Health and Justice: Neoliberalism, Apps and the Limits of Individual Choice

In our technologically saturated society, health is defined as a state of mental, physical and social well-being, constituted by the absence of disease, a definition filtered quite narrowly through the lens of economic objectives and outcomes. Good health is seen as important insofar as it increases efficiency and productivity, as well as acting as a source of the social and professional status that Pierre Bourdieu refers to as cultural capital.

While the observation that health improves our productivity, social standing and vocational opportunities might seem intuitive, what has often gone unnoticed are the ways in which a number of health-related structural, technological, economic and cultural factors have converged and intensified in worrying ways post-2008. One of the most notable of these is the simultaneous transfer of responsibility for maintaining good health and treating disease to the individual actor, as well as the recontextualization of health as a form of labour, supported by corporate tracking technologies and apps (as opposed to state-sponsored healthcare initiatives). This represents something significantly new.

The Turn to Individual Responsibility

The first prong of this was a process of responsibilization which, following the 2008 financial crisis, resulted in the cutting of subsidised state services including healthcare, particularly in the US and UK. It is now the individual who is seen as the autonomous agent accountable for, say, preventing heart disease, instead of culpability being placed on “poor working and living conditions, stress, lower rates of formal education, and reduced access to health care and health education.”

In place of a robust public health care system, aided by economic structures that support a clean environment, safe housing, a basic income, stable employment, access to healthcare and fresh food and effective community organisations, we have a vast infrastructure of privatised services and products. This includes a combination of personalised healthcare services, including DNA testing companies like 23andMe, which offers genetic ancestry testing and personalised diet advice; resource-intensive forms of exercise, like Soulcycle and pilates; and specialized dietary practices, such as the paleo/caveman diet and clean eating. Also of note are health and health adjacent technologies, including tracking technologies and nutritional apps, such as MyFitnessPal and Fooducate; health- and lifestyle-driven social media like Gwyneth Paltrow’s Goop website, and an enduring belief in individual will and its ability to follow these programmes over time. These dynamics have coalesced to form an ecosystem of health discourses and policies that fetishize technologies, insist on monocausal answers to complex social problems, undermine the social determinants of health model, and present health as a choice in ways that not only individualise the problem, but also moralise it, such that individuals with non-normative bodies are stereotyped as lazy and unintelligent, with poor hygiene and not enough willpower.

The operating principle upon which most of these changes are based is neoliberalism. In common usage, neoliberalism is a buzzword meant to refer to a general set of economic and cultural changes that are liberal, in that they promote free markets and an entrepreneurial culture. Neoliberalism, as it is understood today, however, is much more proscriptive and agenda-driven. Under neoliberalism, we are made to take on many more of the burdens and responsibilities of society (retroactively packaged as empowerment) because we are seen as atomistic individuals with the ability to exercise high degrees of agency, autonomy and freedom. That is, we are given much more personal responsibility to contribute in specific ways to society, at the same time as being seen as free agents making our own choices.

However, as intimated above, we are certainly not all free to act as we please since we are, to various degrees, constrained by material, informational, cultural, political and structural realities. These barriers and cleavages are often felt more acutely by groups who are racialized (meaning that they have been designated by society as belonging to a particular race), who identify as female, who are members of sexual minorities and/or who are disabled. A 2016 article which, drawing on statistics from the Health and Retirement Study, found that a person’s health status could be largely predicted based on whether that person was economically secure, identified as female or was racialized. While there is some disagreement about why these differences persist, statistical evidence, like that presented in the study, suggests that thinking of health in purely individualistic terms is inadequate. Nancy López and Vivian L. Gadsden refer to this perspective as one that examines,

The interplay between and among relevant systems and the statuses accompanying power attributed to different ethnic, racial, cultural and socioeconomic groups affect both individuals and their social networks (e.g. family, neighbourhood and community). They are tied directly to and within institutional and structural hierarchies.

Which is to say that belonging to one or more marginalised groups tends to place the individual in a less powerful position economically, socially and geographically and has negative knock-on effects on those around her.

Operating beside and in conjunction with the neoliberal agency-driven ethos, is, as research has demonstrated, a much more complicated reality when it comes to assessing someone’s state of health and might lead us to question a culture in which it is believed that one can easily discern someone else’s health status from her body. This is not only patently untrue, since people with normative bodies can also suffer from, for example, high cholesterol, diabetes etc., but it also justifies our tendency to infer attributes and character traits from health information. Anti-fat bias and attitudes, wherein fat individuals are seen as inherently lazy, unreliable, self-indulgent and out of control, are intensified in contexts in which expanded neoliberal health consumerism has taken hold.

The Pressure of Technology

This health consumer landscape has been buttressed by a whole host of new tracking technologies, which we are encouraged to purchase and use around the clock, even by employers and insurance companies. These technologies of surveillance are shockingly stringent in their nutritionist tracking of vitamins, minerals, calories and fat grams, where nutritionism is defined as an approach to food wherein “a focus on nutrients has come to dominate, to undermine and to replace other ways of engaging with food and of contextualizing the relationship between food and the body.” My rather unsuccessful experience with Fitbit resonates with findings of studies of users and examinations of the technologies themselves, which suggest that they encourage a kind of self-surveillance that (1) normatively defines what constitutes an acceptable body; (2) aims to produce good workers and pliable citizens; (3) collects financially lucrative data; and (4) functionalizes our relationship with food. Users are encouraged to share their app experience with others, thereby providing a sense of community, but one that is highly mediated and promotes performativity that can take on a particularly pernicious valence—particularly for women, due to their proximity to wellness culture. A salient example is the ways in which women consume and use wellness- and diet-oriented hashtags and social media posts to perform and display the health identities expected of them and their families, as research has demonstrated. Evidence also shows that many of these sites and communities, which present themselves as pro-health, mask the sharing of disordered eating practices and techniques. Debbie Ging and Sarah Garvey discuss this in their article “‘Written in these scars are the stories I can’t explain’: A content analysis of pro-ana and thinspiration image sharing on Instagram.”

Moreover, there is little evidence to suggest that the use of these technologies actually results in better health outcomes, particularly since most of these devices and apps name weight loss as their ultimate objective—a highly questionable endeavour, particularly in terms of its success rate, given the very complicated relationship between body size, food intake, exercise and health.

What Is To Be Done?

Should we reject these technologies and revolt against medical, corporate and state definitions of health as a product of individual responsibility and a site for surveillant data mining? Any solution will require a strong, responsive, universal public healthcare system that is service driven, but also takes on the “task of identifying and ameliorating patterns of systematic disadvantage that undermine the well-being of people whose prospects for good health are so limited that their life choices are not even remotely like those of others.”

I see a role for individual responsibility in this new milieu. It would, however, need to be understood as contingent on the socioeconomic, cultural and demographic factors, including identity-based ones, that make the realisation of good health more difficult. Access to open space, clean air and water, unprocessed food and spaces for movement and engagement are also important. For example, we cannot talk about an individual’s responsibility to pay attention to her diet and exercise when she is working twelve-hour days to support her family and can barely afford a small flat, far away from any safe open spaces or free gym equipment. Principles of health justice incorporate these elements into a social policy and legal framework that ensures that “individuals have the ability to access opportunity, achieve what they see as their responsibility and agency to do, and realize their fullest potential.”

Food, on the other hand, is an area that should resist further functionalisation. While attending to health, we also need to recognise the value of enjoyment, pleasure, cultural resonance and collective conviviality. National holidays, family gatherings, pivotal life events and religious ceremonies are traditionally marked by the eating and sharing of food. I am not opposed to the use of technologies to aid in some forms of health monitoring, particularly tracking blood pressure or blood sugar levels in at risk individuals, or for those for whom tracking food intake is medically necessary. However, such practices need to be curtailed if their sole objective is data collection, surveillance and sales.

We need to think about health, pleasure, leisure, community and productivity in the context of the pressures of a society that gives priority to individualism, consumerism and technological advances. It is possible to accept some role for individual responsibility, without neglecting the rich statistical and qualitative evidence that race, gender, class and disability shape our health outcomes. Overall, this nexus between health, neoliberalism, culture, social media and tracking technologies constitutes an important site through which to unpack how we relate to our bodies, identities and each other. This deserves more discussion outside of academic, legal and policy circles.