Sot. Sci. Med. Vol. 38, No. 10, pp.

1347-1365, 1994
Copyright 0 1994 ElsevierScienceLtd
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THE BOUNDARIES OF THE SELF AND THE

UNHEALTHY OTHER: REFLECTIONS ON HEALTH,
CULTURE AND AIDS
ROBERTCRAWFORD
University of Washington at Tacoma, 1103 “A” Street, Tacoma, WA 98402, U.S.A.

Abstract-Most accounts of the cultural stigmas associated with AIDS have not adequately considered
the meanings through which the stigmatizing self imagines his/her difference from the stigmatized other.
This paper argues that ‘health’ is a key concept in the fashioning of identity for the modem and
contemporary middle class and that the ‘unhealthy’ come to be represented as the other of this self.
‘Healthy’ and ‘unhealthy,’ however, must be understood both in their biomedical meanings and in their
implicit metaphorical meanings. The ‘unhealthy,’ ‘contagious,’ ‘sexually deviant,’ and ‘addicted-minority’
other-all condensed in the negative symbolism of AIDS-have become images which are mobilized as
part of a cultural politics of reconstructing the self in conformity with intensified mandates for self-control.
The expulsion of ‘unhealthy’ meanings from the self, an act of patrolling the borders of identity, finds
its projected physical location in the figure of the person with HIV-AIDS.

Key words-AIDS, culture, self

The AIDS epidemic has forced many of us working
in the fields of health and illness to re-examine our
work and to ask questions about its relevance to the
present crisis. For over a decade I have been inter-
ested in the culture of health in the United States and
how health is a concept that provides valuable in-
sights into the socio-cultural order. I have argued, for
example, that health is an important symbolic do-
main for creating and recreating the self. The pursuit
of health, so much a part of the American cultural
landscape since the mid-1970s can be understood as
a ritual of personal regeneration in which middle class
identity is secured and conspicuously displayed. If
health, in its various meanings, is so important for
constructing the social self, what then are the impli-
cations for the cultural construction of the AIDS
epidemic, an event that has generated a multitude of
highly charged meanings attached to individuals and
groups? The following is an attempt to answer this
question and to apply my interpretation of health in
contemporary American culture to discussions well
under way about the cultural politics that define the
social meanings of the AIDS epidemic.
At the heart of the cultural politics of AIDS is a
contestation over the meaning of the self. It is a
politics about identity and difference, about the
boundaries of personhood which distinguish legiti-
mate from non-legitimate identities, and about the
meanings upon which identities are constructed,
managed, and reworked. How individuals meaning-
fully shape their identities, what boundaries they
draw and thus what meanings are expelled as not
belonging to the self, and how experienced conflicts
within the self are resolved all define the territory of
this politics. This contestation occurs befween ‘per-
sons,’ that is, it entails conflicts over the represen-
tations by which individuals imagine others. Such
images are inseparable from the ‘group-fantasies’
with which those others are identified. Critical actions
and critical non-actions follow from such represen-
tations. Contestation also takes place within the self,
particularly in periods of rapid social change or crisis
when varying social forces make claims for ‘appropri-
ate’ responses and the normative bounds of person-
hood are more assertively articulated. Responses to
tension between conflicting aspects of the self may
include a closing down or a tightening of the bound-
aries of identity, uneasy accommodation, conflict or
confusion, or a self-reflexive opening. The two dimen-
sions of contestation, between and within, are con-
nected. Images of self are crucial for determining how
the other is imagined. Thus, how individuals attempt
to resolve conflicts of self-definition will affect the
outcome of conflicts about difference. Conversely,
how one imagines the other and how conflicts about
difference are resolved in practice affect the internal
efforts to shape a viable self in the face of social crises
which are at the same time crises of identity.
The AIDS epidemic is clearly both a social crisis
and a crisis of identity. AIDS has been called an
‘epidemic of signification,’ which means in part that
it lays bare questions of identity [l]. The epidemic has
radically and urgently transformed the cultural poli-
tics over homosexuality in American society and may
soon do the same with respect to race.. It has altered
both the politics of identity and recognition waged by
gay and lesbian movements and the conscious and
unconscious responses of straight men and women to

1347
1348 ROBERTCRAWFORD
the identity implications raised by the apparent con-
vergence of life-threatening disease with homosexu-
ality. Identity work-protecting or reformulating self
boundaries, reinforcing images or reimagining the
other-is required of people as they respond to fears
of contagion and stigma, as they adopt strategies to
protect themselves from implication, that is, symbolic
connection to ‘infected’ others and the negative
characteristics ascribed to them. It is also demanded
of people as they make decisions about their own
sexuality and sexual behavior and as they respond to
the infection of friends and family members. Finally,
identity work also becomes unavoidable as people
attempt to develp their own political stance amidst
the politicizations swirling about them: as the media
continues to generate its outpourings of ‘infor-
mation,’ stories, and coverage of AIDS ‘events’ both
domestically and internationally, as public officials
take explicit or implicit ‘positions,’ and as political
mobilizations from AIDS activists to right-wing,
anti-gay organizing are all variously assimilated. My
argument is that the highly charged character of the
articulation of AIDS and identity should be under-
stood not only in terms of stereotypes of already
stigmatized groups associated with the disease but in
terms of the social self that has a stake in continuing
to generate such stereotypes. Valuable work examin-
ing prevailing notions about ‘deviant’ sexuality, dis-
ease, and otherness-and their historically presumed
concurrence-has already been undertaken. The pre-
sent effort, indeed, relies upon this work. My point is
that stigmatizing images of the other are founded in
a social self which needs this other.
In particular, images of the other associated with
HIV/AIDS can be better understood by considering
how they are incorporated into an identity structure
for which ‘health’ (and the meanings associated with
it) has become a key, organizing symbol. I want to
discuss how the self acquires a particular and power-
ful set of concrete meanings through the concept of
health; and how, by way of this self construction,
disease takes on the symbolic weight of a negated self.
I believe this step to be necessary for understanding
how disease acquires the insidious and historically
specific set of associations noted by so many observ-
ers. In this way, I hope to show how the identity
signified by HIV/AIDS comes to be seen as the other
of this ‘healthy’ self: an ‘unhealthy’ other who is
perceived not only as a physical danger, but as an
equally threatening and dangerous identity.
The ‘healthy’ self should be seen in terms of an
interrelated set of oppositions: (1) a biologically
healthy set that is conceived in opposition to disease
and death; and (2) a metaphorically healthy self by
way of which conventional beliefs about the self are
imagined as opposed to the qualities of ‘unhealthy’
persons already positioned as subordinate, outside,
and stigmatized. This ‘healthy’ self is fashioned in
opposition not only because of the prevailing medical
dichotomization of health/disease, but because the
boundaries that secure the ‘healthy’ self-in both of
the stated senses-are never secure. It is precisely the
deployment of symbolic sentinels, including medi-
cine, to patrol the boundaries of identity which needs
to be uncovered. My work has taught me to appreci-
ate just how much ‘health’ has become a primary
means of signification by which borders are main-
tained, threats, specified, and internal weaknesses
shored up. The imagined identity of the ‘diseased
other serves as a boundary-reinforcing device in ways
I will review.
My point of departure, then, is health, for in our
concept and beliefs about health some of our most
powerful images of disease and images of people who
are seen as ‘diseased’ can be found. My argument will
proceed as follows: First, the concept of health is
absolutely central to modern identity. This assertion
is premised on another: that health and the body
imagined through it (or conversely the body and the
‘health’ imagined through it) are not only biological
and practical, although they are meaningfully these,
but are also metaphorically layered, packed with
connotations about what it means to be a good,
respectable, and responsible person. These meanings
are in turn connected to prevailing images of class,
race, and sexuality. Second, since the mid-1970s
health and its pursuit have become increasingly val-
ued and thus have become a crucial terrain upon
which contemporary, personal identity is fashioned.
Third, the ‘healthy’ self is sustained in part through
the creation of ‘unhealthy’ others, who are imagined
as embodying all the properties falling outside this
health-signified self. Disease, especially contagious
and sexually transmitted disease, is tainted with
otherness and in our healthiest culture is seen in terms
of otherness itself. The ‘diseased’ as other and the
‘other’ as diseased is most easily imagined when the
social distance between the perceiver and the per-
ceived is great-for example, between middle class,
white Americans and Africans, Haitians, the inner-
city poor, etc. But interestingly, identity work may
become most active and intense, when the social
distance is close; for example, between middle class
straights and middle class gays. Finally, I believe that
an adequate engagement with the stigmatizing prac-
tices and the perceptions on which they are founded
will be aided by re-thinking health itself, the meanings
expressed through it, and the ways which ‘health’ is
employed as an implicit language of the self. The
effort to rethink health, however, cannot be under-
taken in isolation from the totality of social and
cultural relations in which we are enmeshed and
which provide the substance and boundaries for the
articulation between health and personhood.
The anxiety provoked by the AIDS epidemic
among the so-called ‘general population’ is not only
a fear of the epidemic ‘breaking out’ of the cultural
and social ghettos in which it is, at present, largely
contained; it is also about preserving the social self as
it is structured in domination. The fear occasioned by
 Reflections on health, culture and AIDS
this disease and its epidemic character is simul-
taneously a fear of the destabilization of the tenuous
relations of identity--both within and between-by
which self is insulated from other. At stake in the
AIDS epidemic is a ‘spoiling’ of identity, a fluidity
that dissolves ‘immunity’-the ability to distinguish
self from non-self. Therein lies its perverse utility:
AIDS provides a ‘natural alibi’ for the strengthening
of defenses against dangerous identities-against sex-
ualities, addictions, vulnerabilities and the unsafe
meanings that threaten from within and without the
boundaries of legitimate selfhood.
THE HEALTHY SELF
In order to appreciate how health came to be
associated with, and indeed emblematic of modern,
Western identity, it is necessary to review its emer-
gence as an individual and social goal. As traditional
contours of identity were assaulted by the massive
social, economic and cultural changes of the modern
world, individuals recreated themselves by way of
projects that represented the new order and their
desired place within it. As Europe and America
modernized, health became one of those projects.
That it did so tells us something about those social
orders and the modes of identity essential to their
formation and reproduction. For the expanding
middle class of the commercial and industrial so-
cieties of Europe and America, the goal of health
became an essential component of what it meant to
be modern, progressive, rational, and distinctive. The
language of health came to signify those middle class
persons who were responsible from those who were
not, those who were respectable from those were
disreputable, those who were safe from those who
were dangerous, and ultimately, those who had the
right to rule from those who needed supervision,
guidance, reform, or incarceration.
Health did not always occupy such a central place
in Western culture, though certainly health and its
cousin, longevity, have a long history as cardinal
values in Western thought. They have been the
objects of philosophical and folk wisdom, religious
incantation and prayer, and the counsel and admoni-
tions of healers. Before the eighteenth century, how-
ever, they were commonly believed to be more an
outcome of good living, ritual observance, or divine
grace, and more likely to be considered as part of an
inclusive ‘good fortune.’ The Book of Common
Prayer originally contained the following passage:
We have left undone those things which we ought to have
done; And we have done those things which we ought not
to have done; And there is no health in us.
Here, as literary critic Bruce Haley comments, “the
word health means a life in perfect accordance with
the essential spiritual laws governing man” [2, p. 191.
But sparked by the Enlightenment embrace of science
with its promise of the discovery of the laws of life,
1349
and epistemologically prepared by the Cartesian ob-
jectification of the body, health became from the
eighteenth century onward a social and individual
project of immense proportion. Health emerged as an
avowed goal of scientific investigations and medical
practices, an object of public policies, institutional
and familial concerns, and a widely espoused and
adopted, individual pursuit. Among the expanding
middle classes, health appeared as something that
could be achieved. The extensive regiments of diet
and everyday practices advocated by Greek phys-
icians were revived, refashioned, and popularized
amid a new confidence about the efficacy of practical
activity [3]. By the nineteenth century, health-now
understood as the outcome of scientifically informed
practice upon a natural body-had become a ‘key
word,’ spoken and written about medically, socially,
and philosophically. Health became a social ideal, the
axis of debates about the relative importance of
religious and secular world views, an essential foun-
dation of character for the middle class, and a widely
accepted responsibility of both the state and the
individual [2,4].
Several developments contributed to these changes.
One of them was the new religious individualism and
asceticism of the Protestant Reformation, a trans-
formation in culture that articulated with the radical,
individualizing changes wrought by the growth of the
market economy. In the Calvinist conception, indi-
vidual betterment and worldly pursuits were not
simply ends in themselves but a duty to God, an
opportunity to demonstrate moral rectitude and to
reassure oneself and others of being among those
elected for eternal salvation. Protestantism placed a
burden of constant doubt and therefore constant
striving upon the devout. The result was the well-
known ‘Protestant temperament’ of austerity and
denial of pleasure and a ‘work ethic’ that inculcated
a predisposition toward applied entrepreneurial ac-
tivity and disciplined savings as well as a spirit of
obedience, discipline, and self-denial in an unruly,
factory proletariat [5]. The point to be emphasized is
that Protestantism helped create a self that would
become preoccupied with discipline and order, a
fixation that would serve as a defense against dangers
both from within the self and perils from ‘below’
during the chaotic changes wrought by industrializ-
ation and urbanization. At the heart of Calvinism, as
philosopher Charles Taylor has written, was a “hor-
ror of disorder,” a fear of
a social disorder, in which undisciplined gentry and the
unemployed and rootless poor, the underclass of rogues,
beggars, and vagabonds, pose a constant threat to social
peace; a personal disorder, in which licentious desires and
the hold of intemperate practices make impossible all disci-
pline and steadiness of life; and at the connection between
the two disorders and the way they feed on each other. What
was needed was personal discipline; first, individuals capable
of controlling themselves and taking responsibility for
their lives; and then a social order based on such people
[6, p. 2291.
1350 ROBERT CRAWFORD
Continuous striving and discipline of work were
instrumental to these ends; but so too was the pursuit
of health which also called for a disciplined body. As
Greven notes [5, p. 431, healthy “habits” were pur-
sued for their value in achieving and demonstrating
regularity-“the daily, discipline of diet, dress, and
manner.” Likewise, the pursuit of health became an
“agency of discipline.” Anticipating the “muscular
Christianity” of the nineteenth century, John Wesley,
the founder of Methodism, saw no incompatibility
between a Godly life and the individual pursuit of a
this-worldly health. His Primitiue Physick (1747) was
among the first of a burgeoning literature of advice
on how to achieve health. Like the pleasure of
unrestrained eating, unhealthy habits were for Wesley
“an invitation to lust and unbridled sensuality”
[5, ~441. For these early health reformers, and for
many reformers who would follow in this religious
mode, health would become a weapon in the battle
against indolence and passion, and the persona1 and
social disorder they were said to precipitate. Given a
religious world view founded on the belief that the
body was the source of depravity and corruption of
the soul, imminently susceptible to vices, the pursuit
of health provided a drama of denial and redemption.
Further, the discipline of health was also useful for
teaching and demonstrating the ‘habits of industry’
so essential to the Protestant love of order. Finally,
Protestant-inspired healthiness helped bridge the
more traditional conceptions of providential health,
a health ultimately founded on the moral order of the
church, with newer forms of practical knowledge
rooted in the sciences.
Secular forces were also reworking the body. Nor-
bert Elias’ account of the reform of manners among
the upper and then the middle classes and Mikhail
Bakhtin’s study of the containment and enclosure of
medieval bodiliness (extravagant, carnivalesque, far-
cical, risible, violent, sensual) both speak to the
process by which ‘civility’ was worked upon the body.
The minimalization of gesture, the privatization of
bodily functions, the constriction of the passageways
of the body-where ‘inside’ becomes ‘outside’ and,
conversely, where ‘outside’ threatened to penetrate
‘inside’-all contributed to changing self-definitions
linked to emerging forms of social differentiation.
The point to be made here is that a new inwardness
and self-reflexivity was externalized in the form a
struggle with ‘excess.’ The controlled body would
become the gauge in this struggle of a distinctive
individuality which was rapidly becoming the hall-
mark of bourgeois identity. The ‘health’ of the body
provided the universally accepted ideal and practice
by which this sense of class-coded individuality could
be realized and demonstrated [7]. It should be no
surprise, then, that by the last half of the nineteenth
century other dimensions of an increasingly disci-
pline-preoccupied culture, particularly sexuality,
would be incorporated into the domain of health
practice. The ‘medicalization’ of deviance would am-
plify the self-defining and other-defining power of
‘health’ in the modern world, naturalizing the socio-
moral agenda of the now dominant bourgeoisie.
This vast medicalization and the question of how
health became such an important concept in the
modern West is also a question about how the body
became an object of scientific investigations. Along
with other crucial changes, the emergence of scientific
medicine marked the advent of health as a primary
social and personal goal. The foundations are trace-
able to Descartes, who provided modern culture with
the epistemological capacity to see the body as an
object, a thing that could be known and acted upon.
Pre-Cartesian philosophy, through premised on a
soul-body distinction which privileged the former,
never perceived the body as purely ‘extended matter.’
Corporeality was infused with significance, a manifes-
tation of spirit, inseparable from the essential self [8].
Cartesian thought, and the notion of a mechanical
body that was premised on it, forged a series of
separations-first, the notion of “the separate self,
conscious of itself and of its own distinctiveness from
a world ‘outside’ it” [9, p. 71; and second, the separ-
ation of the mind or soul from the body, the latter
also now situated outside the place of subjectivity.
The self of a Cartesian world became a de-corporeal-
ized self.
Conversely, the body, now separated from the soul,
took on a dual significance. On the one hand, this
radical separation of mind and body laid the foun-
dation for a new kind of knowledge, a cognition
aimed at mastery and control of the body, at maxi-
mizing its potential, at putting it to more efficient and
instrumental use [lo]. Medicine-or more accurately
the multiple scientific investigations that began to
coalesce under the umbrella of a medical purpose-
developed as the science aimed at knowing this newly
objectified body. It set out to do so with a repertoire
of conceptual and technical operations aimed at
description. When the body became an abstracted
entity, identical to all other bodies, detached from
living situations [l 11, health became a concept for
describing its normal state. The description became
the goal: the restoration or maintaining of normal
functioning. Thus, in unlocking the secrets of the
body, medical science claimed to have discovered the
laws of health. These laws were to be subjected to
manipulation in behalf of the humanistic goals of the
Enlightenment-the extension of life and the elimin-
ation of suffering.
On the other hand, the sensate and sensual body
appeared as a source of danger-the place of desire
and subversive sexuality to be banished from con-
sciousness and confined by a new bourgeois re-
spectability and a deterrence in the quest for clear
thinking and certain truth. The objectified and con-
trolled body, moreover, remained elusive. The body
in pain, the body in illness, the dying body, and the
collective, epidemic body thwarted the projects of
control, transformation, and perfection undertaken
 Reflections on health, culture and AIDS
in the name of health. The body, made visible by the
gaze of the biomedical sciences, simultaneously pro-
jected a darkening shadow in its unconquerability.
The body in sickness became the locus of a menacing
presence from which the healthy self would seek
refuge through tactics of stigmatization increasingly
centered on images of lack of control. Interestingly,
control or its absence were the key judgments
brought to bear in response to both the sexual and the
diseased body. This articulation facilitated the in-
creasing condensation of health and ‘normal’ or
controlled sexuality throughout the nineteenth and
twentieth centuries. The medicalized body was separ-
ated only to be reconnected to a complex web of
social and environmental ‘etiologies.’ These recon-
nections laid the foundations for the social, environ-
mental, and behavioral ‘medicines’ which would
subsequently claim a multiplicity of social objects as
their proper domain of intervention. Medicine con-
tinually advanced its jurisdiction, armed with the
dual legitimacy of natural truths and individual and
collective health. Health became the summum bonum
by which the elaborate projects of categorizing the
normal and the pathological would proceed [12].
The work of Foucault has also directed attention
to how projects of health were applied to multiple
aims of creating persons and populations compatible
with emergent forms of power. He has demonstrated
how politics to protect, restore, and promote health
became an essential component of institutional activi-
ties. The state, for example, assumed a more active
role in the control of people falling under its jurisdic-
tion and in providing supportive services for manu-
facture and commerce, becoming increasingly
involved in what is now referred to as ‘human capital’
or ‘human resources management.’ Governments, in
other words, began to recognize the importance of
collective human resources and to occupy themselves
with the flow and location of people, the availability
and productivity of labor, housing conditions, popu-
lation growth, and the protection of public health and
safety [4]. Health became the sine qua non of these
demographic and political objectives. Certainly, epi-
demics have been understood to produce economic
disruption and social and political disorder and from
the late middle ages on governments have been active
in their control. At a more routine level, however,
health became the cornerstone of policies aimed at
the production of ‘useful bodies,’ able to labor for the
secular utopias of industrialism and empire. As Her-
bert Spencer aptly put it, “To be a nation of good
animals is the first condition to national prosperity”
[2, p. 221. Thus, governments undertook programs of
public hygiene, sanitation, the supervision and subsi-
dizing of medical activities, and the collection of
‘medical’ information. For state administrators and
captains of industry, the body had to be made
healthy. In Foucault’s words, “Different power ap-
paratuses [were] called upon to take charge of ‘bod-
ies’ . . . to help and if necessary constrain them to
1351
ensure their own good health. The imperative of
health [became] at once the duty of each and the
objective of all” [4, p. 1701.
Foucault also emphasizes how the health of indi-
viduals came to be regarded as a criterion of a good
society and a good government. The traditional
‘pastoral’ power of the Christian church, power
premised on the achievement of eternal salvation for
the individual, acquired more secular forms and
worldly aims. A new discourse spoke of the enhance-
ment of the individual. Health became one of these
aims, a secular salvation promoted by secular insti-
tutions. One such institution was the family which
became a primary site and agent of medicalization;
that is, where medical notions of individual and social
well-being and deviance were internalized and
diffused. Beginning in the nineteenth century, the
family came to be seen as an institution which was
capable and, in fact, obliged to undertake the proper
development and protection of both child and par-
ental ‘health.’ The family was designated as a site
where the physical body, increasingly mobilized into
regimes of diet, sexual control, and physical develop-
ment, would become the object of a more finely tuned
attention and a more concerted, medically informed
and directed, practice. Thus, the family assumed
more of the burden of social control in the contain-
ment of a proliferating series of deviances [ 131.In this
way, health became the umbrella under which a
number of moral and disciplinary projects were in-
itiated, a social objective for which the family acted
as an agent of surveillance, normalization and con-
trol. Historically, these projects have included the
regulation of sexuality and gender, the policing of
boundaries of class, ethnicity and race, and the
inculcation of the psychological and behavioral req-
uisites for an increasingly stratified work force.
In the name of health, then, a number of con-
ceptions, aims, and practices converge, all of which
contribute to shaping the modern individual. The
new self, for which health would achieve an almost
sacred quality, came to be understood as a discrete
individual detached or abstracted from the ascribed
roles and expectations of moral personhood rooted in
tradition. Paradoxically, this new ‘autonomous indi-
vidual,’ self-determining and self-responsible, would
simultaneously become the object of new forms of
power that would ‘discipline’ it. The ‘emancipated’
individual of modernity, in other words, was ab-
stracted only to be reincorporated and mobilized for
objectives initiated and controlled by forms of power
characteristic of the emerging economic and political
order. The goal of health became one means by which
the disciplinary ‘hold’ on the individual would be
advanced. Health legitimizied an expanding series of
practices throughout the social body. These practices
enhanced the observation and monitoring of individ-
uals, brought more of their behaviors, attitudes, and
dispositions into the ‘benevolent’ sphere of concerted
action for social and individual improvement, and
1352 ROBERT CRAWFORD
extended social control through a detailed identifi-
cation of ‘deviances’ from the ‘healthy’ norm. And
like other forms of disciplinary power, medical-moral
control in the name of health relied, in large part, and
continues to rely, on the self-observing, self-regulat-
ing practices of the individual pursuing aims of
self-enhancement.
Thus, throughout the nineteenth century, the pur-
suit of health became a route to the achievement of
moral personhood for the rapidly expanding middle
class. As historian Bruce Haley writes, “Victorians
used physical health as the mode1 for a higher human
excellence, a way of envisioning it” [2, p. 2521. The
Victorian emphasis on character and will power, for
example, could be demonstrated by healthy pursuits
like physical exercise, sport, and mountain climbing.
The healthy person would employ up-to-date knowl-
edge to accomplish individual, team, and national
goals. The conditioning of behavior acquired through
sport, the pinnacle of healthy activity for men, sup-
plied, according to American historian Donald
Mrozek [14], a medium through which a “quest for
meaning” and “a sense of renewal” could be
achieved. Health, in other words, became a rich
source of metaphor, and this capacity to condense
and express a wide range of meanings added momen-
tum to its pursuit. Increasingly, a healthy mind was
said to depend on a healthy body-mens sana in
corpore sano.
Health provided ample opportunities for the dem-
onstration of character. The healthy individual, for
example, was a person who, in resisting immediate
gratification, took command of his or her life possi-
bilities. The ‘new man’ would not only mobilize his
body for the competitive struggle, he would also
acquire a body and a longevity commensurate with
his self-designated role in history. Thus, the pursuit
of health became an arena for the display of the
growing bourgeois ideal of taking responsibility for
determining one’s future. In the thought of Herbert
Spencer, this ideal was to expand beyond the physical
survival of the individual and apply to the evolution
of the ‘race:’
Take a part in your own evolution, [pleaded one health
reformer]. Select a mate of sound inherited constitution and
impeccable hygienic habits, pass your superior health on to
your children, and natural selection would do the rest: this
was the millennial health message as revised by Darwinism
[15,p. 1561.
Health, and the penalty of disease, assumed a central
role in solidifying positions of class and race through
programs of ‘racial hygiene’ and eugenics [16]. Any
violation of the laws of health were described by
many health reformers not only as ‘physical sins’ but
as betrayals to the social body and to human pro-
gress.
The concept of health as a practice was much like
the work required of the emerging professions-self-
motivated, self-disciplined, sustained over a lifetime,
and premised on new forms of knowledge. Through
demonstrating the appropriate concern for health,
individuals identifying with this new class could
display values previously associated with the Protes-
tant work ethic, an ethic which had by the late
nineteenth century become increasingly secularized.
Health-conscious people-both men and women-
could also become the vehicles of progress through
science and education. The progressive person would
embrace these resources for the future and utilize
them for self-enhancement [17]. Health reform in-
spired by professionals would not only contribute to
a more rational and efficient social order, but would
become the hallmark of the reasonable and free
individual. The body, abstracted as a composite of
technical operations and functional capacities, could
be treated as a possession, something one ‘has’ and
thus something for which one has responsibility to
‘maintain.’ By following the advice of experts and
employing scientific knowledge, the individual could
be transformed-a new body, a new self. Similar to
the scientific management proffered to control the
workplace and reform the polity, the ‘life sciences’
promised a meliorative management of biological
and social well-being. Rational control over the body,
amplifying its capacities and enhancing its efficiency,
would bring the dream of technology to its personal
apotheosis. Making health a personal goal was to
turn the notion of progress into a practiced convic-
tion: the ‘perfection of man’ could be a personal
project; and the body could become a site of measur-
able self-improvement. Thus, through objective
measures, one could gage oneself, comparing self to
others less diligent in their application of natural law.
The pursuit of health, then, in evoking the science
that claimed to know and tame nature, became a
practice that recreated the individual in the image of
the emerging, symbolic order. To be healthy was to
be modern. Thus, as the middle classes in both
Europe and America created themselves as a class,
they created a class body-a distinctive sexuality,
distinctive gestures, and distinctive bodily practices in
sport, drinking and eating habits, and health. My
argument has been that since the eighteenth century
‘health has become a key symbolic marker by which
the middle classes have defined the content, bound-
aries, and otherness of their personhood.
THE NEW HEALTH CONSCIOUSNESS
What was true of the expanding middle classes of
the nineteenth and early twentieth centuries has
reappeared with new force in the United States since
the mid-1970s as the middle class embarked on
projects of personal reconstruction and renewal. The
following interpretation of the new health conscious-
ness was originally based on in-depth interviews I
conducted in the early 1980s. I have argued that the
values expressed when people talk about health are
not simply values considered essential in order to
achieve health. Rather, such values constitute the
 Reflections on health, culture and AIDS
implicit meaning and the symbolic substance of
health. Health, in other words, may be pursued in
order to express these values. Contemporary popular
thinking about health is complex, but in my inter-
views a clear and consistent theme stood out from all
others: health can be understood as a metaphor for
self-control, self-discipline, self-denial and will power
[18]. This should be no surprise to the reader who has
followed my argument so far. In the late twentieth
century, health continues to be a moral discourse, an
opportunity to reaffirm the values by which self is
distinguished from other.
Why the mid-1970s and since? Certainly, middle
class Americans have, for several reasons, become
deeply concerned with real threats-both persistent
and emerging-to their physical health. They have
acquired a sense of somatic vulnerability largely as a
result of medical, political and commercial messages
sensitizing them to a plethora of hazards. Continued
high rates of cancer, heart disease, and other chronic
diseases have, of course, provided tangible reasons
for paying close attention to the endless array of
medical prescriptions and proscriptions. Health pub-
licity has also emphasized the importance of individ-
ual responsibility and the requisite qualities of
discipline and denial claimed to be essential for
protecting health. To an already predisposed middle
class, this constellation of health-promoting at-
tributes and associated behaviors made sense.
Millions of Americans have embarked on a health
and fitness regimen that continues today, with dra-
matic changes in smoking, diet, exercise, and alcohol
consumption.
Concurrently, however, Americans began to ex-
perience a social and economic vulnerability that
threatened their identities as secure members of the
middle class, a vulnerability that has continued into
the 1990s. In 1974, real incomes began to fall and, for
most of the middle class, have continued to fall or
stagnate. Only temporary and modest gains have
countered this trend. Although an increasing number
of working wives cushioned the fall for many (and
helped account for the meteoric, 1980s rise in income
of the more fortunate), economic distress has been
widely experienced. As the price of housing skyrock-
eted, for example, the American dream of home
ownership became more distant, or at the very least,
it has consumed an increasingly burdensome portion
of family income. Costs of other items emblematic of
middle class status also dramatically increased, in-
cluding big consumer items like automobiles, medical
care, and education. People from across a broad
eonomic spectrum have ‘tightened their belts’ and/or
are working harder to maintain a desired level of
consumption and a secure place in the middle class
for their children.
The late 1970s and 1980s have also been years
when management in both the public and private
sectors has undertaken a ‘disciplining’ of labor. One
aspect of this project targeted labor costs and has
1353
included the breaking and weakening of unions, the
closing of factories, and the shifting of production to
lower-waged areas of the Americans south and the
Third World. The professional middle class, however,
has not escaped this economic tightening. Many have
faced lay-offs or the threat of lay-offs and most have
experienced demands for higher output which have
often translated into longer hours. Citing a Bureau of
Labor Statistics report, Peter Kilborn of the New
York Times wrote in June, 1990,
Among 88 million people with full-time jobs last year, nearly
24 percent-largely executives, professional, self-employed
people, journalists, bureaucrats, and the secretaries and
clerks who toil alongside them-spent 49 or more hours a
week on the job . . Ten years ago only 18 percent worked
so much [19].
Increased competition to acquire jobs or demands to
keep them have sent many back to school for ad-
ditional course work and degrees: and the demand in
colleges for more vocationally related programs re-
mains high. In sum, a more serious and anxious
mood has descended upon working people in the
United States. The recession of the last few years has
served to reinforce this mood. It is in this climate that
middle class Americans, experiencing what Barbara
Ehrenreich calls a “fear of falling” [20], have per-
ceived the need for a reconstructed, more disciplined
self-a perception that corresponds with the agendas
of economic and political leaders. This has also been
a period when middle class parents intensified per-
formance demands on their pre-school and school-
aged children. In the American idiom, success will be
achieved only by applying more effort. It would
appear that as access to the symbols of class belong
ing diminish, identity might be made more secure by
a display of those values traditionally associated with
the middle class.
As in previous eras, health and fitness provide an
opportunity to mobilize symbolic resources. The
body is a tangible self that can be harnessed and
transformed in conformity with consciously chosen
designs. As the competitive struggle for jobs and
social position intensifies, the middle class immerses
itself in training, building resistance and extending
endurance. The best selling, non-fiction book in the
spring of 1984 was entitled Tough Times Never Last
but Tough People Do [21]. “If you’re in shape, you’ve
got the edge!” proclaimed a 1980s television ad for
deodorant. Portraying a 1976 photo of a disheveled
man under the heading “Hard Rock” alongside a
1989 photo of the same man, now muscular, short-
haired, and lifting weights and labeled “Rock Hard,”
an advertisement for a health club intoned “You’ve
got to face the music sometime. So listen up. No
matter who you are or what your record is, it’s never
too late to get your act together . . . We can make it
easier to get your show on the road. And keep it
there” [22]. In June of 1985, Hofstra University ran
an ad featuring a woman running. The caption read,
“What does it take to be the best? Determination,
1354 ROBERTCRAWFORD
hard work and the resources which place Hofstra
University [etc] . . . The ad. ends with the declaration:
“Hofstra University. We teach success” [23]. The
healthy body, a symbol of the value of the individual,
has once again become a sign of individual achieve-
ment and the value of the individual as a commodity
in the labor market. In “the war of each against all,”
body, and the identity it signifies, has become destiny.
The healthy body is the mark of distinction that
differentiates those who deserve to succeed from
those who will fail. In pursuing health, the self is
reconstructed in conformity with a more intensely
competitive and insecure world.
The turn toward disciplinary self-improvement in
the latter 1970s and 1980s cannot be adequately
explained without considering the unprecedented
challenge from middle class youth, who in the 1960s
and 1970s sought to redefine norms of sexuality, drug
use, and ‘careerism, and the response to that chal-
lenge. Combined with the anti-war and civil rights
movements of the era, the mood was one of social
and personal transformation and possibility. For the
parents and elders of the ‘sixties generation,’ whose
professional middle class identity depended on the
delayed gratification and norms of achievement
which had seemingly guaranteed their privilege, and
whose own ambivalence about the consumer lifestyle
had engendered fears of ‘softening’ and downward
mobility, the counter-cultural and politicized youth
of the sixties represented class betrayal and bred
fantasies of a ‘lost generation’ [20]. The repressions
perceived to be requisite for class success and cultural
stability, already feared to be weakened by post-
WWII abundance, appeared to be in jeopardy. When
middle class women asserted a new freedom from the
conventional boundaries of gender and demanded the
right to sexual pleasure, anxieties about ‘the family’
and unrestrained sexuality escalated. Additionally, as
if to verify the worst-case scenarios of cultural conser-
vatives, the gay liberation movement began to assert
its claims to rights and recognition and thousands of
men came out of the closet celebrating the pleasures
of the body and same-sex love.
The cultural movements of the 1960s and early
1970s were experiments in exceeding limits. The
‘sixties generation’ contested many of the externally
and internally imposed controls upon which conven-
tional selthood had been premised (even though
many of the terms of relationship to others remained
unexamined; and even though the experiments had
been made possible by the culture of cornmodified
pleasures which had come to compete with the ‘sur-
plus repressions’ associated with ‘performance’) [24].
Contrary to current conventional wisdom, the ideals
of self-discipline were never absent from the move-
ment (for all those who ‘dropped out’ how many
more ‘stayed in,’ trying to balance performance ex-
pectations with one or another aspect of the counter-
cultural lifestyle? And how many experienced
anxiety, ambivalence or guilt?). Significantly, health
and fitness consciousness, though politicized and
congruent with counter-cultural ideals, heralded an
early receptivity to the harsher climate of restraint
that would settle in as the seventies progressed. Still,
the challenge to conventional social and political
values set in motion the expected reaction. Ellen
Willis reminds us how much was at stake [25, p. 1301:
. . women’s chastity policed by the dubious promise of
male ‘respect’and lifetime monogamy, backed by the with-
holding of birth control and the threat of social ostracism,
sexual violence and exploitation, forced marriage and moth-
erhood, illegal abortion; men’s schizophrenia, expressed in
hypocritical ‘respect’ for the frustrating good girl and
irrational contempt for the willing bad one, pride in their
lust as the emblem of their maleness and disgust with it as
the evidence of their ‘animal natures’; homosexuality un-
speakable and invisible.
The response was immediate. Mobilizing around the
targeted symbols of ‘permissiveness,’ ‘promiscuity,’
and ‘perversion,’ the cultural right launched its coun-
ter-attack in the name of discipline and traditional
values. The backlash against gay liberation began
with Anita Bryant in 1977, and expanded to other
sexual and anti-feminist issues with the Moral Ma-
jority in 1978. Cultural conservatism lent critical
support to the election of Ronald Reagan, which in
turn spurred the anti-gay, anti-abortion, and anti-
drug organizing of the 1980s and early 1990s. More-
over, the continuing sexism of ‘liberated’ men enlisted
feminist opposition to the sexual ‘freedom’ that had
served to guarantee sexual access without genuine
mutuality or intimacy. Though limited by the “com-
mercialization of sex and the sexualization of com-
merce” [26], cultural conservatives had by the
mid-1980s made deep inroads into American media,
education, and other community institutions. Along
with the self-disciplining response to performance
demands and class insecurity, increasing numbers of
middle class men and women began to assert the
values of sexual restraint, a drug-free society, and
‘family life’*ven if they were yet unwilling or unable
to live them. The energy that had powered the
boundary-stretching politics of the now-ageing sixties
generation could not be sustained. Once again, health
provided a readily available symbolic terrain upon
which the new disciplined self would be re-made or,
at least, publicly displayed. Before AIDS had
emerged as the weapon-of-choice against sexual ‘de-
viance,’ herpes had been promoted as the ‘scarlet
letter’ of the 1980s; marijuana was re-framed as a
health issue; and a proliferation of newly identified
hazards instilled an atmosphere of danger and the
necessity for personal vigilance and control.
The somatic self-fashioning of the 1980s along
with the class-defining, moral regeneration it sig-
nified, formed the back-drop for the psycho-cultural
response to the AIDS epidemic. The spirit of self-ex-
perimentation had been derailed and it had been
replaced by a more sober mood of ‘getting down to
business’ and mobilizing personal (marketable) re-
 Reflections on health, culture and AIDS
sources. In the lexicon of American individualism,
people were re-visioning their task as ‘taking respon-
sibility.’ At the very time that the AIDS epidemic
appeared in the United States-an epidemic quickly
associated with deviant persons and excessive behav-
iors-health had reemerged as a moral discourse and
as a symbolic site for the affirmation of conventional
personhood. Encased in the rhetoric of self-control,
self-denial and individual responsibility, the pursuit
of health had become emblematic of a conventional
and approved self. HIV-AIDS was seemingly des-
tined to become a disease that signified the negation
of that re-fashioned self.
THE UNHEALTHY OTHER
Disciplinary society is perpetuated through the production
and deployment of the bifurcated self.. . One side of the
self-the site of the free, self-interested, rational, and re-
sponsible agent--endorses the norms of the order as its own
postulates of reason and morality; and when it breaks
one of the codes to which it has consented, it is worthy of
being held responsible for the infringement. The second side
is ‘the other’ in the self, which does not fit neatly into this
affirmative construction; it is the locus of wishes, feelings,
and desires that escape articulation. To give these impulses
verbal expression today is to translate them into the
language of therapy, medicine, psychiatry, and moral per-
versity. The other side of the self is also a site of political
control; for behavior that escapes the self-control of reason,
interest, and responsibility is located within categories that
require bureaucratic intervention to control, reform, or
prevent it [27, pp. 1061071.
The HIV virus has manifested itself in three constituencies
in the West-blacks, intravenous drug-users, and gay men.
The presence of AIDS in these groups is generally perceived
not as accidental but as a symbolic extension of some
imagined inner essence of being, manifesting itself as disease
[2& p. 81.
The modern, conventional formation of self and its
contemporary reformulations cannot contain nor ad-
equately allow for the expression of a range of
experiences that are increasingly positioned as out-
side the realm of the ‘normal’ or the ‘self-responsible
individual.’ As I have suggested, experiences that fall
outside the limits of legitimate selthood nonetheless
press upon those boundaries and, at least, implicitly,
bring them into question. Under certain social con-
ditions, one of which I believe to be the AIDS
epidemic, conflicts within and between identities are
intensified. The creation of an external other, people
and groups that are negatively stereotyped, deters
these conflicts from being openly and fully engaged.
The experienced discomfort of internal conflict is
temporarily resolved by devaluing, denying, and re-
pressing the proscribed or conflicted aspects of the
self and by recreating an imagined and seemingly
safer unity through externalization. Mosse, Volkan,
Gilman and others have written about the dynamics
of projection by which the other is imagined and
distanced from the self [29]. The social and personal
costs of this tactic in terms of stigmatization of
scapegoated individuals and groups as well as its
1355
utility for providing rationales for their subordina-
tion are relatively well known [30]. Less apparent are
the costs to the individuals who employ such de-
fenses: repression, fear and anxiety, self-hatred, and
a refusal to be open to potentially valuable experi-
ence.
In this section, I will explore the dynamic whereby
disease takes on the symbolism of a negation of the
conventional self understood as ‘healthy.’ The ‘epi-
demic of signification’ is a fear of a particular kind of
contagion, a fear that the boundaries which dis-
tinguish self from other cannot be maintained. The
mark inflicted by AIDS, other sexualy transmitted
diseases, and to a certain extent, all serious affliction
is an inscription of otherness. The visible component
of this otherness is the external object of abjection-
the ‘homosexual,’ the ‘addict,’ the ‘prostitute,’ or,
simply, the seriously ill. The dynamic force of other-
ness, however, is the projection of the internaI other-
experiences not permitted the recognition accorded
by identity. I am speaking about vulnerabilities-par-
titularly about disease, psychic disintegration, and
death-but also about desires, dependencies, addic-
tions, and a range of experiences that are either
excluded from legitimate selfhood or only tenuously
integrated within it.
The biomedically healthy self and the unhealthy other
In all cultures, critical illness represents a danger
both to the individual and to the social order and thus
is a symbolically charged event. For the healthy
individual, illness threatens to disrupt the everyday
activities, obligations and social roles upon which
identity largely depends [31]. Serious affliction also
threatens individuals with the prospect of varying
degrees of disorientation and loss of control, Not
least, the life-threatening shadow of illness sets in
motion a psychological defense. For Sandor Gilman,
this fear of death or dissolution and the defense it
engenders provides an explanation for why the
seriously ill person is so often seen as different:
It is the fear of collapse, the sense of dissolution, which
contaminates the Western image of all diseases, including
elusive ones such as schizophrenia. But the fear we have of
our own collapse does not remain internalized. Rather, we
project this fear onto the world in order to localize it and,
indeed, to domesticate it. For once we locate it, the fear of
our own dissolution is removed. Then it is not we who totter
on the brink of collapse, but rather the Other [29, p. I].
Thus, the individual’s fear of loss of control and loss
of life engenders a defense: a perception of the
afflicted as particularly susceptible due to their dis-
tinctive behaviors, emotional predispositions, social
or geographic environment, or unexplained suscepti-
bilities believed to be the property of groups. Death
is kept distant, far from the ‘natural’ or ‘normal’
vitality of the healthy self. Projection is a tactic of
self-reassurance. Susan Sontag’s well known essay
makes a similar argument. Thinking about illness in
metaphorical terms-metaphors which usually blame
1356 ROBERT CRAWFORD
the victim-is a way of taming death in a secular age
[32]. The statistical basis of attributions that connect
particular diseases to certain groups and behaviors
only gives an appearance that rational inferences are
at work. These connections, however, often resonate
with deeply ingrained, implicit meanings and power-
ful moral judgments. The sick are not only made
responsible for their illness, they are also made
different. The person who is momentarily free of
illness is thus reassured; s/he is not like those who are
sick. Thus, the tacit assumptions so frequently heard
in everyday conversations: “He has lung cancer.“/“Is
he a smoker?” or “He was injured in an auto
accident.“/“Was he wearing a seat belt?” “He has
AIDS.“/“Is he gay?’
The cholera epidemics of the nineteenth century
challenged the somatic security of the middle class (as
well as a bourgeois identity premised on the progress-
ive march of technology). Reassurance (on both
scores) was achieved, however, by the observation
that the hardest hit areas were the poor and over-
crowded districts of the industrial towns and the
explanation that inhabitants of such areas were surely
‘degenerate’ and thus responsible for their fate [33].
The logic offered to explain “why her” or “why
them” provides an answer to the anxious query “why
not me?’ or “why not us?” Conversely, displaying the
culturally sanctioned signs of health provides a sym-
bolic shield: “I am healthy. I am not vulnerable
because I do those things one should do in order to
be healthy.” The loss of health or simply the charac-
terization of a person as ‘high risk’ entails a setting
apart. Thus, the claim of health is simultaneously a
declaration of identity: “I am responsible and
rational.” “ I am in control of my body and my life.”
The healthy body is the property of a deserving
owner. Illness must have a reason located outside the
normal self-in deviance from the rapidly expanding
mandates for healthy behavior, in a fatal flaw of
character or personality defect, in an unconscious
predisposition toward illness, or in living a ‘high
stress’ life with poor ‘stress management.’ AIDS, in
its association with illicit drug use or an illicit,
promiscuous, or extra-marital sexuality, powerfully
reinforces this notion of health as the property of the
normal self. Undoubtedly, significant degrees of pro-
tection do, in fact, follow from these medical and
popular understandings. Yet, there is also a social
distancing from the ‘unhealthy,’ a further stereotyp-
ing of already stigmatized groups who then, because
of their ‘irresponsible’ habits, are confirmed in their
otherness. The healthy person who has come to invest
so much in her health buttresses her immunity against
illness by constructing a quarantine of identity
against the ‘unhealthy.’
If the sick and the ‘at-risk’ (those who are poten-
tially sick by virtue of behaviors or even group
membership) are made different as a defense against
one’s own vulnerability, the ‘contagious’ or ‘poten-
tially contagious’ represent the dangerous bridge over
which that psychological distance is portentously
closed. The afflictions of the other threaten to become
one’s own. I may become an ‘innocent victim;’ or
another ‘innocent victim’ may become the source of
infection that may reach me. Thus, contagious dis-
eases threaten to ‘break out’ of their imagined ghettos
and enter the presumed zone of safety-designated,
in respect to AIDS, as the ‘general population.’ The
attempt to confine ‘contagion’ within its presumed,
originating groups becomes the rationale for calls for
quarantine, immigration controls, and incarceration
of ‘reckless’ or ‘willful’ individuals. With serious,
contagious disease, the source is still the other who by
his/her (im)moral nature lives in such a way as to
pose a physical threat to those who would not
otherwise be ‘exposed.’
Gilman may be right that denial and repression of
physical and psychic disintegration and projection of
vulnerability onto an other is a universal human
process. There are strong reasons, however, for be-
lieving that the concept of health as it has developed
in the modern West reinforces this psychological
defense. Robert Romanyshyn has argued, for
example, that the Cartesian objectification of the
body distances the body from the experiencing self-
or in Barbara Duden’s terms, one comes to ‘have a
body’ rather than ‘be a body’ [7]. Did the ‘re-birth’
ascribed to the Renaissance initiate a massive forget-
ting, an attempted separation of self from the embod-
ied experience of decline and death? Romanyshyn
suggests that transforming the ‘dead’ body, which
was a body of remembrance, into a ‘corpse,’ the body
of science, changed our relation to death. The scien-
tific objectification of the body constituted an epis-
temological flight from the body of experience, an
experience of life and death, vitality and decline.
Through the epistemology for which the health of the
body would become the crowning achievement, the
figure of death was to be banished from a place in life,
a figure with which one came to terms, to a figure on
the other side of life, to be tamed and defeated. Was
this the first step, Romanyshyn asks, toward the
modern wish of life without death, a life where death
is most easily imagined on the other side of a
television screen? Or as Illich has put it [34], has
modern culture adopted a medicalized belief in a
‘natural death’-a life without illness or decline until
the very end when one allows the care-takers to pull
the plug? Illich refers to a ‘cultural iatrogenesis’
whereby a medicalized health undermines the cultural
and individual capacity to embrace and respond to
pain and suffering. Health has become the expression
of a technological dream and serious illness has
increasingly become the shadow world of that dream.
The guardians of the divide between life and death
are medical experts who ensure, with our responsible
cooperation, that we do not cross the boundary until
finally we must-and even then the crossing will be
facilitated by the new therapeutic technologies [35].
Unable as a culture to maintain a close proximity to
 Reflections on health, culture and AIDS
illness, decline, and death, we are unable to mirror
our own fate. No longer living ‘toward death’ but in
a flight from it, the healthy self mobilizes all available
resources to fend-off the threat of dissolution. The
unhealthy then come to represent the inevitability we
would deny. They disturb the dream of technology
and its promises of health delivery. In the unhealthy,
the seculr meliorism of a technical and scientific
world view confronts the reality of failed systems of
management and control. As the ritual of rational
control moves ‘upstream’ toward prevention (in the
face of increasing doubts since the mid-1970s about
the therapeutic and economic efficacy of ‘down-
stream’ medical interventions), the unhealthy, labeled
as complicitous in their fate, and said to compromise
the physical and economic well-being of all, are
further stigmatized as obstacles to the achievement of
health. And since the citizens of the healthy state are
already and always complicitous as well, the stakes in
differentiating the healthy self from the unhealthy
other are all the greater.
One might reasonably doubt, as does William
Arney in a personal communication, whether the
healthy self must necessarily oppose itself to an
unhealthy other. The notion of risk and the elabor-
ation of degrees of deviation from a norm, writes
Arney, turns people into individuals with risk profi-
les. We all become deviants all the time and thus
become the objects and subjects of ‘risk manage-
ment. ’ “There is a constant threat that the ‘other’
may be ‘us’ (me!). . . . The problem is not that the self
is forcefully limited; the problem is that the self in
these times, has shown itself to be potentially limitless
and then there is serious question of what to do about
that” [36].
In contemporary health promotion discourse, the
healthy self is portrayed as a composite of risks-be-
haviors, ‘life events,’ and a host of other stress
factors. The new health consciousness is, on a practi-
cal level, a response in part to this risk awareness. The
healthy individual has, in a sense, been converted into
a person who is potentially sick, even well on the way
to becoming sick. Medicine has expanded the mean-
ing of illness beyond clinical manifestation of symp-
toms and therefore the boundary between health and
sickness has become blurred. The ‘at-risk’ self is
vulnerable; and responsibility is currently said to
consist of a willingness to monitor, confront and do
something about that vulnerability. This is precisely
what is mandated in the countless programs of
risk-assessment and risk-management undertaken by
public and private employers worried about the costs
of medical care and worker productivity.
Yet, if individuals are assessed at varying degrees
of deviance from the norm, it is the norm itself that
is thereby strengthened. Deviance within the self must
be managed. Individuals with high-risk ‘profiles’ are
identified and reproached not only by medical prac-
titioners but by employers, colleagues, friends and
family. The behaviorally ‘unhealthy’ are, with in-
1357
creasing frequency, excluded from the workplace.
Deviance, constantly articulated about the self, be-
comes the opportunity for a social and self-disciplin-
ing. The self as a composite of risks is the
contemporary extension of the self as defined by the
parameters of ‘health’-in both is denotative and
connotative senses. That deviance from a norm of
health is now characteristic of the self and not just the
other does not point to a loss of identity in the
healthy self nor a diminution of stakes in defining the
healthy self in opposition to an unhealthy other. The
other just becomes the person who, unlike self, does
not properly manage risks once they (the risk and the
person) are identified. Risk awareness becomes the
opening gambit of a ritual which, in revealing dangers
and simultaneously what must be done to protect
against them, affirms the rational control which lies
at the heart of technological culture and which claims
the identities of its most ‘progressive’ members. Risk
consciousness increases the healthy anxiety for which
risk management offers its healthy solution. The
ritual thus distinguishes the responsible from the
non-responsible individual.
Thus, I would argue that this discourse of insecu-
rity, with its proliferation of threats and the somatic
vulnerability it imparts, triggers an even greater
defense. As the ‘mirage of health’ begins to lose its
clarity, as the medical promise of a somatic salvation
recedes, and as antibiotics are no longer able to
provide a cordon sanitaire against the re-emergence of
life-threatening epidemics, healthy identity comes to
depend even more on strategies of opposition. ‘Bor-
der anxiety’ demands a strengthening of immunity
(distinction of me from not me) and the mobilization
of personal resources so that the individual can
remain within the boundaries of normality. I am
suggesting, in other words, that in a risk-conscious
era, the ‘healthy’ self develops an even greater invest-
ment in the delineation of boundaries: between
‘reasonable’ risks and ‘unreasonable’ risks, between
those who have an ‘internal locus of control’ and
those who have an ‘external locus of control.’ If the
biomedical individual has become an at-risk individ-
ual, the social self is also at-risk. The unhealthy,
risk-averse person sets a bad example. The out-of-
control individual is also one of the causes of out-of-
control medical costs. As if to prove the case, the
emergence of a deadly, sexually transmitted disease in
epidemic proportions extends the moral lesson: the
sick suffer their fate because they have a fundamen-
tally different ‘risk portfolio,’ and, unlike me, they
belong to a ‘risk group.’ The Spector of contagion
only reinforces this sense of difference. The ‘epidemic’
is no longer a relic of the pre-antibiotic past or the
tropical or the African present; it is in ‘our’ midst-or
at least threatens to be. The entire notion of where the
boundary is to be located (present/past, here/there)
must be reformulated and the new delineation is
much closer to home.
With respect to border anxiety, AIDS as an im-
1358 ROBERT CRAWFORD
mune system disease is doubly threatening. Not only
is it an epidemic against which defenses must be
mounted, HIV is a contagion that undermines de-
fenses. The idea of resistance is essential to the notion
of a ‘healthy self.’ Immune system strength is the last
line of defense; avoidance having failed, it is the
defense that comes into play upon ‘exposure’-the
very exposure, for example, that the continuous,
medical-media identification of hazards has im-
planted in the health conscious middle class. Perva-
sive hazards do not permit avoidance. When I
interviewed people in the early 1980s-on the cusp of
public awareness of the AIDS epidemic-‘good re-
sistance’ or its lack was frequently identified as a
quality that helped explain health [18]. While for
some, resistance seemed to be fixed or solid, for
others it appeared to be variable, a flux that was
related to personal experience and other personal
qualities. Immunity could be compromised: in
periods of stress, if one allowed oneself negative
attitudes, if one did not stay on course with the
proper diet, if one did not control one’s Type A
inclinations etc. The concept of individual suscepti-
bility has likely always been present in one form or
another, but in the age of immune system disorders,
the biological self is susceptible to a Trojan Horse.
The source of danger has shifted to a new locale:
inside the ‘fortress body.’ The immune system is the
heart of the individual’s ‘control system.’ A compro-
mised immunity is a compromised self-a self that is
‘open’ to infections which are described as oppor-
tunistic. As Donna Haraway has argued, immune
health and immunity enhancement have become key
health strategies. The goal is to strengthen the inside
against the outside, self resources against threats
posed by the other [37]. Citing an immunology
textbook, subtitled “The Science of Non-Self Dis-
crimination,” Haraway writes that the author
“defines ‘self as ‘everything constituting an integral
part of a given individual.’ What counts as an
individual, then, is the nub of the matter. Everything
else is ‘not-self and elicits a defense reaction if
boundaries are crossed” [37, p. 301. HIV, in targeting
and ‘killing off cells of the immune system, is easily
imagined as the supreme threat to the ‘healthy’ self.
The unhealthy other in the person of an HIV ‘carrier’
is conflated with the other within in the form of a
compromised immunity. Without immunity the self is
overrun by other. The fantasy is one of ultimate loss
of control and loss of self.
Finally, there is yet another aspect of illness which
gives additional impetus to the attribution that the
sick are different. Serious affliction also poses a
danger to the social order. The disorientation of the
individual is simultaneously a disordering of social
relations: social roles are not performed, obligations
are not met, medical care may be costly, and the sick
may require extensive care giving, especially by family
members. The ‘deviance’ must be controlled. More-
over, as Michael Taussig emphasizes [38], “the every-
day routine of more or less uncritical acceptance of
the meaning of life is sharply interrupted by serious
illness.” There is a ‘destructuring’ of conventional
understandings. What, the afflicted person tends to
ask, are the personal, social and moral implications
of my misfortune? Why me? Why now? Illness fosters
a crisis of self-definition and in so doing raises
questions, despite the naturalizing categories of
biomedicine, about the adequacy of the conventional
structures and expectations within which that self had
previously functioned. Life-changing illness can un-
dermine acquiescence to difficult and oppressive life
situations, even if only in the form of providing an
exit or a defense against them. That which is normally
tolerated may become untenable, the illness becoming
a symbol that life as previously lived in no longer
bearable. Healing practices, including biomedicine,
act as agents of re-socialization, employing diagnostic
explanations and therapeutic strategies to focus and
deflect problems in system-enhancing directions. In
epidemics, the dangers posed by the dislocation of
experience and social life are magnified. Latent social
and political tensions may be exacerbated and resent-
ments activated. Public authorities are often held
accountable for the spread of the epidemic and
resisted when they impose extreme measures of con-
trol. So volatile are existing social arrangements and
so enormous are the economic and political stakes
threatened that the word ‘epidemic’ is itself frequently
a matter of contention [39]. The ways in which
modern medicine conceives and treats illness through
categories that both reproduce and insulate existing
social relations (and their ideological premises) has
become an important line of inquiry in critical medi-
cal anthropology [40].
What should be apparent is that at both individual
and social levels, there are strong motivations to
represent the sick as different. For the social order-
that is, the configurations of power which dominate
its institutions and shape its social relations-the
defensive move is one of deflection of social prob-
lems, tensions and resentments away from their struc-
tural social source and on to the pathologies of
individuals and groups. It is the disinherited and the
marginalized of any society, after all, who suffer
most, psychically and somatically, from the pathol-
ogies of social organization. For individuals the
defensive move it not only a denial of vulnerability
and loss of control. The preservation of existing
social relations is at the same time a preservation of
individuals’ privileged place within those relations.
Though the moralization of health promotion has
substantially increased among the middle classes
since the mid-1970s [41], the stigma of ‘self-induced’
disease and unhealthy behavior is more likely to be
modified among individuals who share a common
social space. As social distance widens, however,
attributions of self-destructive disregard and irre-
sponsibility also increase, even if couched in a
language of victimization from a destructive social
 Reflections on health. culture and AIDS
and physical environment. Such judgments easily
converge with other victim-blaming ideas about the
poor and marginalized. ‘High-risk’ and its pathologi-
cal consequences are ascribed to individuals who,
unlike the privileged, are ‘locked’ into ‘cycles’ of
deviance and self-destruction. ‘Their’ very existence
as ‘self-inflicting’ agents becomes a screen for the
projection of a putatively self-reproducing social
world. The imagined distinction serves the socially
sanctioned identity of health, responsibility and priv-
ilege and the reassuring belief in their mutual re-
inforcement. The otherness of the sick or the
high-risk individual is, in short, a boundary maintain-
ing device that serves multiple agendas.
The metaphorically healthy self and the unhealthy
other
Given the complex fears and motivations aroused
by serious illness, it is also important to consider how
affliction is mobilized symbolically and utilized in
sustaining the ‘healthy’ self as an identity which has
been metaphorically encoded and ariculated with
class, race, gender, and sexual identities. In the first
section of this paper I argued, in effect, that modern
social life has narrowed the prescribed boundaries of
selfhood, even as it has, paradoxically, appeared to
widen them. The transformations worked upon and
within the person have gradually restricted permiss-
ible, bodily expressions in ways that roughly corre-
spond to the ideal of the self-contained and
self-controlled individual. In order for the individual
to obtain social recognition and acceptance appropri-
ate to privileged social position, and thus to some
degree maintain a secure and stable sense of identity,
the non-conforming aspects of the experiential self
must be repressed-or at the very least limited to
relatively safe, approved, ritualistic expressions of
release in socially designated times and places-for
example, holidays, period of acceptable inebriation,
Christmas shopping, or the vicarious releases pro-
vided by televised violence through war, sport, and
drama. As the surveillance of the village and church
has declined, the individual has been increasingly
expected to scrutinize him/herself. Such self-scrutiny
is said to be constituent of modern, individual auton-
omy and freedom. As disciplinary methods are ex-
tended, indeed as an essential mode of such methods,
self-policing becomes an expected behavioral prac-
tice. My thesis has been that both historically and
since the 1970s health consciousness and practice can
be understood in part in terms of its metaphoric
capacities for these self-disciplining requirements.
A culture of self-surveillance, however, is unable to
maintain requisite identities by purely self-referenced
and self-enhancing projects such as the ritualistic
evocations of control that punctuate middle class life.
Cultures continually preoccupied with policing the
boundaries of legitimate selfhood become equally
obsessed with persons that do not conform to the
mandated categories and, in fact, develop an even
1359
greater stake in creating persons who represent trans-
gressed boundaries. These cultures tend to develop a
fear, fascination, and sense of horror of the other-a
non-self who is believed to assume all of the charac-
teristics antithetical to conventional selfhood.
Howard Stein [42] argues that this culture’s preoccu-
pation with alcoholism and the alcoholic is precisely
this kind of cultural drama, the other side of a
cultural immersion in control and various escapes
(including alcohol) from control. The alcoholic is
characterized as a person who has lost control, who
has in a sense been ‘possessed’ by a substance that has
stolen the controlled self. Similar insights can be
applied to the current ‘war’ on drug addiction. Thus,
crucial to the boundary-maintenance work of any
system of hierarchical categories of persons is both
the affirmation of the distinctiveness of the relatively
dominant groups and the identification of defiling
signifiers of subordinate group status. Defiling per-
sons must be made conspicuous in ther defilement.
Pollution (symbolic contamination by a person or
thing) is the first act in a drama of purification
continually acted out in behalf of sustaining individ-
ual and group identities. The danger of the other
proliferates to the degree that dominant identities
themselves are volatile or otherwise threatened [43].
Once again, projection onto an other of incompatible
and denied aspects of personal experience provides
the means by which group identity and cohesion are
secured. Self needs other.
It is my contention that the ‘diseased’ and ‘conta-
gious’ other, the sexual other, and the addicted,
minority other-all condensed in the negative sym-
bolism of AIDS-have become key images which are
mobilized as part of a cultural politics of reconstruct-
ing the self in conformity with intensified mandates
for self-control. As health becomes a medium for
expressing what is believed to be essential about the
self, disease-which has always been employed as a
device for stigmatizing outsiders-increasingly comes
to signify otherness within the self. Those aspects of
personal experience no longer in conformity with the
mandate for ‘health’ (read self-control) are split off
from the self and projected onto the identity of the
other. Just as the sick are perceived as essentially
different, lacking the discipline and will power to
maintain or restore health, people who are character-
ized for other reasons as lacking self-control (homo-
sexuals, addicts, minorities) are also perceived as
diseased or as agents of disease. When, as in the
AIDS epidemic, people who already carry the stigma
of undisciplined sexuality and addiction, become sick,
and moreover, when the disease they suffer is conta-
gious, the two forms of otherness are dangerously
combined. The subordinate or marginalized other is
culturally situated both as a physical danger to the
healthy individual and as a symbolic danger to the
social self. Disease in the already stigmatized other is
the embodiment of a moral pollution. The self thus
acquires-in the body of the other-a ‘natural alibi.’
1360 ROBERTCRAWFORD
A twin danger is then posed against the two-fold
purity of healthy morality and moral health. Projec-
tion is most effective when corporealized just as
disease is most dangerous when it carries the signify-
ing power to ‘spoil’ identity. The symbolic conden-
sation of disease and otherness suggests the more
general association, in Sandor Gilman’s phrase, of
“difference and pathology” [#I. Gilman’s explo-
ration of this connection has been highly suggestive
for me. The location of ‘pathology’ in stereotyped
others not only deflects attention from the pathol-
ogies of self and social system; the pathologized other
becomes useful as a threat. Thus, in externalizing the
problem in the stigmatized individual or social group,
the ‘normal’ self is defensively opposed to the ‘patho-
logical’ other. ‘Pathology’ externalized, in other
words, does not eliminate danger; the threat is merely
displaced. As an external threat, pathology becomes
contagious. This is what I take to be Watney’s point
about why ‘heterosexuals’ need ‘homosexuals:’ as a
pathologized deviant, the homosexual is an ever-
threatening presence against whom a wall of exclusion
must be constructed [28].
In a society where people are preoccupied with
control and anxious about its loss, contagion carries
a heavy symbolic load. Contagion is the opposite of
control. It evokes images of violating boundaries,
wildness, and nature untamed. In contagion, cat-
egories are shattered. If the symbolic logic of health
suggests purification, locating threatening elements to
the outside, then disease, along with associated im-
ages of contagion, provides a model for all feared
threats. The pure inside is contaminated by the
impure outside. The Jew in anti-Semitic ideology, for
example, has alternatively been perceived as a carrier
of disease and a ‘germ’ contaminating the social
body. Throughout the nineteenth century, the indus-
trial working class was perceived by the bourgeoisie
as both a moral and physical threat. In the United
States, the notion of working class contamination
was amplified by the imagined corruptions of foreign
immigrants and the industrial city, combined in the
figure of “the teeming masses” [45]. Working class
districts were imagined as caldrons of disease result-
ing from physical degeneration, filth, overcrowding,
immoral conduct, and ignorance. Along with the fear
of imminent revolt and retributive violence, the re-
spectable also feared for their health. Similarly, since
the late nineteenth century, homosexuality has ac-
quired an association with disease. Not only have
homosexuals been seen as agents or carriers of dis-
ease, they have also been both medically and popu-
larly categorized as sick. As the control of sexuality
became a preoccupation for the middle class family,
sexual deviations became more threatening. Notions
of pathology were thus linked to pre-existing con-
cepts of contamination, such as predation, moles-
tation, and seduction, The authority of medicine was
(and continues to be) employed to identify homo-
sexuality as fundamentally different from ‘healthy’
sexuality. Homosexuality was then linked with other
sexual and psychiatric deviances by way of imagined
causative chains. Only under political pressure did the
American Psychiatric Association formally de-medi-
calize the disease of homosexuality in 1974 [46].
Further, both ‘prostitutes’ and unescorted women
(especially black and working class women who were
often stigmatized as prostitutes) were and are dispro-
portionately punished as carriers of disease. Also,
middle class women of the late nineteenth and early
twentieth centuries were perceived as either sickly or
prone to sickness, particularly madness. Women of
any class have periodically had their sexuality and
their putative seductiveness portrayed metaphorically
in terms of disease [47,29]. To enclose culturally
threatening behaviors and persons in the language of
health is to lend legitimacy to their surveillance and
regulation in the modern, secular order.
The pathologized other is fantasized not only as
diseased but also as dangerously sexual. Gay men,
Native Americans, Africans and African Americans,
Jews, the working class, the poor, and women have
all been periodically characterized as hyper-sexual
and deviant [48,29]. Sexual excess, perversion, and
seduction provide compelling symbolic media for the
guardians of sexual and political order. The other is
thought to be inherently dangerous-which is pre-
cisely the reason for his/her sexualization. Outside the
reach of the familiar, traditions of deference, and nets
of surveillance, the other is imagined as inhabiting a
dark world of secrecy and conspiracy. What better
conditions for prolific sexual fantasy? The chain of
associations leads from violence to sexuality and back
again. Like contagion, sex is associated with the
violation of boundaries: the social self is penetrated,
contaminated, and diluted by proscribed identities. I
believe that Freud’s insight still holds: an undifferen-
tiated, ‘polymorphous’ sexual drive is only imper-
fectly forced into object choices that conform to the
cultural determinations of gender and is subordinated
to the culture’s demands of repression only with
considerable emotional costs to the individual. One
response to these costs is a projection of what is
experienced as an internal danger onto a sexualized
other.
Projection occurs not only because the individual
experiences an unacceptable sexuality but because
since the nineteenth century sex has come to represent
a force undermining the bourgeois’ preoccupation
with ‘control over the world.’ Thus, the projection of
sexual danger is, as Gilman argues, a distancing move
whereby anxiety about loss of control over diffuse
aspects of the world and one’s experience in it are
metonymically condensed and discharged. The other,
already represented as outside the domain of control,
already dangerous, is thus identified as over-sexed: by
nature, homosexuals are pederasts, women
temptresses, and black men rapists. The internal
struggle for control has its external location precisely
because within the social order control is also at
 Reflections on health, culture and AIDS
stake. Sex, as a force in opposition to control, reveals
the true nature of the other, it becomes the other’s
insignia. Like disease, then, sexual deviance (the sex
of the other) has immense utility for the regulation of
subordinate groups. Sexuality provides the ground
for a pervasive danger, for magnifying the inherent
threat of the other, and for mobilizing highly charged
components of personal and group identity.
Since the nineteenth century, the sexualization of
self and other has become medicalized [49]. Sup-
ported by the science of sexology, a new medical
surveillance began to specify its object on a detailed
grid of deviations. Contingent pathologies were then
elaborated: infertility, madness, social failure in one’s
designated role, etc. Sanctioned by medical authority,
the family extended its internal supervision, purity
crusaders and social workers ‘reformed’ the lower
classes, and an increasingly active state extended its
legal and administrative control over sexuality. A
proliferating medical advice literature linked health,
male success, and female reproductive responsibility
to proper sexual conduct. Later, sexual ‘health’ was
introduced into school curricula [48,49]. By re-fram-
ing sexuality in terms of health and disease, social
authorities were able to employ the commanding
legitimacy of medicine for the construction and en-
forcement of the normalized self, that is, a self
increasingly bounded by the disciplinary and self-dis-
ciplinary mandates of the modern era. In this way,
homosexuality was pathologized as disease and as a
predisposing cause of disease; homosexuals were sim-
ultaneously positioned as transmitters of disease. The
threat to health and the threat to the social self were
thereby fused and magnified.
Since both disease and an excessive and deviant
sexuality are said to characterize the other, their
combination in the representation of sexually trans-
mitted diseases engenders a compelling symbol of
danger. From the close of the fifteenth century,
sexually transmitted diseases have become the terrain
upon which fantasies of cantagion originating from
already stigmatized groups and various policies of
containment have been constructed. Social historians
have extensively explored the relationships of class,
race, gender, medicine, and morality in the control of
sexually transmitted diseases. Allan Brandt, for
example, has shown how the languages of medicine
and morality have never been divorced in the preven-
tion and treatment and how in the United States
thousands of women were incarcerated in and im-
mediately after WWI in response to an imagined
“enemy at home” [47]. Dorothy and Roy Porter and
Judith Walkowitz have documented how the British
Contagious Disease Acts of the 1860s (later repealed)
targeted prostitutes and other women in a period of
moral panic about venereal disease [SO].James Jones
has described the syphilis experiments using black
sharecroppers and day laborers at Tuskegee Univer-
sity between 1932 and 1972 and the racist beliefs that
justified them [51]. Much of Sandor Gilman’s work,
1361
cited above, has provided iconographic evidence of
how syphilis and the ‘syphilitic’ have been key mark-
ers of otherness-lower class women, Jews, homosex-
uals-and how these images are currently extended to
people with AIDS. The perceived threat of deviant
sexuality is attached to disease and is conveyed by it.
The threat is to physical and moral well-being, to
healthy bodies and persons-and by extension, the
health of the family, the health of the ‘race,’ and the
health of the nation. The danger is heightened since
the homosexual or the ‘loose’ woman is close to
home, difficult to identify, and imagined as seeking
out the momentarily capricious, who then unwit-
tingly become agents of infection. Sexuality and
disease combined present a formidable adversary to
the images of control upon which modern identity is
founded. ‘Sexually communicated’ is an attribution
which signifies illicit association and thus provides a
powerful reinforcement for all forbidden associ-
ations. Thus, in the present epidemic, not only mis-
trust of medical authorities is at work in the fearful
imaginings of transmission of HIV from mere prox-
imity to suspected ‘carriers’ or even to the places they
may have been (including neighborhoods and entire
cities); ‘innocence’ is a demonstrative act by which
identity is purified in the name of prevention. ‘Safe
sex’ become safe association becomes a safe self.
If the individual were, in fact, safe in the sense of
experiencing himself and his world within flexible and
secure boundaries of identity, the threat of contagion
would perhaps not carry the double symbolic load I
have been suggesting. However, this cannot be the
case when the contemporary cultural mandate for
self-disciplining proscribes experiences and pleasures
which since the 1960s have become so widely shared.
PLEASURES AND DENIALS
Neither self-concept nor self-awareness are deter-
mined by a single, dominant voice. The prevailing
mandates for legitimate selfhood, issuing from vari-
ous social institutions and interests, may themselves
be splintered. Multiple and conflicting prescriptions
can be a source of anxiety for individuals as they
attempt to negotiate the situational appropriateness
of such directives. Potentially inappropriate behav-
iors and experiences that reflect upon the self must be
continuously managed. This is where projection be-
comes so useful. The other is said to display and
express those attributes promiscuously, unrestrained
by good character or adequate ego controls. Through
ascriptions about the excessive or out-of-control
behaviors of the other, conflicting mandates for
appropriate selfhood can be integrated, albeit provi-
sionally. The integrity of the social self is thus
protected.
I will address my remarks only to one structural
source of such conflicting self-definitions: the necess-
ary creation of a self that, at least at the moment of
commodity-directed desire, must abandon the very
1362 ROBERT
CRAWFORD
foundations of control on which it normally relies. I
want to suggest, in other words, that the self in
contemporary American culture is defined in part by
a tension between a configuration of meanings and
values that cluster around the symbol of control and
another configuration premised on release from those
controls. In the latter, identity depends on pleasures,
the satisfaction of desire, play, gratification, and
extricating oneself from the interdictions of a “renun-
ciatory moral demand system” [52]. Here, the social
self is one that must be filled by acts of continuous
consumption and the enjoyments of ‘lifestyle’ and
‘leisure.’ The consuming self, however, coexists with
a self that can only be realized through satisfactory
performance and its attendant psychological and
moral qualities, a self still rooted in the realm of
production and the moral demands of work.
The postponed gratification and self-discipline as-
sociated with the Protestant work ethic and an indus-
trializing capitalism have been forced to make room
for their antithesis. Immediate gratification and the
proliferation of desire have become indispensable to
advanced capitalist society. The flow of commodities
requires an entirely new psychology, one that Jackson
Lears has called ‘therapeutic’-a sense of well-being
tied to the purchase and use of commodities. Modern
selthood is thus constituted as much by the pursuit of
diverse pleasures as by their denial, a ‘fun morality’
as much as a morality of applied effort. Moreover, as
Judith Williamson argues, advertising provides a
prolific array of images with which, in our hunger for
a differentiated yet group-identified self, we can ident-
ify by way of purchase, possession and use [53].
The intra-psychic tensions between these two forms
of identity-founded on the separate yet interlocking
terrains of work and consumption-have never been
resolved, despite claims about their complementarity
and the persistent attempts in everyday life to mediate
their contradiction. Contemporary Americans are
caught between these two cultural mandates, each
insisting on a complaint modal personality. The
uneasiness is fed by a continuing ambivalence about
a consumption-oriented life and guilt about ‘ex-
cesses.’ The reform of leisure has been a recurrent
theme throughout the nineteenth and twentieth cen-
turies [54]. Intellectual, religious, and political com-
mentary continues to focus attention on the
‘declining’ work ethic in American society-the ‘dis-
appearance’ of traditional values, the ‘softening’
effects of abundance, the alleged ‘deterioration’ in
workers’ willingness to work dutifully and diligently
for their employers. I want to suggest that one of the
effects of the deepening ambivalence about the
leisured, pleasured, and sexualized ideals of modern
consumption is an attempted reformulation of the
self towards the ideal of control. Several possible
explanations come to mind.
First, the work ethic is more deeply ingrained than
is generally acknowledged. The kind of work a person
does and how good he or she is at it are still among
the most important markers of identity, all the more
so as the social value of the work performed in-
creases. For the professional middle class, delayed
gratification and internalized demands for sustained
productivity and achievement continue to be defining
characteristics [20]. Second, experiences of disap-
pointment, emptiness, and a continuing hunger for
meaning associated with a high consumption lifestyle
are probably more widely felt than is openly acknowl-
edged. Third, an emerging awareness of the necessity
for ‘limits’ has accompanied the increased commit-
ment to environmental protection and the widespread
apprehension about industrial health hazards.
Fourth, as previously discussed, in the 1980s a
compelling, conservative ideology gained credibility
which identified permissiveness and excess as the
cultural source of problems as diverse as marriage,
the family, adolescence, downward mobility, and the
destruction of community. Permissiveness was
claimed to be responsible for declining standards and
performance in the public schools, for rising crime
rates, and for a ‘failed’ welfare policy which under-
mined motivation for work and self-improvement.
Finally, ambivalence about a consumption-ori-
ented lifestyle has been deepened by the reactivated
mandate for discipline and control. This mandate,
and the class vulnerability through which it is so
readily internalized, induces dissatisfaction with those
parts of personal experience and desires that continue
to fall outside the new requirements for a more
disciplined self. The revitalized mandate for a
disciplined self, however, comes up against the re-
quirement for self-conceptions and personal predis-
positions compatible with continuous consumption.
The social contradiction between production and
consumption and the conflict within individuals issu-
ing from it are not easily resolved. The managers of
production and the managers of consumption con-
tend in shaping the identities of modern men and
women. A disciplinary mandate derived from a re-
industrialization agenda must still make room for
that ‘gorgeous variety of satisfactions’ without which
the whole edifice of production would collapse. The
decades devoted to building a consumption ethic, of
engendering diverse needs and pleasures and tying
these to a repertoire of cornmodified wants cannot be
easily reversed-and neither will the efforts of a
generation to break through the limitations on self-
and sexual expression. Contemporary Americans are
attached to the pleasures.
While there are numerous ways to persist in enjoy-
ing one’s pleasures in the midst of a disciplinary
restructuring, the internal tension must somehow be
managed. The discordant elements of the self may be
experienced as an increasing source of discomfort and
even self-disparagement. Previously acceptable parts
of the self may now be felt to be out of sync.
Individuals must now attempt to delineate between
desires presently held to be illegitimate and those that
are still said to be authentic and to repudiate those
 Reflections on health, culture and AIDS
that are currently targets of social disapproval. The
present mandate, it should be stressed, does not call
for a banishment of desire nor a suppression of
pleasure. If anything, the effort to expel inappropriate
desires intensifies authorized ones. The reverse is also
true: the ‘need’ to retain legitimate desires for both
social and individual ends intensifies the need to expel
desires that are held to be illegitimate. The contradic-
tion in social structure and the conflict in personal
experience compel acts of purification, a purging of
the illicit.
Health has provided a symbolic domain through
which this tension is expressed and negotiated. Illegit-
imate desires are clearly those which threaten the
body-and, increasingly, the fetus. The effort to
expunge pleasures in the name of health has become
a self-directed and peer-pressured preoccupation of
the middle class. But the effort falls short. Will power
is lacking; time is not available; stress induces back-
sliding; addictions are difficult to break. My point has
been that health promotion is the physical location of
a much broader mandate for control. What then,
becomes of these self-judgments about not being
good enough, responsible enough, or ‘healthy’
enough?
There is, of course, no simple answer. Many Amer-
icans may simply reject the moralized demands for a
more disciplined self. Others might find themselves
unable to integrate the conflicting mandates and
alternate between each, mobilizing disciplinary re-
sources during the week and “waiting for the week-
end” for “deserved” enjoyment [%I. My point is that
there are strong motives to conform at least publicly
to the new mandates and thus to externalize the
experienced conflicts. ‘Unhealthy’ others take on the
burden of the lack of control and the inevitable
failures of ‘responsible’ behavior. It is ‘they’ who, in
not taking responsibility, deserve the diseases they
contract and ‘spread’ their afflictions to ‘innocent
victims.’ The gay subculture with their ‘fast lane’
lifestyles, the underclass of the ghetto with its addic-
tions, the blue collar worker polluting the air with
cigarette smoke, the overweight incapable of denial,
are not only the pariahs of the health conscious; they
are the embodiment as well of an otherness signifying
lack of control. The image of gay sexual excess
functions not only as a projection of all that has gone
wrong with the ‘sexual revolution,’ but also of the
barely repressed desires that, having been activated
and repeatedly incited, continue to seek expression.
The image of the sociopathic drug addict ‘feeding’ his
habit reveals a middle class disquiet with its own
dependence on commodity-driven pleasures-a life-
style that ironically includes similar dependencies on
pharmacological aids for pleasure, elevating mood,
reducing anxiety, aiding in sleep, amplifying pro-
ductivity, and easing the transition to ‘off-hours.’ The
prized internal locus of control so essential to middle
class identity is fashioned at the expense of a censured
and disparaged other, blamed for his own demise and
1363
isolated so as not to morally infect the healthy self.
The repressed will always return-but in disguise: in
the stigmatization of an other who is assigned the role
of scapegoat for internal conflicts and self-judgments.
In such a culture, ‘sexually-deviant,’ ‘inner-city ad-
dicted’ and ‘unhealthy’ others will serve unexamined
agendas, both personal and social.
CONCLUDING REMARKS
If contemporary American culture draws a circle
too narrowly around the legitimate self, deviance
from which is thought to be irresponsible, unnatural,
ungodly, out-of-control, or sick, that which falls
outside the circle does not simply disappear. As I
have suggested, there is much in personal experience
and imaginative life that traverses such arbitrary
borders. To the extent that individuals are unable to
integrate ‘unruly’ experiences into self-concept or
permit them acceptable expression, they will likely be
denied, repressed, and projected. Narrowly bounded
persons will symbolically and literally push away
individuals and groups that represent what they reject
in themselves. The suffering of this other will be
neither recognized nor embraced. The misfortune of
the other will be of no concern because they are
persons outside that collective circle of identity called
community. Todorov reminds us that in demanding
identity, that is, in excluding, subordinating or stig-
matizing difference, a community remains closed; in
such a community, difference will be treated as a
transgression and cannot be permitted equality [30].
Moreover, the social and physical harm these others
endure may be seen as deserved, a mark signifying
their fundamental inferiority or their incurable devi-
ance. Anti-gay and anti-black forces are able to
exploit such sentiments. These dangers are real and
immediate. The symbolic power of a “contagion’
seemingly on the verge of ‘breaking-out’ of America’s
social and cultural ghettos provides fantastical ma-
terial for punitive reaction. The preoccupation with
self-protection-which I have argued is simul-
taneously physical and psychological, a defense of the
body and the social self--engenders fear and hostil-
ity.
An overly controlled, repressed, and vigilantly
defended self is a fragile self. If the culture that
provides the ground of my moral being and by which
I am recognized and recognize myself does not permit
in its conception the prolific needs, desires, feelings,
and experiences that belong to my phenomenal per-
son, then I will have difficulty clearly recognizing and
respecting the separate difference of others. The
constricted self, intent upon policing boundaries, will
not sanction and therefore will not serve those parts
of experience that are excluded from socially sanc-
tioned identity. Neither will such a self permit or
invite an encounter with those parts of experience
that are chaotic, disintegrating, and potentially
threatening. As Philip Rieff reminds us [52], one of
1364 ROBERTCRAWFORD
the most crucial functions of culture is to forestall the
impending, psychological collapse of the individual.
Without boundaries, there could be no self. The
concentrated spotlight of modern selfhood, however,
darkens the field of phenomenal being. The ‘shadow’
becomes a place for both fear and forbidden desire.
The constricted and fragile self, through a psycho-
cultural obsession with finding and maintaining iden-
tity, mounts a defense, one for which the borders are
by definition insecure. Thus, if in my insecurity, you
try to speak your different truth to me, I will not hear
you. What I will hear instead is the threat of incur-
sion. How I perceive your personhood will be the
distorted mirror of my own repressed self or a
difference I am unable to integrate into my under-
standing. In such ways the other is irrevocably bound
to the self; and since not admitted to a place of
connection-through commonality and difference-
the other will inevitably be relegated to a place of
subordination, containment and control.
In closing, I return to health. The metaphors we
regularly employ to talk about health and through
which we internalize and reproduce our social selves
clearly need to be examined for their adequacy. In
what sense are they healthy? Clearly, without control
we could not achieve our aspirations. But control has
other faces-an illusion of security, a mark of distinc-
tion by which we regulate social interaction and
establish position in a hierarchical social order, the
‘surplus repression’ required for imposed mandates of
performance, and a relation of instrumentality in
which other subjects become objects. Control has
little room for reciprocity. Control is the language of
management and regulation, not openness and trans-
formation. As long as the dominant metaphors of
health connote control, we lend our participation to
a regime of disciplinary power and to the self-disci-
pline on which it relies, to a self-regulating, contained
sellhood that narrows our identities to that which is
compatible with various institutional, corporate, and
bureaucratic agendas, Moreover, we attribute to the
unhealthy other personal qualitites that are con-
sidered outside the boundaries of legitimate, that is,
‘healthy’ personhood. Control, or simply its equally
managed opposite, release, will confine our efforts to
achieve individual and collective well-being to pro-
grammatic ends.
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