Critical Public Health

ISSN: 0958-1596 (Print) 1469-3682 (Online) Journal homepage: www.tandfonline.com/journals/ccph20

Understanding health promotion in a neoliberal

climate and the making of health conscious
citizens

Nike Ayo

To cite this article: Nike Ayo (2012) Understanding health promotion in a neoliberal climate
and the making of health conscious citizens, Critical Public Health, 22:1, 99-105, DOI:
10.1080/09581596.2010.520692

To link to this article: https://doi.org/10.1080/09581596.2010.520692

Published online: 30 Mar 2011.

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Critical Public Health
Vol. 22, No. 1, March 2012, 99–105

Understanding health promotion in a neoliberal climate and the

making of health conscious citizens
Nike Ayo*

Faculty of Physical Education and Recreation, University of Alberta, W1-34 Van Vliet
Centre, Edmonton, Alberta T6G 2H9, Canada
(Received 20 May 2010; final version received 27 August 2010)

Neoliberal rationality is frequently invoked in critical analyses of health

promotion, particularly those analyses stemming from a Foucaultian
governmental perspective. Such references made to neoliberalism have been
beneficial in highlighting the interconnections between health promotion
policy and practice and the larger social, cultural and political systems of
governing in which health discourses are embedded. However, beyond
referential illustrations of neoliberal ideology, there has been little
elaboration as to how specifically the logic of neoliberalism is deployed
in such a way as to contribute to shaping contemporary health promotion
policies and facilitating the modern-day health conscious movement. In this
article, I will elaborate on this issue and add a level of depth to this
discussion. I will specifically explore how neoliberal thought and practice is
directly implicated in shaping the way health is promoted. This analysis
contributes to the growing body of literature on critical perspectives of
health promotion.
Keywords: health promotion; neoliberalism; governance

Neoliberal rationality is frequently invoked in critical analyses of health promotion,

particularly those analyses stemming from a Foucaultian governmental perspective.
Such references made to neoliberalism have been beneficial in highlighting the
interconnections between health promotion policy and practice and the larger social,
cultural and political systems of governing in which health discourses are embedded.
The purpose of this paper is to add a level of depth and breadth to this discussion
through specifically exploring how neoliberal rationality has shaped the way health
is defined and promoted.
Drawing upon Ericson et al.’s (2000) five key tenets of neoliberal rationality, as
identified in their study of risk and governance within the private insurance industry,
I will extend and build upon these principles as they apply to contemporary health
promotion strategies. These principles include minimal government intervention,
market fundamentalism, risk management, individual responsibility and inevitable
inequality as a consequence of choice. Through this effort of situating contemporary
health practices within a larger social, political and cultural framework, it is my

*Email: nayo@ualberta.ca

ISSN 0958–1596 print/ISSN 1469–3682 online

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http://dx.doi.org/10.1080/09581596.2010.520692
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100 N. Ayo

intent to elaborate, and highlight specifically how existing health promotion policies
both reflects and reinforces the prevailing political ideology of neoliberalism and
furthermore operates in such a way as to facilitate the making of the ‘good’ and
‘healthy’ citizen.
The Foucaultian concept of governmentality will also be drawn upon throughout
this article. Foucault was interested in the ways in which humans come to engage in
self-constituting practices. In other words, how individuals are made into particular
types of subjects (Markula and Pringle 2006) such as the health conscious citizen.
For Foucault, governmentality was seen as a method of social control and political
rule (Lupton 1999) in which the formation of such subjectivities were brought about.
Moreover and key to this concept of governmentality within the context of
contemporary neoliberalism is that such social control is neither deemed as being
overtly coercive nor forceful, but rather as operating on autonomous individuals
wilfully regulating themselves in the best interest of the state (Lupton 1999). In this
way, the concept of governmentality provides a useful tool for demonstrating how
health promotion works, not by making social and structural changes which impede
upon the health and wellbeing of the population, but rather, by inciting the desire
within autonomous individuals to choose to follow the imperatives set out by health
promoting agencies, and thus, take on the responsibility of changing their own
behaviours accordingly.

The pursuit of healthiness

Upon examination of this pursuit of healthiness, it becomes evident that health
consciousness has become deeply engrained within our social fabric. Since the mid-
1980s, there has been a drastic increase in the amount of health policy that focuses on
health promotion (Burrows et al. 1995). Not only has health promotion been
increasingly prevalent in the public policy arena, but it has also gained popular
media and corporate attention since this period as well. From the Jane Fonda
workout videos of the 1980s and 1990s, to the prominence of the Lululemon athletic
apparel of this period, the health, wellness and fitness industries have managed to
inculcate an obsessive preoccupation with health. As will be discussed below, this
type of health mania has been made possible in the context of a capitalistic,
neoliberal climate, whereby healthism and neoliberalism mutually reinforces the
vision of the responsible, entrepreneurial citizen (Crawford 2006).
Healthism, a term coined by Robert Crawford in 1980 to describe the then newly
emerging health consciousness, can be explained as ‘a particular form of ‘‘bodyism’’;
in which a hedonistic lifestyle is (paradoxically) combined with a preoccupation with
ascetic practices aimed at the achievement or maintenance of appearance of health,
fitness and youthfulness’ (Dutton 1995, p. 273). Healthism works under the
assumption that everyone should work and live to maximize their own health
(Petersen and Lupton 1996). This not only benefits the individual, but it is also
presumed to work for the good of society as a whole. As the burden of health care
is reduced from the shoulders of the state, it is then placed upon the consciousness
of individual citizens.
Such health consciousness has resulted in a pursuit of healthiness that is
facilitated by a burgeoning health industry propagating throughout nearly every
realm of society at an ever increasing pace. New gyms pop up not only on street
 Critical Public Health 101

corners (Galvin 2002), but also in work places and grocery stores. Fitness apparel,
such as Lululemon Athletica (2009), are no longer confined to ‘yoga, dancing,
running, and. . . other sweaty pursuits’ (lululemon.com), but has instead become a
fashionable statement in everyday wear of one’s pursuit of health. The purchase of
certified organic food products also echoes this same statement; as does a whole slew
of other products labelled as ‘natural’ or ‘green’. The intent here is not to condemn
such items as ‘bad’, but rather to demonstrate how contemporary health
consciousness can be seen as contributing to the spur of a ‘consumerist frenzy’
(Galvin 2002, p. 127), whereby health promoters prescribe a certain lifestyle (Parish
1995) intended to minimize risks, and construct responsible, prudent, health
conscious citizens who are expected to buy into this lifestyle.
Thus, the enormous amount of personal resources invested into healthy living, be
it in time, money, physical effort or a range of aesthetic regimes, is not seen as a
narcissistic obsession with the self (Rose 1990), nor is it considered to be frivolous.
Rather such personal investment is deemed as a wilful obedience to the duties and
obligations imposed by citizenship.
In essence, the healthy lifestyle culture as we know it within contemporary
Western neoliberal societies can be seen as a moralistic one whereby values such as
prudence, hard work, responsibility and asceticism are expressed through such
pursuits as listed above. The impetus to undertake such pursuits under the banner of
healthy lifestyles exemplify what Foucault refers to as technologies of the self, efforts
humans make to ‘transform themselves in order to attain a certain state of happiness,
purity, wisdom, perfection, or immortality’ (Foucault 1988, p. 18). It is through
technologies of the self that aspects of self-constitution are carried out rendering
particular images, statuses and identities into being.

Health promotion in a neoliberal framework

To understand the significance of neoliberal rationality in which this citizenry is
formed, I provide here an explanation of what is meant by both neoliberalism as well
as rationality. A general consensus of the term neoliberalism can be commonly
understood as a political and economic approach which favours the expansion and
intensification of markets, while at the same time minimizing government
intervention. Though the emphasis here is on the market and government structures,
neoliberalism is by no means just an economic or political term – it is inherently
social and moral in its philosophy. An explanation of the concept of rationality will
further help to bring this to light.
Simply put, Dean (1999) explains a rationality as ‘any body of systemic thought
about the nature of things’ (p. 11). Rose (1996) further elaborates on this as he
explains a political rationality to be ‘a kind of intellectual machinery or apparatus for
rendering reality thinkable in such a way that it is amenable to political
programming’ (p. 42). Thus, we can think of the political machinery of neoliberalism
as a system of thoughts and beliefs about the effective rule of state, society and the
market. These beliefs are pervasive in that the corresponding discourses directly
shape the ways in which society is governed and expected to conduct itself, right from
the privacy of one’s own home to the administration of public institutions and across
all demographics. The five basic tenets of neoliberal rationality as outlined above:
minimal government intervention, market fundamentalism, risk management,
102 N. Ayo

individual responsibility and inevitable inequality as a consequence of choice,

provide the basis of a framework for understanding how neoliberalism works to
facilitate present-day health promotion discourse and health consciousness. I will
now speak to each of these tenets as they relate to contemporary health promotion in
the Western world.
Central to the political posturing of neoliberalism is the idea of minimal
government intervention. This can be seen as a key explanation in the failure to
implement the strategies and actualize the goals of the Ottawa Charter for Health
Promotion. Rather than invest in the prerequisites of good health, such as income,
shelter and food, as urged to by the contributors of the Charter, the framework for
health promotion was quickly reverted back to the individualized lifestyle approach
as advocated in the Lalonde Report. In this way, what were once seen as social
problems, a failure of the state even (Galvin 2002), has come to be seen as a personal
failure requiring personal accountability. Unemployment, poverty, lack of educa-
tion, all major established social determinants of health, are rendered as poor
personal choices made by freely choosing citizens. Health promotion policy and
practice has appeared to largely ignore these fundamentals of health. Though talks of
social determinants are often tossed around in government documents and speeches,
it is questionable to what extent such talks actually move beyond that of rhetoric
such as was seen with the Ottawa Charter. Instead, the health promotion policies
which tend to receive the greatest amount of endorsement are those which suggest
that all will be well if individuals simply exercised 30 minutes a day and ate more
fruits and vegetables. This discourse prevails at the same time when increasing
homelessness and affordable housing have become nationwide problems
(Hulchanski 2002, Moore and Skaburskis 2004) and social and economic conditions
have deteriorated for many citizens. The objective here is not to dispute the real
benefits that physical activity and nutrition has on one’s health. Rather, the intent
is to demonstrate how such self-regulating, individualized practices become
championed over other forms of well-established knowledge such as the social
determinants of health.
In this shift away from state intervention, citizens are not left alone to completely
fend for themselves in achieving health and wellbeing. A massive array of expert
knowledge, in which Foucault argues is integral to the formation of particular
subjectivities (Lupton 1999), is made available to citizens providing them with lists of
do’s and don’ts and other guidelines to healthy living. The corporatization and the
commodification of health also facilitates this process, thus assisting citizens in
becoming ‘consumers and enterprising individuals’ (Galvin 2002, p. 117); two virtues
of neoliberalism that speak to the principle of market fundamentalism. While the
state takes a step back from directly intervening in social and economic affairs, it
simultaneously gives way for the creation of new markets in domains where they may
not have previously existed (Dean 2008). This is evident as we consider the rise of the
health industry and its expansive reach in all areas which pertain to the body, mind
and spirit. Rather than the state focusing on the determinants of health, ‘experts’ and
corporations alike are encouraged to offer their goods and services through the free
market, whereby, it is expected that the responsible, health conscious, neoliberal
citizen will buy into them.
It is hard to ignore the supremacy of the free market in neoliberal states over
matters pertaining to health promotion. Whereas the capitalist state prior to the
1980s health promotion movement may have encouraged self-indulgence and a spur
 Critical Public Health 103

of cheap and unhealthy foods and other products, modern-day capitalistic neoliberal
states in Western societies are increasingly encouraging a new type of self-indulgence.
That is, one which better corresponds with the image of the healthy citizen. Grocery
store isles are now littered with low-sodium, reduced-fat, calorie-wise and health
check symbols on food items. Coupled with running shoes, athletic clothes, sports
bras, health books, fitness magazines, exercise DVDs, diet pills, sport drinks, energy
bars and machines which build, bend and bulk-up the body as just a small sample of
what the health industry has to offer, Health consumerism greatly abounds. There is
no limit to the reach of the free market and its entrepreneurial role in the health
industry. Thus, the healthy and wise citizen is taught that insurance against health
risks is based upon consumption of both the dominant ideals of what it means to be
healthy and the goods and services which reinforces them.
Risk management, is another one of the five tenets of neoliberal rationality as
stated by Ericson et al. (2000). From a Foucaultian perspective, modern-day ‘risk are
directed at the regulation of the body’ (Lupton 1999, p. 90). This is evident in
modern-day health promotion strategies as individual’s bodies are targeted as the site
of intervention and regulation as oppose to overarching social systems. According to
the Merriam-Webster’s Online Dictionary, a risk can be defined as ‘the possibility of
loss or injury’. In terms of health promotion, we can understand this loss or injury as
the possibility of morbidity or premature mortality. It is the imminence of such
harm, the potentiality for life threatening chronic diseases that legitimizes health
promotion strategies. As such, the particular strength and effectiveness of deploying
risks as a neoliberal tool, a technology of government indeed, is the impending harm
that it implies, thus stimulating a sense of panic, a sense of urgency, and a sense that
action must be taken now. Not only is it expected that prudent and responsible
individuals will embrace the goods and services offered by the flourishing health
industry as part of their reasonable service to themselves, but as well, as part of their
duty of citizenship to the state.
With this in mind, it becomes evident as to how individual responsibility works as
a tenet of the neoliberal state. This principle of personal responsibility is not only a
matter of economic efficiency, but it is also highly value-laden and situated as a code
of ethics, an obligatory duty of citizenship. Ideally, personal responsibility is
intended to relieve a great amount of burden off the state as social issues become
personal issues. Yet, the rendering of such personal issues, such as health-related
lifestyle behaviours, into moralistic issues in the air of secularism, has been highly
effectual in supporting this new breed of health consciousness and self-regulating
subjects.
The issue of personal choice, and the freedom to choose, is another key tenet of
neoliberal rationality. In fact, the very foundation of neoliberalism stands upon the
premise of liberty and freedom. It is these rudiments of rational government which
are transferred over to citizens in efforts to empower them to become self-governing,
enterprising individuals (Petersen and Bunton 1997, Schee 2008). Thus, within this
political, economic and social climate, matters pertaining to inequalities in health
become an inevitable outcome as a consequence of freedom of choice. Just as there
are those who take heed to health promotion messages promulgated through ‘expert’
knowledge, there will also always be those who ‘choose’ to navigate along their own
way, failing to attend to the loud cries broadly disseminated by health promoters of
what it means to be healthy. In this way, responsibility for the differences in health
and illness are again removed from the conscience of governing bodies and placed
104 N. Ayo

onto health conscious individuals who are made to be accountable for their own
actions and circumstances. Of course, the issue of choice here can be seen as more of
a facade as it is understood that a number of oppressive social and structural forces
mediate the choices in which one is able to make.
It is evident that the manner in which contemporary health promotion is
employed within Western neoliberal societies both reflects and reinforces this
prevailing political ideology. The neoliberal agenda of restructuring governmental
techniques so as to minimize state intervention, secure competitive markets, while
at the same time evading risks and establishing a social body comprised of
knowledgeable, prudent, health conscious citizens, while also accepting the
inevitability of inequality as a side effect of the freedom of choice, is symbolic of
the ‘healthy’ society. As can be seen, and is thus worth reiterating, health promotion
works not by way of making social structural changes which impede upon
population health, but instead by inciting the desire within individuals to choose
to follow the imperatives set out by governing health bodies, and thus change their
own lifestyles accordingly. However, I contend that this notion of choice based upon
the liberties of neoliberalism, is more illusory than it is a true act of volition. The
consequences for those who fail to conform to the prescribed mandate as to what
constitutes a healthy lifestyle are real. Such include among other things, public
disdain and reproach for being a part of societal problems rather than a part of the
solution, gazes of repulsion due to one’s failure to manifest the symbolic metaphors
of neoliberal citizenship, such as the self-governing individual or the capitalistic hard
work ethic, embodied in the taut, refined and fit body, and admonitions from both
health experts and loved ones alike.
Health promotion messages such as ‘be active’, ‘eat healthy’ and ‘lose weight’, are
boisterously propagated throughout Western neoliberal societies as the panacea to
modern day health concerns of chronic diseases. Under this logic, it is individuals
who are placed at the centre of health promotion strategies, as opposed to
overarching social systems that also determine health outcomes. They are seen as
being both the cause and the solution to potential health problems and thus are made
to be accountable for their own health. However, when exercising one’s autonomy
and freedom, it is expected that the responsible citizen will allow his or her lifestyle to
be guided under the auspices of knowledgeable experts and normative prescriptions
of what it means to be healthy. This requires attending to one’s own health in ways
which have been socially approved and politically sanctioned.
In this manner, it can be understood how health promotion and health practices
are not merely the result of objective reasoning, but rather as contingent on
aggregates of social, cultural, political and economic conditions. Highlighting the
role of neoliberalism in this set of contingencies provides insight as to how this
rationality has contributed to shaping the way contemporary Western societies have
come to understand what it means to be healthy.

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 Critical Public Health 105

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