the relationship between past, present, and future in Western culture has been progress” (Jordheim and Wigen 2018: 425). Their claim is that “the concept of crisis is about to replace the concept of progress as the main tool of historicization in the Western world and beyond”. In their view, what happens with these concepts is vitally important for the future world order: “which one [i.e., progress or crisis] is allowed to dominate world politics is highly decisive for what we are able to experience, to plan and to do”. 

Jordheim and Wigen (2018: 438) draw a link between their argument on the important role played by concepts and the Cambridge school’s use of “speech act” theory (see discussion in Research Hub 27 Feb 2023) They state that “labelling something a crisis can be thought of as a speech act that shapes political contestation over a particular issue or field”. This outcome, they argue, is due to the work that concepts do. To illustrate this point, using the example of the concept “security”, they describe how “managing to label a particular issue, topic or field a matter of security excludes a great many actors who would otherwise be party to discussion from legitimately debating it” (Jordheim and Wigen 2018: 438). They also describe how crisis functions as a “collective singular” (see Research Hub 27 Feb. 2023), “with a capital C if you like” (Jordheim and Wigen 2018: 431).  

As with the Cambridge school the focus in this account is on social actors and their deployment of concepts, though Jordheim and Wigen insist that they are interested in more than “rhetorical skills” (Jordheim and Wigen 2018: 425). The starting questions for their analysis, however, target language users and their motivations: “Who uses the word? In what way? What does it mean? What does the user want to achieve?” (Jordheim 2021). And they explicitly identify their concerns as the ways in which political leaders use concepts: “To organise and take control over time, state leaders, politicians and intellectuals of statecraft use concepts as tools of synchronisation” (Jordheim and Wigen 2018: 439). 

This focus on language use can also be seen in the ways in which the authors refer to “discourse/s”. For example, they describe “calling something security” and “calling a particular issue or set of events a crisis” as two related “discursive moves” (Jordheim and Wigen 2018: 439; emphasis in original). Such a reference indicates that “discourse” here is conceptualized as language use rather than as knowledges, illustrating the important distinction between these positions introduced in the previous Research Hub entry.  Concepts in Begriffsgeschichte are up for grabs and serve the specific political purposes of “discourse participants”, akin to the position developed by Molla and Cuthbert (2022; see above).  

What does WPR do differently? The three Research Hub entries (27 Feb 2023; 30 March 2023; and today’s) on this difficult topic have a single goal – to suggest that WPR opens up new terrain for exploration when dealing with “concepts”. Approaching concepts as governmental problematizations leads to different foci of attention and to different questions. Rather than asking about who is using a concept or what they want to do with it (see above), the focus becomes the complex of forces and practices that go into a concept’s making, and the effects that accompany its production and use. Clearly, this stance puts in question any attempt to define “crises” as “real” and measurable (the scientific option). It also moves the analysis past local actors and their attempts to deploy “crisis talk” for political purposes (the rhetorical manipulation position). Finally, it does not imply that “crises” are “unreal” and socially constructed. Rather, it asks how the concept functions to shape realities and possible futures.

Here there is some overlap with the notion of “conceptual work” developed by Jordheim and Widen (2018). They offer useful insights into the ways in which the concepts of “progress” and “crisis” can be seen to shape political possibilities. However, where they target the people who deploy concepts, WPR interrogates how concepts operate to shape realities within governmental directives (guides to conduct) – with governmental understood to encompass wide-ranging societal administration (Dean 1999). To put it starkly, the concepts that are the focus of analysis in WPR are to be found in governmental accounts and records, not in people’s heads. Hence, I argue, interrogating them provides insights into how governing takes place that are unavailable if the target is restricted to politicians’ and intellectuals’ “statecraft” (see above). 

The link drawn by Jordheim and Wigen between Koselleck’s history of concepts and Austin’s speech act theory, associated with the Cambridge school, raises the whole issue of “illocutionary forces”, and hence of performativity theory (Research Hub, 29 Sept. 2022, 26 Oct. 2022). In the Keynote Address at Karlstad ( KEYNOTE ADDRESS – CAROL BACCHI – 18 August 2022) I suggest that proposals, recommended as starting points for WPR analyses, are “in a sense analogous to Austin’s (1962) illocutionary performatives that do not describe ‘reality’ but that (help to) make worlds”. I need to stress the word analogous in this argument given the ways in which, in both Koselleck and the Cambridge group, speech act theory is linked to “human agency as the prime mover of history” (Van Gelderen 1998: 231). Koselleck confirms this interpretation of his work with his description of concepts as “linguistic performances” (Koselleck 2004: 232). By contrast, the focus of analysis in WPR is not “linguistic performances”; rather, its target consists of governmental directives, read broadly. This position can be illustrated by reflecting briefly on how WPR approaches the topics of “crisis”, “risk” and “uncertainty”. 

Standing back from “crisis”, “risk” and “uncertainty”

Above I noted that “crisis” is commonly treated as “real” (scientific) in fields of risk. This alignment can be explained through the ways in which “risk” features in so many aspects of our lives – consider health, insurance, “risk management” technologies, and so on. Beck (1992, 2009) is best known for theorizing the “risk society”. As Rose (2000: 246) describes, in Beck there is an acceptance that risk reflects “changes in the contemporary existential conditions of humans and their world”. In other words, “risk” is treated as something we have to deal with and live with – “risks” are real. 

By contrast WPR and other governmentality analyses approach “risk” as a governmental strategy, with governmental read broadly, rather than as an inescapable part of contemporary lives. Rose (2000: 246; emphasis in original) notes that “genealogical studies have analysed risk as a particular style of thinking born during the nineteenth century”.  As he explains, “risk thinking brought the future into the present and made it calculable”. He notes a shift from an earlier period of the collectivization of risk to a contemporary individualization of risk.

Also, within a governmentality framework, Nettleton’s (1997) work on risk categories in health highlights how an individualizing logic is at work in health policy, with important subjectification effects. Says Nettleton, we are produced as “risky selves”, responsible for continuous scrutiny of diet and lifestyle to avoid threats to health (Nettleton 1997). 

This example illustrates how approaching the concept of “risk” as a problematization creates the space to reflect on the ways in which we are governed through “risk” categories and “risk” technologies. Importantly, there is no presumption that people are passive in response to such directives. As Nettleton (1997: 217) asserts, “discourses on health and health policy presuppose a self that is able to react to and challenge ‘expert’ knowledge”.  

Developing the governmentality position, Dean (1999: 177) states that “There is no such thing as risk in reality”:

“Risk is a way – or rather, a set of different ways – of ordering reality, or 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 for particular goals”.

The objective for researchers, therefore, is to ascertain the interconnected sets of practices involved in the production of “risk” thinking and “risk technologies”, including practices of emergence, insertion/institutionalization and functioning (Foucault 1972: 163; 1991: 65). Dean (1999: 178) elaborates this research agenda clearly: 

“What is important about risk is not risk itself. Rather it is: the forms of knowledge that make it thinkable, such as statistics, sociology, epidemiology, management and accounting; the techniques that discover it, from the calculus of probabilities to the interview; the technologies that seek to govern it, including risk screening, case management, social insurance and situational crime prevention; and the political rationalities and programmes that deploy it, from those that dreamt of a welfare state to those that imagine an advanced liberal society of prudential individuals and communities”.

WPR suggests treating “crisis” in precisely this way. In research, the task is not to identify “crises” but to examine how the concept “crisis” operates to shape political possibilities and political outcomes. For example, Larsson (2020: Abstract) examines the “preemptive logic of contemporary security and crisis management” to show how “civil and war preparedness are merged into an ever-present dimension of everyday existence”. 

In an earlier Research Hub entry (31 March 2021) I considered how the concept of “uncertainty” can be examined as a problematization and a governmental technology. “Uncertainty” is, of course, a close cousin of “crisis” and “risk”. We are constantly being told that we live in uncertain times – though it is uncertain (forgive me!) how that observation is to assist us. 

Standing back from “uncertainty” as a presumption about our existential condition allows us to consider its implications for how society is ordered and governed. Pre-COVID-19 Pellizzoni (2011) made the case that uncertainty has become a way of governing, a technology of governing: “Uncertainty, thus, is seen no more as a circumscribed situation on which to build a few strategic decisions, but as an empowering everyday condition”. Describing the orientation as neoliberal, he notes: “proper calculations of risk are seen as an exception, while reasoned bets over unpredictable futures are regarded as the rule”. 

These “reasoned bets” produce a style of governing based on experimentation. As I described in the earlier entry (Research Hub 31 March 2021), experimenting has become increasingly normalized as a mode of governing. That is, it has been generated as a legitimate way to govern, as a kind of “truth” of governing.

This style of governing has important effects. Schroth (2016) makes the point that experiments reduce the “enigmatic world” to what are deemed to be manageable proportions. Hence, we need to consider what gets left out – what is silenced. In relation to COVID-19 the focus on “uncertainty”, “crisis” and “risk” produces a tendency to concentrate on what Aly (2020) calls “the symptoms” of a crisis. There is no space in this reactive approach to consider how we have got here – how pandemics, for example, are an increasing likelihood due to a range of practices such as deforestation (Zimmer 2011). At the same time, the invoking of “uncertainty” works paradoxically to “reinforce the authority of expertise” (Demeritt 2001: 327), those who will guide us through “uncertain” times. 

Conclusions

In this and the preceding two entries, I have explored the proposition that we are governed through the ways in which concepts problematize issues and that, hence, applying WPR to concepts produces new forms of questioning and analysis. I hope the examples of “crisis”, “risk” and “uncertainty” successfully illustrate the kinds of questions that arise in WPR thinking, and how these are vitally important questions for considering how we govern and how governing takes place.

Clearly, this position on concepts has repercussions for our own research. It imposes an obligation to consider the concepts we use, where they come from and how they operate politically. This self-interrogation can, doubtless, be uncomfortable (Foucault 2000). Some might also query the usefulness of such self-problematization. The claim advanced on behalf of this poststructural theorizing is that there is a need to reflect critically on the frameworks of meaning we may inadvertently adopt. Such interrogation creates the space to explore alternative problematizations, the space to think differently. We can only be the beneficiaries of such endeavours. 

 References

Agamben, G. 2020. The invention of an epidemic, http://www.journal-psychoanalysis.eu/ coronavirus-and-philosophers/ (originally published in Italian on Quodlibet,www. 

quodlibet.it/giorgio-agamben-l-invenzione-di-un-epidemia).

Aly, W. 2020. Get to the root of mess. The Melbourne Age, Saturday 26 Dec., p. 48.

Austin, J. L. 1962. How to do things with words. Massachusetts: Harvard University Press.

Beck, U. 1992. Risk Society: Towards a New Modernity, London: Sage.

Beck, U. 2009. World at Risk, Cambridge: Polity.

Boin, A., ‘t Hart, P., & McConnell, A. 2008. Conclusions: The politics of crisis exploitation. In A. Boin, A. McConnell & P. ‘t Hart. (Eds.), Governing after crisis (pp.285 – 216). Cambridge University Press.

Dean, M. 1999. Governmentality: Power and rule in modern society. London: Sage.  

Demeritt, D. 2001. The Construction of Global Warming and the Politics of Science. Annals of the Association of American Geographers, 91(2): 307-337.

Foucault, M. 1972. The Archaeology of Knowledge, translated by A. Sheridan Smith. New York: Pantheon Books. 

Foucault, M. 1991. Politics and the study of discourse. In G. Burchell, C. Gordon & P. Miller (Eds), The Foucault Effect: Studies in Governmentality. Chicago: University of Chicago Press.

Foucault M. 2000a. For an ethics of discomfort. In J. D. Faubion (ed.) Power: Essential Works of Foucault, 1954– 1984, Volume III. New York, NY: The New Press. pp. 443–448.

Hall, T. 1998. Conceptual History and the History of Political Thought. In I. Hampsher-Monk, K. Tilmans and F. van Vree (Eds) History of Concepts: Comparative Perspectives. Amsterdam: Amsterdam University Press. pp. 75-86.

Hay, C. 1996> Narrating crisis: the discursive construction of the ‘Winter of Discontent’. Sociology, 30(2): 253–77. doi: 10.1177/0038038596030002004 

Jordheim, H. and Wigen, E. 2018. Conceptual Synchronisation: From Progress to Crisis.  Millennium: Journal of International Studies, 46(3): 421-439.

Jordheim, H. 2021. Conceptual History. In Bloomsbury History: Theory and Method.DOI: 10.5040/9781350970878.066

Koselleck, R. 2004. Futures Past: On the Semantics of Historical Time. Trans. K. Tribe. Columbia University Press. 

Larsson, O. L. 2020. The connections between crisis and war preparedness in Sweden. Security Dialogue, 1-19.

Molla, T. and Cuthbert, D. 2022. Crisis and policy imaginaries: higher education reform during a pandemic. Higher Education, https://doi.org/10.1007/s10734-022-00899-5 

Nettleton, S. 1997. Governing the risky self: How to become healthy, wealthy and wise’. In A. Petersen and R. Bunton (Eds) Foucault, Health and Medicine. London: Routledge.  

Odium, A. et al. 2021.  Use of COVID-19 evidence in humanitarian settings: the need for dynamic guidance adapted to changing humanitarian crisis contexts. Conflict and Health, 15:83 https://doi.org/10.1186/s13031-021-00418-w

Pellizzoni, L. 2011. Governing through disorderz: neoliberal environmental governance and social theory. Global Environmental Change, 21(3), 795-803.

Rose, N. 2000. Powers of Freedom: Reframing political thought. Cambridge, UK: Cambridge University Press. 

Roychowdhury, D. 2020. 2019 Novel Coronavirus Disease, Crisis, and Isolation. Frontiers in Psychology, doi: 10.3389/fpsyg.2020.01958 

Schroth, F. 2016.The Politics of Governance Experiments: Constructing the Clean Development Mechanism. PhD thesis, Berlin Institute of Technology. 

Tanesini, A. 1994. Whose language? In K. Lennon, & M. Whitford (Eds.), Knowing the difference: Feminist perspectives in epistemology. New York: Routledge. 

Van Gelderen, M. 1998. Between Cambridge and Heidelberg. Concepts, Languages and Images in Intellectual History.

In I. Hampsher-Monk, K. Tilmans and F. van Vree (Eds) History of Concepts: Comparative Perspectives. Amsterdam: Amsterdam University Press. pp. 227-238.

Walby, S. 2022. Crisis and society: developing the theory of crisis in the context of COVID-19. Global Discourse, 12(3-4): 498-516. Special Issue: Critical Explorations of Crisis: Politics, Precariousness, and Potentialities.  Zimmer, C. 2011. A Planet of Viruses. University of Chicago Press

Discourse traditions

In the previous entry I developed the argument that concepts ought to be treated as governmental mechanisms, centrally involved in how governing takes place. This description follows Dean’s (1999: 44-45) proposition that political vocabulary can be usefully viewed as a governmental technology due to its role in making “politics thinkable”. By approaching concepts in this way, they are “denaturalised, made specific and their governmental implications revealed” (Larner 2008: 23).

How then are concepts related to “discourse” and “discourses”? 

This topic became relevant while I was researching the German tradition of Begriffsgeschicht (History of Concepts), introduced in the last entry (27 Feb 2023). An important article by Krzyzanowski (2010) suggests the theoretical benefits of bringing together Critical Discourse Analysis (CDA) – or more precisely Discourse-Historical Analysis (DHA) – and Koselleck’s  Begriffsgeschichte. Krzyzanowski (2010: 128) makes the case that “discourses” in DHA equate to “concepts” in Begriffsgeschicht.

This argument relies on a particular understanding of “discourse”, an issue that comes up repeatedly when considering the relationship between WPR and CDA/DHA. Many researchers have adopted the practice of developing a dual theoretical stance, combining WPR with CDA. Some time ago I discussed why I have concerns regarding this blending of theoretical approaches (Research Hub, 14 May 2018). As the practice continues, however, I feel the need to revisit the topic. The issue is also clearly connected to how “concepts” are conceptualized, our theme in this series of entries. 

To state the case clearly, I argue that WPR is best described as “an analysis of discourses” rather than as “discourse analysis” (Bacchi 2005). “Discourse analysis” involves the study of language use. By contrast, “an analysis of discourses” involves the study of discourses, understood as “knowledges”. I developed this distinction in a 2005 article titled provocatively, “Discourse, Discourse Everywhere: Subject ‘‘Agency’’ in Feminist Discourse Methodology”. I can remember at the time feeling overwhelmed by the ubiquity of the term “discourse” in the academic literature with which I engaged. It became clear to me that researchers were not always referring to the same thing when they spoke about “discourse”. 

I distinguished two central analytic traditions in discourse theory, a social psychological focus on patterns of speech (discourse analysis), and a political theoretical focus on the ways in which issues acquire a particular meaning within a specific social setting (analysis of discourses) (Potter & Wetherell 1990; Burr 1995:164). As mentioned above, in the first tradition the term discourse means something very close to language. There is a focus on the “linguistic and rhetorical devices” used in the construction of a text (Burr 1995:184). In the second tradition the goal is to identify, within a text, “institutionally supported and culturally influenced interpretive and conceptual schemas (discourses) that produce particular understandings of issues and events” (Bacchi 2005: 199).

In the 2005 article I note that this distinction should not be drawn too sharply. Clearly, WPR is interested in language use; however, attention to the operation of binaries and concepts/categories is a supplementary exercise, set in train through a focus on problematizations (Bacchi 2009). At the same time discourse analysts often pay heed to the interpretive and conceptual schemas that form the primary focus among those interested in the analysis of discourses. 

Nor am I suggesting that there is one correct definition of “discourse”. As discussed in the last entry (27 Feb. 2023), poststructuralists do not defend one meaning of a concept over another but consider how different meanings rely on contrasting presuppositions and produce diverse effects. For a poststructuralist, it is inconsistent, therefore, to search for a “correct” definition of discourse because the whole idea of discourse is that definitions play an important part in delineating knowledge (Bacchi 2000). Hence, definitions require scrutiny, not replication. 

What are these knowledges/discourses that are scrutinized in a WPR analysis? In a Foucault-influenced poststructural analysis, discourses/knowledges comprise both general background knowledge, apparent in epistemological and ontological assumptions, and forms of relatively bounded social knowledges, such as disciplines (Bacchi and Goodwin 2016: 21). Question 2 targets the epistemological and ontological assumptions that underpin specific problem representations. The concern with disciplinary knowledges appears in a particular emphasis on “expert” discourses. For example, the common reform proposal that women need training courses to gain access to higher paying and higher status occupations relies on a particular understanding of how “people” develop “skills” – a behavioural focus in other words – and an ontological conception of “people” as having “skills” ( KEYNOTE ADDRESS – CAROL BACCHI – 18 August 2022). In WPR, these assumptions, or presuppositions, underpin the knowledges identified as necessary to make the proposal to train women intelligible – e.g., psychological theories of development. These become the discourses/knowledges that require critical interrogation.

This distinction between “an analysis of discourses” and “discourse analysis” can be identified by examining how researchers in specific traditions use the term “discourse”.  For example, those who are interested in discourse as language use talk about “discursive practices” in terms of the ways in which people converse or argue. By contrast, in WPR, “discursive practices” refers to the ways in which discourses – or disciplinary knowledges – operate (or practice). Illustrating the latter stance, Foucault describes how, “in the nineteenth century, psychiatric discourse is characterized not by privileged objects, but by the way it forms objects that are in fact highly dispersed” (Foucault 1972: 44).  Therefore, when Foucault refers to “the discursive practice of psychiatry” (Foucault 1972: 75), he is not referring to how psychiatry is practised “discursively”, through writing, speaking or producing texts within psychiatry. His interest is not language use; rather, he is describing the practices of psychiatry, the operation of the sets of relations characteristic of psychiatry as an accredited form of knowledge (Bacchi and Bonham 2014: 182).

Other usages also indicate the two “discourse” traditions I have described here. When authors refer to discourses on or about an issue, e.g., climate change (Reisigl and Wodak 2017: 87, 119), this usage indicates a language perspective. The same is the case with references to “discourse participants” (Reisigl and Wodak 2017: 87), a phrase that points the way to a clearer delineation of the competing perspectives under examination here, as elaborated shortly. I need to repeat that these comments on the uses of “discourse” do not in any way suggest that one usage is correct and the other in error. Consistent with the argument developed in the previous entry (27 Feb. 2023) the task is to approach the contrasting uses of “discourse” in terms of how they offer contending proposals about how we ought to proceed from here (Tanesini 1994: 207).  

Krzyzanowski (2010: Introduction) indicates his positioning in this field through his recognition of and reliance on Ruth Wodak, commonly identified as a leading theorist in Discourse-Historical Analysis (DHA). Wodak (2015) and Reisigl and Wodak (2017) clearly lay out the theoretical parameters of DHA. Wodak (2015: 3) identifies the “ideas of Habermas” as “of fundamental importance”.  The goal of DHA is to improve “public discourse” through “a theory of rational argumentation” among “discourse participants” (Wodak 2015: 3). The goal of critique is to point to “intended biases in representations (especially media coverage) and to contradictory and manipulative relationships between discourses and power structures” (Reisigl and Wodak 2017: 119).

WPR sits in contrast to this position. It is not a form of discourse analysis in the tradition of Wodak, Kryzyanowski, Fairclough (1992) and many others who engage in studies of language use. Instead, it offers a way to critically interrogate discourses as knowledges, highlighted in Question 2 of the approach. It targets what it is possible to speak of by examining the knowledges (discourses) that limit and form “the sayable” (Foucault 1991: 59, 63). Rather than looking for “intended biases” or “rational argumentation”, the goal is to show how knowledges form their truths. This position is illustrated above in the description of how psychiatry as an accredited knowledge forms objects for thought – e.g., “behaviours” and “skills”. Approaching these concepts as “proposals about how we ought to proceed from here” best describes the WPR engagement with concepts.  

Relying on “context” 

Alongside the theoretically distinct approaches to discourse just described, it is important to reflect on how the tradition of discourse analysis as language analysis treats “contexts”. This topic was raised briefly in the previous entry (27 Feb. 2023) where we discussed how Koselleck (1998) appeals to “social history” as “occurring history” and “what ‘actually’ – and not just linguistically – happened”. There I describe his position as realist and, with Van Gelderen (1998), call for clarification of the ontological distinction between language and society. 

Whereas Koselleck lays out his position clearly, many theorists inadvertently adopt a realist perspective in relation to the conditions they identify as “background” in their analyses. I would imagine that many readers have a section on “background” in their work and I have also slipped into referring to “context” on occasion as if its meaning is straightforward. Happily, on one occasion, in the 2009 book I specify: “the task of ‘filling in’ context is never simply a descriptive exercise” since “reflections on context are themselves interpretive”. “Indeed”, I proceed to argue, “in many cases it is necessary to pay attention to how a context, for example, ‘globalisation’, is represented” (Bacchi 2009: 21). 

Genealogy in WPR (Question 3) acts as a corrective for or defence against the simple recording of “context/s”. Foucault explicitly identified the “role of genealogy” in tracing the “history of the concept of liberty or of the ascetic life”. In his view, the task is to make such conceptual histories appear “as events on the stage of historical process” (Foucault 1977: 1). “Events” in Foucault are not simply bits of data; they need to be analyzed in terms of the practices that give rise to them (Bacchi and Goodwin 2016: 46). These genealogies of practices demonstrate how selected concepts or categories of analysis (e.g., “alcohol problems”, “drug problems”) are made under specific circumstances, and hence, how they can be unmade (Bacchi 2015). 

In a special issue of Discourse & Society on “Theories and concepts in Critical Discourse Studies” Krzyzanowski and Forchtner (2016) explore some possibilities for theoretical developments within CDA and DHA. One contributor, Macgilchrist (2016), suggests that CDS (Critical Discourse Studies) must move beyond its theoretical and conceptual foundations and incorporate “post-foundational” thinking in discourse studies. She expressly endorses “productive integration” with the post-structuralist discourse theory associated with Ernesto Laclau (1990). 

At the same time Petersen (2015) cautions researchers who ascribe to poststructural precepts to be wary of the frequent tendency in their work to refer to social realities (“contexts”, “backgrounds”) as if they simply exist. In her view, “mainstream post-structuralist policy analysis is presently overwhelmingly realist”, while the serious and ongoing onto-epistemological challenges of post-foundationalism are “glossed over in order to ‘get on with it’” (Petersen 2015: 148).

It seems, then, that we all have some work to do. 

In the last of three entries on applying WPR to concepts, which follows in a month’s time, I pursue the concept of “crisis”, alongside “risk” and “uncertainty”. I hope to clarify how the distinct theoretical perspectives introduced in this and the preceding entry (27 Feb. 2023) engage these concepts. The task, using WPR thinking, is to discern how different usages of “crisis” involve contrasting proposals about how we ought to proceed from here (Tanesini 1994: 207).  

References

Bacchi, Carol 2000. Policy as Discourse: What does it mean? Where does it get us? Discourse: Studies in the cultural practices of education, 27(1), pp. 45–57.

Bacchi, C. 2005. Discourse, Discourse Everywhere: Subject “Agency” in Feminist Discourse Methodology’. NORA: Nordic Journal of Women’s Studies, 13(3): 198-209. Reproduced in C. Hughes (Ed.) (2012). Researching Gender. Sage Fundamentals of Applied Research Series. 

Bacchi, C. 2009. Analysing Policy: What’s the Problem Represented to be? Frenchs Forest: Pearson Education. 

Bacchi, C. 2015. Problematizations in alcohol policy: WHO’s “alcohol problems. Contemporary Drug Problems, 42 (2), 130–147.

Bacchi, C. and Bonham, J. 2014. Reclaiming discursive practices as an analytic focus: Political implications. Foucault Studies, 17: 173-192.

Bacchi, C. and Goodwin, S. 2016. Poststructural Policy Analysis: A Guide to Practice. NY: Palgrave Macmillan. 

Burr, V. 1995 An Introduction to Social Constructionism. London and New York: Routledge. 

Dean, M. 1999. Governmentality: Power and rule in modern society. London: Sage. 

Fairclough, N. 1992. Discourse and social change. Cambridge, MA: Polity Press.

Foucault, M. 1972. The Archaeology of Knowledge, translated by A. Sheridan Smith. New York: Pantheon Books. 

Foucault, M. 1977. Nietzsche, genealogy, history. In D.F. Bouchard, (Ed.), Language, counter-memory, practice: Selected essays and interviews. Ithaca: Cornell University Press.

Foucault, M. 1991. Politics and the study of discourse. In G. Burchell, C. Gordon & P. Miller (Eds), The Foucault Effect: Studies in Governmentality. Chicago: University of Chicago Press.

Koselleck, R. 1998. Begriffsgeschichte and social history. In I. Hampsher-Monk, K. Tilmans and F. van Vree (Eds) History of Concepts: Comparative Perspectives. Amsterdam: Amsterdam University Press. pp. 23-36.

Krzyzanowski, M. 2010. Discourses and Concepts: Interfaces and Synergies between Begriffsgeschichte and the Discourse-Historical Approach in CDA.  In R. de Cillia, H. Gruber, Krzyzanowski, M. and Menz, F. (Eds) Diskurs-Politik-Identitaet / Discourse-Politics-Identity. Tuebingen: Stauffenburg Verlag. 

Krzyzanowski, M. and Forchtner, B. 2016. Theories and concepts in critical discourse studies: Facing challenges, moving beyond foundations. Discourse & Society 2016, Vol. 27(3) 253–261.

Laclau, E. 1990. New Reflections on the Revolution of Our Time. London: Verso. 

Larner, W. 2008. Comments on Kevin Stenson’s “Governing the local: Sovereignty, social governance and community safety”. Social Work and Society – International Online Journal, 6 (1), 21–25, http://www.socwork.net/sws/ article/download/87/144. Accessed 14 January, 2016. 

Macgilchrist, F. 2016. Fissures in the discourse-scape: Critique, rationality and validity in post-foundational approaches to CDS. Discourse & Society, 27(3): 262–277. 

Petersen, E. B. 2015. What crisis of representation? Challenging the realism of post-structuralist policy research in education, Critical Studies in Education, 56:1, 147-160, DOI: 10.1080/17508487.2015.983940 

Potter, J. & Wetherell, M. 1990. Discourse: Noun, Verb or Social Practice? Philosophical Psychology, 3(2/3), pp. 205–218.

Reisigl, M. and Wodak, R. 2017. The Discourse-Historical Approach (DHA). In R. Wodak and M. Meyer (Eds) Methods for Critical Discourse Analysis. London: Sage. pp. 87-121. 

Tanesini, A. 1994. Whose language? In K. Lennon, & M. Whitford (Eds.), Knowing the difference: Feminist perspectives in epistemology. New York: Routledge. 

Van Gelderen, M. 1998. Between Cambridge and Heidelberg. Concepts, Languages and Images in Intellectual History.

In I. Hampsher-Monk, K. Tilmans and F. van Vree (Eds) History of Concepts: Comparative Perspectives. Amsterdam: Amsterdam University Press. pp. 227-238.Wodak, R. 2015. Critical Discourse Analysis, Discourse-Historical Approach. The International Encyclopedia of Language and Social Interaction, First Edition. Karen Tracy (General Editor), Cornelia Ilie and Todd Sandel (Associate Editors). © 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
DOI: 10.1002/9781118611463/wbielsi116