Academic journal article Health Sociology Review

Hazardous Good Intentions? Unintended Consequences of the Project of Prevention

Academic journal article Health Sociology Review

Hazardous Good Intentions? Unintended Consequences of the Project of Prevention

Article excerpt

The project of prevention as it is defined and practised in the early 21 st century arises from a history of good intentions. The prevention of disease and injury, and the maintenance of good health, have long been recognised as preferable to therapeutic intervention. Prevention averts pain and suffering, and is generally believed to be more cost-effective than medical care. The term 'prevention', however, is not limited to stopping health problems before they start. Particularly when clinical care is being discussed, 'prevention' is typically subdivided into primary, secondary and tertiary types. Only primary prevention involves avoiding ill-health before onset. The term secondary prevention is used to refer to early detection of asymptomatic people, while tertiary prevention has become another name for medical care that strives to restore an optimal level of health and functioning in a person with established disease (U.S. Preventative Services Task Force 1996). Although my interest is mainly in primary prevention (particularly community-based rather than clinical), I touch on the other forms, and note here that the distinctions between them presume boundaries that are empirically and experientially more blurry than the definitions might suggest. The proliferation of meanings complicates the task of re-imagining, but it is indicative of the contemporary discursive and socio-political context within which health care and prevention occur. This context, and the way the definitions and implementation of prevention have developed, contribute collectively to the unintended effects which form the subject of this paper.

I begin by overviewing several key characteristics of the contemporary context, touching on illustrations of the unintended consequences. Then, I refer briefly to the example of cigarette smoking to show that public health has yet to mobilise a thoroughly classed and gendered analysis of this most significant health risk, and has therefore subverted its explicit agenda and paradoxically contributed to the reproduction of health inequalities in the process of advancing prevention.

Characterising prevention

Contemporary prevention could be described in many ways. Here, I discuss four of its key characteristics: 1. Its focus on the individual; 2. The increasing emphasis on an evidence base; 3. Medicalisation and the expansion of the field of health; and 4. The location of prevention in a distinctive neo-liberal political economy and a cultural economy of modernity. These characteristics are closely interrelated, although a systematic deconstruction of their relationships is beyond the scope of this paper.

Individualised health

The focus of contemporary prevention is fixed largely on the individual, and especially on individual behavioural risk factors (Lin and Fawkes 2007; Pitts 1996). An emphasis on individuals is hardly surprising, in light of contemporary ideology and political culture. For example, in Australia's 2005 National Research Priorities, the priority of Promoting and Maintaining Good Health is quickly glossed as 'enabling individuals and families to make choices that lead to healthy, productive and fulfilling lives', noting that 'all Australians stand to benefit from preventive health care through the adoption of healthier attitudes, habits and lifestyles'. Even the priority goal Strengthening Australia's social and economic fabric which might be expected to have a strong structural dimension, emphasises 'enabling people to make choices' (DEST undated).

The apparent success of this approach is evident from improvements during the 20th century in the prevalence of certain risk factors such as saturated fat intake and smoking, and the accompanying decline in cardiovascular disease. Health promotion through education continues to be the most popular intervention for improving health-related behaviour, although clinical interventions (such as nicotine replacement therapy, lipid lowering drugs, and medications to manage hypertension) are believed to contribute to improved health, as are the development and marketing of food products with lower saturated fat content. …

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