Critical Public Health, 2014 Vol. 24, No. 2, 132–142, http://dx.doi.org/10.1080/09581596.2013.836590 Health education’s fascist tendencies: a cautionary exposition Katie Fitzpatricka* and Richard Tinninga,b a Faculty of Education, University of Auckland, Auckland, New Zealand; bSchool of Human Movement, The University of Queensland, Brisbane, Australia (Received 28 February 2013; accepted 16 August 2013) Along with other scholars in the field, we are increasingly concerned with the propensity for schools to promote particular messages about health, especially those that encourage body surveillance and control. Indeed, we suggest in this article that certain forms of health education can be seen as a form of health fascism. We begin with a discussion of what we mean by health fascism before considering the historical positioning of health education and its alignment with public health agendas. We also consider how health fascism links with established notions of healthism, the cult of the body and aesthetics. Keywords: health education; health fascism; healthism Health education is also subjugation. Many health education practices involve the imposition of ‘truths’ about health. (Galstaldo 1997, 130) This quote from Galstaldo is essentially an attack on health education as a means of social and behavioural control. We have, admittedly, taken it somewhat out of the context, as Galstaldo here is arguing for an empowerment approach to health promotion instead of health education. It nevertheless makes the point that education about health can involve the imposition of truth, which we argue is both contrary to our purposes in education and may equate to a form of fascism. In this, we are being intentionally provocative, but not, we contend, without good cause. Indeed, along with other scholars in the field, we have become increasingly concerned with the tendency for schools to voluntarily take up certain kinds of health messages, especially those which reinforce the discipline and control of the body and which ascribe individual responsibility for health and illness. In this article, we draw connections between scholarship on fascism and contemporary thinking about health, the body and education. We begin with a discussion of what we might mean by health fascism before considering the historical positioning of health education and its alignment with public health agendas. In the third section, we consider how health fascism links with established notions of healthism and the cult of the body, and finally, we argue that aesthetics are also implicated in what we are calling health fascism. *Corresponding author. Email: k.fitzpatrick@auckland.ac.nz © 2013 Taylor & Francis Critical Public Health 133 Health fascism We realise that the term fascism is a highly emotive one and we say at the outset that we are using the term as a device for thinking about health education in a subversive, radical and perhaps iconoclastic way. While the term health fascism is largely unknown in regard to health education per se, it is not unknown in the broader field of health. For example, in their critique of evidence-based discourse in the health sciences, Holmes et al. (2006) use the term fascism. They begin by stating: We can already hear the objections. The term fascism represents an emotionally charged concept in both the political and religious arenas; it is the ugliest expression of life in the 20th century. Although it is associated with specific political systems, this fascism of the masses, as was practiced by Hitler and Mussolini, has been replaced by a system of microfascisms – polymorphous intolerances that are revealed in more subtle ways. (180, emphasis in original) Pronger’s (2002) challenging account of how these micro-fascisms operate in the field of physical fitness is compelling. His argument, in line with that of the above scholars is that contemporary forms of fascism have replaced the jack-boots of macro-fascism with the ballet slippers of micro-fascism. In their critique, Holmes et al. (2006) draw on the work of Foucault, as well as Deleuze and Guattari (2004a, 2004b) and identify the ‘micro-fascisms’ that operate in health research. As Foucault wrote in the foreword to Deleuze and Guattari’s (1980) A Thousand Plateaus the major enemy, the strategic adversary is fascism … And not only historical fascism, the fascism of Hitler and Mussolini – which was able to mobilise and use the desire of the masses so effectively – but also the fascism in us all, in our heads and in our everyday behaviour, the fascism that causes us to love power, to desire the very thing that dominates and exploits us. (Foucault, xiv–xv, in Deleuze and Guattari 1980) Like Foucault, Deleuze and Guattari (2004b) also differentiate between state level fascism and micro-fascism. They focus on what they call segmentarity in the organisation of power throughout society and argue that, in order to be effective, any form of power must penetrate every part (segment) of society (in its various levels of organisation). However, taking control of rigid structures, the levels of macro-organisation, only ever goes so far. They state that ‘[w]hat makes fascism dangerous is its molecular or micro-political power, for it is a mass movement: a cancerous body rather than a totalitarian organism’ (236). One of the features of modern neo-liberal societies is that the power of the State is diminished. The mantra is that the government cannot and should not do it all. Individuals and non-state institutions should pick up the load. Many of us bemoan this trend with regard to the provision of education and health services. But funding is only one dimension of the shift from state to individual, from macro to micro forms of power. As Rose (1990) informs us, there are new political rationalities and governmental technologies that now control our work and play and even our thinking. According to (Lupton 1995), While the state is important as part of the structure of power relations, so too are the myriad of institutions, sites, social groups and interconnections at the local level, whose concerns and activities may support, but often conflict with, the imperatives of the state. (Lupton 1995, 9) 134 K. Fitzpatrick and R. Tinning In this regard, health fascism can then be seen as a form of micro-politics of health and the body which is taken up by individuals at the personal level. The popular obsession with health was termed ‘healthism’ by Crawford (1980) over 30 years ago. This trend has intensified in the intervening time and health concerns have come to dominate the public consciousness. Current issues include everything from alcohol and drug use, teenage sexual behaviour and pregnancy, through to suicide, obesity and poor nutrition. Issues of safety, risk and decision-making are invariably implicated, along with more traditional calls for hygiene practices and the prevention of illness. The visibility of such health discourses is a form of public pedagogy (Rich and Evans 2012), fanned by a moral panic, by which everyone learns to self-monitor, regulate and medicate their bodies in the name of health. Schools take up these concerns in health education classes (see Leahy 2012b) and also in so-called health related PE classes (see e.g. Humberstone and Stan 2011; Powell and Fitzpatrick 2013). As Rich and Evans (2012) point out, In an effort to monitor and regulate childhood obesity, young people are now being subjected to an increasing range of techniques of surveillance, which involve not only monitoring their lifestyles in and outside school (e.g. their food choices, physical activity levels) but more directly the collection of information on their individual bodies with a view to monitoring and altering their weight and size. In a Deleuzian sense, health education classes are a structured form of organisation that serve as a kind of meeting site of complex assemblages (Leahy and Harrison 2004) of macro and micro politics. Within these sites certain understandings of health (which teachers and students bring with them) mix with the formal curriculum and a range of intentions for the subject. These might include the school’s mission to improve health outcomes of students, decrease teen pregnancy and so on. Importantly, many of these health agendas operate from a macro-political perspective that is located in personal insecurity and fear (Evans and Davies 2004; Peterson and Lupton 1996). Deleuze and Guattari (2004b) argue that fear is indeed a basis for control: The administration of a great organised molar security has as its correlate a whole micromanagement of petty fears, a permanent molecular insecurity, to the point that the motto of domestic policy-makers might be: a macro-politics of society by and for a micro-politics of insecurity. (237) Health education in schools reflects wider notions of health and, indeed, the wider politics of health in our societies. Health and physical education (HPE) curricula and practice represent a particular response to societal health concerns. Gard (2008) illustrates this connection with his analysis of the Ontario HPE curriculum which he claims ‘… appears to be designed to address two specific and related social policy problems: childhood obesity and the reduction of health care costs’ (497). These problems are set or framed (Lawson 1984) by epidemiological evidence of physical and mental health trends. The solutions to solve or ameliorate these problems are offered in the form of recontexutalised recommendations for particular behaviour changes (lifestyle changes) that are deemed necessary (Johns and Tinning 2006). Concurrently, schools are increasingly expected to be responsible for the health and well-being of students and notions of ‘safety’ and ‘risk’ continue to dominate educational discourse (Evans and Davies 2004; Leahy and Harrison 2004). Critical Public Health 135 Schools are, therefore, sites in which health promotion agendas overlap or blur with those of health education. This occurs not only in official HPE curriculum and in the health education or [HPE] classes that enact the curriculum, but also in a myriad of other health related extra-curricula interventions and initiatives (e.g. surveillance of kids lunch boxes [Rich 2010]). Schools and classrooms are sites of micro-politics in that they are spaces where particular forms of knowledge and ways of understanding health are formally legitimated. Health, of course, is not limited to these sites but is, like health education, the result of complex assemblages, of health knowledge, practices and representations (Leahy 2012b). Significantly, as Leahy points out. … within this assemblage of knowledges and technologies, lifestyle risks emerged as a significant concept. Lifestyle diseases referred to those diseases that were thought to manifest solely as a result of individual behaviours, such as poor eating habits, lack of exercise, smoking, drug use and so on. The response by proponents of public health was to develop a range of education initiatives charged with the imperative of changing people’s unhealthy lifestyles via the management, reduction or elimination of risk factors. (23) In the end, the distinction between health education and health promotion can be a question of pedagogy or method as both health education and health promotion are about ‘making’ healthier citizens. Gard (2008) suggests that schools, in being marshalled or co-opted into the ‘war on obesity’, are presented with a particular kind of pedagogical task. ‘This task involves being nothing more than a conduit for already formed healthy lifestyle messages. … Teachers simply need to deliver the messages, and children need to act on them.’ (499). There is no doubt that, in the context of ‘risk society’ (Beck 1992) and what Lupton (1995) called the ‘new prudentialism’, the school student is conceived as a proto-citizen who needs to learn, not only what ‘good health’ is, but becomes committed to its attainment through self-management and lifestyle construction. Health education is seen as an important site for the operationalisation of these objectives and in the process has the potential to become a form of health fascism. Histories of health in education The state has used schools consciously and strategically in the last 150 years to promote certain health behaviours and address disease control and prevention. In this process, health education in schools has overlapped significantly with public health promotion agendas in many countries. Indeed, the terms health education and health promotion are frequently confused and used interchangeably. Within education circles, the term health education is usually employed with reference to the school curriculum subject (e.g. Health Education or HPE) but in other disciplines, it takes on a different meaning. For example Whitehead (2003), a nurse educator, differentiates the two in the following way: Traditionally, health education activity is associated with behaviourally focused medical/ preventative approaches to practice. Health education strategies are usually firmly rooted within biomedically positivist frameworks that advocate the use of reductionist, mechanistic, individualistic and allopathic [conventional medicine] activities in health interventions. Health promotion strategies, on the contrary, are usually associated with broader empowerment-based and socio-political approaches that concern themselves with community-based social, environmental, economic and political determinants of health care. (796–797) 136 K. Fitzpatrick and R. Tinning However, this definition, which relates to the field of nursing, is not an accurate representation of school health education in many countries. For example, health education curricula in Australia and New Zealand have been greatly influenced by the Ottawa Charter on Health Promotion of 1986. They are explicitly about empowerment and take a socio-cultural, rather than a biological perspective toward health. But even in those curricula the central place of behaviour change and individual responsibility are often confusingly part of the health education discourse. In this regard, when health education does have allocated time in schools (and that is far from universal), it is often approached as a preventative means to mitigate perceived social ills. This paradox is captured nicely by Harrison and Leahy (2006) who claim that: … although there is some acknowledgement that social contexts are significant in shaping health status, at the end of the day the field of health education has trouble reconciling that understanding alongside its imperative to change individual behaviour and to produce the health-seeking citizen. (Harrison and Leahy 2006, 158) Moreover, as Burrows and Wright (2004) note: Current school-based health education programmes and health promotion strategies work primarily on the premise that as young people become more knowledgeable about health they will behave in ways which lead to their own better health and well-being. (211) Interestingly, although the assumption that building knowledge will, in turn, lead to behaviour change has been widely challenged (Leahy 2012b), it still holds sway in the context of health promotion and health education. While this might be a technical issue for health promotion (i.e. in terms of efficacy of message take-up), it is an educational issue for health education. The tension for health education is that it increasingly advocates knowledge, critical thinking and empowerment as its educational goals, yet it also expects behaviour change (a’ la healthy lifestyle practices) to result from such knowledge, critical thinking and empowerment. At the end of the day, it seems that Health education is still perceived and, indeed, taught as a means of behavioural control, rather than a discipline of study. To further complicate the picture, throughout its history, health education in the school curriculum has often been associated with physical education. Contemporary manifestations of this association are evident in the official curriculum of many countries (e.g. in Sweden Physical Education and Health [PE and H]; in New Zealand, Australia and Ontario, Canada its HPE). The roots of this association are encapsulated in the famous Latin aphorism Mens sana in corpore sano, literally translated as ‘A sound mind in a healthy body’. This association has often been problematic, not the least because physical education has long focused on regulation of the body, the corporeal, through regimes of fitness and technologies of systematic body exercises (e.g. Kirk 1998). As Pronger argues ‘Modern physical education … casts wisdom primarily as the technology of physical fitness, which understands the body as a biophysical object whose functions can be maximised by instrumental programs of training and diet’ (Pronger 2002, xiii). Such underpinnings are in tension with a socio-cultural understanding of health as advocated in many contemporary HPE curricula. Lawson (1983) argues that in the late nineteenth century, early health educators and physical culturists believed that ‘ordinary people were inherently weak and feeble, needing to be protected from their own folly and rashness’ (3). They believed that ‘[w] Critical Public Health 137 ithout professional regulation, the health, lifestyles, and lives of ordinary people will be adversely affected’ (4). Accordingly, they advocated for compulsory forms of systematic physical exercise, exercises for their own good! In contemporary social context, such compulsion is anathema to many citizens (and even school students) and the ‘good citizen’ now voluntarily submits to certain disciplinary techniques regarding their health. This is the common face of friendly health fascism in which the desires of the state are backgrounded (perhaps hidden) and citizens, engage, of their own free will, in the pursuit of good health. Of course not everyone is a good citizen and resisters and recalcitrants effectively ignore or turn their back on the friendly face. The changing political context, in particular the rise of neoliberal ideology, has been a key influence on what stands for contemporary health education in schools (Harrison and Leahy 2006). Indeed, neoliberalism, with its championing of a smaller (less intrusive) state and the importance of individual responsibility for one’s life (financial, health etc) provides, in our view, the perfect discursive space for the propagation of micro-fascisms that regulate the body in particular ways and thus the perfect space for a form of health fascism. Healthism, the cult of the body and schools This brings us back to Crawford’s work on healthism. Crawford’s chief concern with the increasing focus of attention on health was the overt focus in campaigns on individual responsibility for health. Despite acknowledgement by many health professionals and academics that population health is most affected by social, economic and political contexts (as noted above in regard to some health education curricula), healthism puts the focus on the behaviours of the individual, suggesting that people have direct control over their health. The result of such an assumption is to blame those who are unhealthy for their own behavioural (read lifestyle) choices. This is most obvious in recent times in media campaigns and popular attitudes towards issues such as obesity and smoking. The link between healthism and health fascism is revealed in the following extended quote by Skrabanek (1994): Attempts in the area of public health to control private lives are occasionally described by journalists as ‘health fascism’. This term is unduly strong, though it conveys the sense of danger. A more appropriate description would be ‘health fascism with a human face’, or ‘friendly health fascism’. It is ‘friendly’ because it is presented with paternalistic concern and it has more in common with the Utopian optimism of Huxley’s Brave New World than with the brutal vision of Orwell’s Nineteen Eighty-Four. However, in its ‘friendliness’ lies its main danger, as a growing tendency towards dictatorial health may go unnoticed and unchallenged. (Skrabanek 1994, 155) This may well reflect the approach to health in health education. Health education, often with the best of intentions to improve the health of young people, can easily become a site of ‘friendly health fascism’. Deleuze and Guattari (2004b, 236–237) remind us that, despite good intentions and a will to be antifascist, the desire for control is in each of us, ‘[i]t’s too easy to be antifascist on the molar level, and not even see the fascist inside you, the fascist you yourself sustain and nourish and cherish with molecules both personal and collective’. So, while health education classes have the potential to be sites of Skrabanek’s friendly fascism, there is another sense in which health education aligns with micro-fascisms – namely through the aesthetics of the body. 138 K. Fitzpatrick and R. Tinning Health and the aesthetics of the body Since the 1970s, there has been significant scholarship on the aesthetic dimension of fascist cultural forms and how, particularly Nazi, signifiers and ideologies have been taken up and applied elsewhere. Links between fascism and art, fashion and beauty have been explored in detail (e.g. Schnapp, 1996; Braun 1996; Falasca-Zamponi 1997, 2008; Sontag 1975; Mosse 1996). Mosse (1996, see also Gentile 2006) argues that the fascism of Mussolini, as a civic religion, was dependant on the visual representation of power and beauty. The aesthetic was of central importance: The aesthetic which stood at the centre of this civic religion was the climax of a long development. The ideal of beauty was central to this aesthetic, whether that of the human body or of the political liturgy. The longing for a set standard of beauty was deeply ingrained in the European middle classes, and the definition of the beautiful as the ‘good, the true, and the holy’ was an important background to the fascist cult. (246) This is important to consider here for several reasons. While the macro-fascist regime is no longer apparent, as we argued earlier along with Holmes et al. (2006), and Deleuze and Guattari (2004b), micro-fascisms are certainly evident in contemporary health and beauty practices. Indeed, one only has to scan the covers of the popular magazines Men’s Health or Women’s Health to recognise that many current health practices and discourses are so closely tied to notions of the aesthetic body that the separation of health and beauty discourses is no longer possible. In his book on the history of aesthetic surgery, Gilman (1999) states that All of us harbour internal norms of appearance by which we decide whom to trust, like, love or fear. We act as if these internal norms are both fixed and accurate … To become someone else or to become a better version of ourselves in the eyes of the world is something we all want. (3, our emphasis) The pressure to alter the self has become increasingly more intense since Gilman’s book was published. Reality television shows focused on ‘helping’ people to lose weight, dress better and ‘make over’ their physical bodies and homes have proliferated in the last ten years. Many of these include surgical solutions to the body as well as health-related interventions such as fitness training and altered diets. Notions of health in such sites intersect in powerful ways with the aesthetics of the body. This is most evident perhaps in the world of health and physical fitness and in the focus put on obesity and health risk. Indeed Pronger (2002) argues that, via a complex ensemble of various texts, physical fitness has an identifiable doctrine. Such texts include: books, magazines, images of the ‘fit’ body as well as academic and scientific volumes, exercise prescriptions and fitness products. These texts create a ‘regime of truth’ about fitness and health that also aligns with a specific body aesthetic. So, a fit body is assumed to be a healthy body and is also an attractive body. The desire for such a body is also a kind of micro-fascism that individuals actively pursue and in which they are actively, and even eagerly, complicit. Alongside the desire and worship of the mythical fit, healthy, aesthetic body, is the relegation of the non-aesthetic, the ugly body to the margins. Mosse (1996) argues that the fascist formation of the ‘ideal’ body drew on older stereotypes of perfect bodily form and needed an alternate, an anti-form as a means of comparison. Accordingly, ‘[t]his meant that the ideal human type must be clearly distinguished and set off against what the Nazis called the “countertype”, the exact opposite of the normative ideal’ (249). Critical Public Health 139 Obesity is a clear example in this regard. The obese body in contemporary times is held up as an example of both illness and ugliness; it serves as a countertype for many different purposes. The obese body signifies the risks of not engaging in certain activities (dieting and exercising) and of engaging in other activities (eating unhealthy foods). Moralistic judgements about health behaviours are made on the assumption that a fat person is not engaged in worthy, health-enhancing activities (Gard and Wright 2005). As Campos (2004) argues, the obese person is the new social outcast. Mosse’s (1996) observations about fascism are intensely prescient in this regard. He argues, indeed, that: Modern society itself needed and apparently still needs an enemy against which to define itself; the ‘outsiders’, designated as such, often denigrated and vilified – those who did not seem to fit the established norm – accompanied our society throughout the last two centuries. (249) He goes on to point out that the ‘fascist aesthetic sharpened and refined the image of the “outsider”’ (249) by using bodily form as a means of marginalisation and persecution. It is worth considering the extent to which (H)PE teachers, often secure in their place in the regime, reinforce this marginalisation and/or to what extent they resist and provide an alternative to the fascist leaning aesthetic of the cult of the body (see Tinning and Glasby, 2002; Peterson and Lupton 1996). Relegating the non-aesthetic body to the margins, as both a side-show and as warning against certain behaviours, is coupled now with the micro-imperative to bodily control. This is not, as Deleuze and Guattari (2004b) observe, a process of submission. Rather, the desire for the right kind of body, for the aesthetic body, is the fascist tool in this regard. Deleuze and Guattari observe that such forms of micro-fascism control people through their own desire and with their personal involvement: The masses certainly do not passively submit to power; nor do they ‘want’ to be repressed, in a kind of masochistic hysteria; nor are they tricked by an ideological lure. Moreover, Desire is never separate from complex assemblages that necessarily tie into molecular levels, from micro-formations already shaping postures, attitudes, perceptions, expectations, semiotic systems etc … They are at pains to point out the artificial nature of this desire: Desire is never an undifferentiated instinctual energy but itself results from a highly developed engineered setup rich in interactions: a whole supple segmentarity that processes molecular energies and potentially gives desire a fascist determination. (Deleuze and Guattari 2004b, 236–237) Teachers of health education are in something of a bind here. How can they, on one hand reinforce a particular body aesthetic (which symbolises the lean ‘healthy’ body) and affirm those students who ‘have’ such a body or who are actively working towards that end, while on the other hand offer a challenge to the body aesthetic which produces the marginalisation? Off course, as Sykes (2011) points out, the process of affirming particular bodies begins well before formal schooling starts. Indeed, the fat 140 K. Fitzpatrick and R. Tinning body is marginalised, denigrated and vilified within most Western societies and it is the very countertype to which Mosse (1996) refers. Conclusion Holmes et al. (2006) identify the ‘desire to order, hierarchise, control, repress, direct and impose limits’ (184) as a form of fascism. It is easy to see the modernist logic of order inherent in this quote. Law (1994) warns us of the modernist slippage from what he calls the ‘cleave to an order’ into the hideous purity’ of fascism. He claims that [m]any of us have learned to cleave to an order. This is a modernist dream. In one way or another, we are attached to the idea that if our lives, our organisations, our social theories or our societies [and we could add our bodies and health], were all ‘properly ordered’ then all would be well. And we take it that such ordering is possible, at least some of the time. So when we encounter complexity we tend to treat it as distraction from the task of achieving certainty. (Law 1994, 5) We can see this ‘cleave to an order’ in the appeal of the rhetoric surrounding health messages that promise order, control and certainty. We can see it in health education curriculum that offers students the knowledge to make the ‘right’ decisions with regard to achieving and maintaining a healthy lifestyle that, in-turn, makes a healthy citizen. From this perspective, health fascism can then be seen as a form of micro-politics of health and the body which is taken up by individuals at the personal level. Health education, appropriated as a possible ameliorative to the obesity crisis, is readily tied both to an aesthetic of the body, and to cleave to an order, at least as much as it is concerned with physical health outcomes. However, if we take seriously the arguments of social analysts such as Giddens (1991), Beck (1992) and Bauman (2001) certainty and control is illusory in contemporary times and attempts to produce it by the friendly face of fascism are, in the end both problematic and futile. According to Deleuze and Guattari (2004b, 236–237), ‘Only micro-fascism provides an answer to the global question: Why does desire desire its own repression, how can it desire its own repression?’ In relation to health, we must ask what is being desired and what is being repressed? In a capitalist economy, desire is created and, in regard to health, the contemporary citizen is constantly faced with the tension between, on the one hand, the pressure to consume and, on the other hand, to abstain. Indeed, the notion of the ‘healthy lifestyle’ that underpins many contemporary health education and HPE curricula is an instantiation of this tension. And this tension is not benign. It can itself lead to unplanned consequences, such as anxiety and mental health issues (see Zanker and Gard 2008). Underpinning this paper is the rather well used, but nevertheless insightful, Foucauldian observation that things are not good or bad, but rather that everything is dangerous. Indeed, if ‘everything is dangerous’ then considering how health education might become a form of health fascism opens up a dialogue on the possible repressive consequences of school health education. Crucially, Finchelstein (2008) argues that Fascism was an anti-theoretical doctrine concerned not with dogma but, rather, with discipline. This is of key importance in health education debates. If health educators reject theory in favour of discipline and body control then they are aligning themselves directly with fascist principles. Critical Public Health 141 References Bauman, Z. 2001. Community: Seeking Safety in an Insecure World. Cambridge, MA: Polity Press. Beck, U. 1992. 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