Biopower Challenges in Contemporary Health Education

In the chapter “Right of death and power over life,” from The History of Sexuality (vol. I), Foucault explains that, in the past, the ruler’s power appeared above all as the right to take life; that is, it was within his competence to determine someone’s death or to let live. Over time, this mode of domination changed. Instead of showing itself mainly through the threat of death, power came to care for, organize, and administer people’s lives, guiding behaviors, creating rules, surveilling, and encouraging certain practices.

Foucault calls this new way of governing biopower. And he says it would have two fronts:

1. one aimed at individual bodies, which would train, discipline, and make people “useful” (think of schools, barracks, factories), called by Foucault the anatomo-political disciplinary face;
2. another aimed at the population as a whole, which would regulate births, deaths, life expectancy, and health (think of campaigns, statistics, public health policies), which he calls the biopolitics of the population.

This conception reveals that what had previously been expressed mainly through the power to kill (“make die”) came to be expressed through an investment in life (“make live”): administering bodies and governing health and the quantity of life through institutions, norms, and numbers.

It is from this idea that I consider the inflections of a “politics of living,” which would cut across the field of health education for the public and education in the health field. To clarify these last two terms, I draw on the article “Educação em saúde e educação na saúde: conceitos e implicações para a saúde coletiva” [Health education and education in health: concepts and implications for public health], by Miriam Falkenberg and collaborators, which distinguishes health education as the educational process aimed at the population to expand autonomy in care and in dialogue with professionals/managers; while education in health would concern the process of producing and systematizing knowledge for the training and development of health workers).

Falkenberg and colleagues’ text also reconstructs the critique of the verticalized tradition, oriented toward the sanitary dimension (“education for health”), which would be opposed to popular health education, which, in turn, mobilizes prior knowledge, participation, and emancipation. In its conclusion, it proposes distinguishing and articulating a health education centered on popular autonomy and an education in health centered on continuing education, focusing on the needs of real work and local specificities.

The encounter between Foucault and Falkenberg reveals, in my view, an isomorphism between disciplines of the body (related to curricula, protocols, “best practices,” etc.) and regulations of the population (related to targets, coverage, performance indicators, etc.), constituting, in the field of health, what could be called biopolitical pedagogies — a kind of “make learn.”

Thus, educational practices aimed at the population would fabricate subjects capable of self-management, but also measurable, comparable, and accountable; formative practices in health work would forge disciplinary dispositions (technical training, standardization) coupled with regulatory regimes (indicators, audits, accreditations). Sexuality itself would function as the “matrix” of this mechanism, as simultaneous access to the life of the body and of the species, from which microscopic surveillance and mass measures emanate, such as statistics, campaigns, and normalizations).

For Foucault, “sexuality” is not merely instinct or the sexual act, but a historical arrangement of practices, discourses, and rules that teaches us to speak, think, and perceive ourselves around sex. Doctors, schools, churches, laws, media, and statistics make up this device (sexuality) of power-knowledge: they put sex into discourse, produce categories and diagnoses, define what is normal or deviant, and orient conduct. In doing so, sexuality becomes a route of government: it connects the intimacy of bodies to collective issues such as birth rates, public health, and education, allowing measurement, comparison, and intervention both in the individual and in the population.

This functioning appears in recurring fronts: children’s sexuality is intensely pedagogized through advice and surveillance; the female body is medicalized with an emphasis on maternity; procreation is socialized through policies and counseling; and pleasures outside the norm are psychiatrized and transformed into identities and treatments. The central point is that we do not “discover” a natural, pre-existing sexuality; we construct it socially and, in that movement, we also construct our identities, limits, and expectations. Therefore, prevention campaigns, clinical protocols, lessons on consent, and “best practice” manuals—aligned with whatever perspective—are not merely informative but, above all, modeling of ways of feeling, speaking, and acting, governing via sex (as a category). Therefore, “sexuality,” in Foucault, names an organized field of meaning-production that fabricates knowledge and normalizes conduct, articulating care of the self and social control of the other in the same gesture.

In this framework, health education under the rhetoric of autonomy can reinscribe old asymmetries when it limits itself to instructing “adequate/inadequate” behaviors and measuring adherence; in a certain way, a return of “sanitarism” that seeks to moralize habits. In turn, education in health can convert continuing education into a technique for docilizing work if it is reduced to protocol updates without problematizing their effects of power. Here lies the tension: emancipation as the watchword, and governmentality as the effect.

In this context, the datafication of care and of education in/for health (coverage dashboards, heatmaps, unit rankings) translates life into explicit calculations, a condition of biopolitics according to Foucault. Such a perception opens up a question that is rare in the field: who governs the data that govern us? Health education/in health should include critical literacy in data and indicators, producing communities of interpretation (users, workers, managers) that decide what to measure and, above all, how to read the numbers, shifting metrics from instruments of control to practices of deliberation. This would update Falkenberg’s emphasis on autonomy and participation in an informational key.

When prevention policies are coupled with incentives/sanctions, a socio-moral duty to remain healthy emerges, a contemporary version of “make live” that can recode inequalities as individual failings. The line is thin between care and tutelage. Popular health education, as formulated in the article, can provide a possible antidote: dialogue with prior knowledge and critical-contextual analysis, which would reintroduce the social dimension into the etiology of ways of life.

We see this, for example, in workplace “well-being” programs that give bonuses to those who reach a certain number of steps per day, lose so many kilos, or keep tests “within the target,” and apply smaller (or no) discounts to those who do not manage to do so. At first glance, it seems like a mere healthy incentive; in practice, those who have time, safe neighborhoods in which to walk, money for adequate food, and a predictable routine benefit more, while those who live in areas without sidewalks, work shifts, care for children, or depend on cheap food are “penalized,” and the difficulty becomes a “personal failing.” The line is thin between caring and tutelaging, almost disappearing when the institution begins to monitor, rank, and reward bodies, as if everyone started from the same place.

The alternative proposed by popular health education is to start from the territory: listen to the group, map real barriers (lack of lighting in squares, food prices, transportation), negotiate simple solutions (walks at safe times, a low-cost market on a set day, an agreement with the company for feasible active breaks), and only then define collectively built goals. Thus, the focus shifts away from “blaming the individual” who does not meet the conditions to be rewarded and back to the living conditions that can — and should — be transformed with community participation.

Foucault also notes that, with the rise of biopower, death becomes the reverse of the management of life and, in certain contexts, massacres become vital, “in the name of the existence of all.” Health education rarely discusses dying, except as a failure of control; it is urgent, in this sense, to integrate the development of literacy for finitude (palliative care, mourning, limits of intervention), under the risk of converting training into a catechism of vital performance; of imposing on the health professional and even on the population, respectively, the duty to make live and the duty to live.

A propositive agenda can be built through pedagogical counter-devices that return agency to people and make visible the power effects of educational practices in health. First, it is necessary to promote semiotic co-management, enabling people to understand not only the content of campaigns and protocols, but also the context of the signs that govern them (slogans, icons, and metrics). Next, a curriculum of applied biopolitics is proposed in initial and, above all, continuing education, in which each technical guideline is accompanied by a space for reflection on disciplines and regulations, effects of categorization, and ethical dilemmas, making explicit the double pole of the power over life within training itself. Complementarily, it is vital to invest in literacy in indicators and data governance, through workshops to negotiate what to measure, with which sources, with what margins of error, and— especially — for what uses, aligning biopolitical management with social control in health. Finally, promote spaces for discussion about finitude integrated into health education, articulating care of dying for users and clinical reflexivity for professionals, in order to prevent “make live” from becoming the imperative to deny death or from overburdening the sensitive dimension of health professionals.

Thus, to educate (in health and for health) can be understood as participating in the politics of living. If modernity made the biological a matter of calculation and, therefore, a field of government, it falls to contemporary pedagogies to return to this calculation its deliberative, plural, and situated dimension. The innovative gesture is not to “abandon” biopolitics, but to twist it: from management over to management with. It is a matter of proposing a turn coherent with the emphasis on autonomy, popular education, and continuing education as practices of co-production of care and knowledge. It is, finally, a matter of inventing pedagogical counter-conducts within the very devices; not to deny “make live,” but to negotiate its ends, its means, and its signs. And, above all, to learn again to live together.

Reference

Foucault, M. (1990). The history of sexuality, Volume 1: An introduction (R. Hurley, Trans.). New York, NY: Vintage Books. (Original work published 1976).

Falkenberg, M. B., Mendes, T. de P. L., Moraes, E. P. de, & Souza, E. M. de. (2014). Health education and education in the health system: Concepts and implications for public health. Ciência & Saúde Coletiva, 19(3), 847–852. https://doi.org/10.1590/1413-81232014193.01572013