Section on Health Promotion

THE MARKETING OF EMPOWERMENT AND THE CONSTRUCTION OF THE HEALTH CONSUMER A CRITIQUE OF HEALTH PROMOTION Victoria M. Grace Health promotion claims to be empowering. However, this claim is not without major problematic contradictions and inconsistencies. The way in which health promotion is also controlling is identified in this article. To understand why the discourse of health promotion is traversed by this empowerin@controlling contradiction, the discourse is critically analyzed, revealing a parallel with the structure of the discourse of marketing. Health promotion, rather than fulfilling its promise of empowerment, effectively constructs the individual subject as a “health consumer” in accordance with the model of consumer capitalism.

This critique of health promotion developed against the background of the women’s health movement of the 1960s and 1970s in New Zealand and its challenge to the medical establishment. The women’s health movement was one of several urban social movements emerging in the 1960s in Western industrialized countries, which were critical of the way procedures associated with bureaucratic institutions tended to ignore people’s concerns and needs. They also mobilized around wider issues of inequalities and oppression. The community health movement and the women’s health movement both represented an attempt to articulate new forms of social and political relations with respect to health and healing, forms that opposed the medically based discourse on, and practices regarding, health and disease (1-3). The issues raised by the health movements included demands for more accountability, more participation in decision-making and increased responsibility for health by the recipients of health care (“more control over our bodies”), an increased focus on health and prevention rather than on the treatment of disease, the provision of more information, and increased discussion of legal and ethical concerns. As these demands and challenges placed increasingly strong pressure on the dominant institutions and on medical and health professionals, pressures were also mounting for health administrations to find cheaper ways to provide health services. Concerns for cost containment were not at odds with encouraging individuals to modify

This article is based on research undertaken for a doctoral thesis entitled “The Marketing of Empowerment and the Construction of the Health Consumer: A Critique of Health Promotion in New Zealand.”The research was supported by a three-year grant from the New Zealand University Grants Committee.

International Journal of Health Services, Volume 2 1 , Number 2, P a g e s 329-343, 1991 8 1991, Baywood Publishing Co.,Inc.

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doi: 10.2190/G4DA-8L3H-EDYH-P6C6 http://baywood.com

330 I Grace their “lifestyles” in health-enhancing ways. These factors influenced the emergence of “health promotion” as a field of professional work within the health establishment. (The emergence of health promotion is evident in governmental documents in New Zealand and Britain in 1985: in the 1985 report of the New Zealand Department of Health to the Minister of Health, and the equivalent document in Britain. Both referred to the AlmaAlta declaration of 1977 in which, with the authority of the World Health Organization, member states agreed to the goal of Health For All by the Year 2000.) Health promotion was heralded as the new and progressive approach to health issues both in New Zealand and internationally (4). Health promotion, it was claimed by its exponents, represented a response to, and encompassed a commitment to, the demands of the health movements (5-9). Attempts were made, and are still being made by health professionals, to articulate an approach to health promotion that is logically consistent, effective in terms of health and disease measures, and politically acceptable in terms of stated beliefs and aims. However, given the institutional positioning of the articulators of this emerging discourse,’ numerous contradictions and inconsistencies become apparent. PROBLEMS WITH ‘‘EMPOWERMENT’ “Empowerment” is used here to mean the notion of people having power to take action to control and enhance their own lives, and the processes of enabling them to do so. The notion of empowerment has a strong link with the tradition of “community development” (10). The concept of empowerment as it appears in the health promotion discourse can be viewed as a health establishment response, or answer, to demands for increased control over their own health by members of “the community.” Empowerment and Community-based Programs Over the last decade, the behavioral sciences, psychology in particular, have contributed substantially to the expanding focus on health, health sciences, health promotion, and disease prevention. There has been an increased focus on the importance of individual behavior within medicine, in medical education (11, 12), and in the social sciences, where there has been a growing interest in individual behavior related to health (13-15). Empowerment is an important concept in the vocabulary of health promotion professionals interested in developing “community-based” behavior-change programs. Raebum (16-18) stressed the importance of decision-making being in the hands of community people while professionals act as a resource; planning for locally based programs must also be locally based so that the “control” remains with the “people.” A The word “discourse” is used to refer primarily to language, but including other significations such as images and gestures, which are a part of a particular field of activity such as “health promotion.” “Discourse” is used instead of ‘‘language’’ because discourse connotes the actively political and strategic role of words and how they are connected to form sentences and construct meaning. This differs from understandings of ‘‘language’’ that imply universal and fixed linguistic structures and meanings for yords. An analysis of discourse is concerned with discovering how and under what conditions words and phrases have specific meanings and what can be learnt about the politics underpinning the structuring of a particular discourse at a given historical moment.

A Critique of Health Promotion / 331 British author, Tones (19), has stated that the “radical” approach to health promotion is that of “self-empowerment.” The Ottawa Conference Report of 1987 highlights the importance of this concept (29, p. 449). Raeburn and Atkinson (21), Katz and Bender (22), and LabontC (23) also discuss the importance of “self-help” to health promotion programs. However, professionals are still required to develop, plan, implement, and evaluate “deprofessionalized, community-based” behavior-change programs. Although the discourse attempts to position the community as being “in control,” being the initiator, there is still an external agent in a background role that has controlling implications. The use of concepts such as “enabling” and “empowering” serves as a way of disguising this role. It appears as though the professional is facilitating what already exists in the community. On closer inspection, it is possible to see the existence of a priori concepts of the professional that are directive and strongly implicated in the succeeding action. Examples of the absent yet guiding professional are evident in the following quotations: Bottom-up approaches have been aimed at increasing awareness among the public as to the importance of health promotion. (9, p. 103)

The purpose of health promotion in this area [developing personal skills] is to enable people to achieve the personal skills and understanding of the environment that will allow them to exercise more control over their own health and make healthful choices. (20, p. 457) Health workers must learn not only to “allow” ordinary people to have the primary power of determining problems and selecting options for their solutions, but must learn skills that encourage (or avoid stifling) lay self-determination. (20, p. 457) One of my prime interests has been in seeing how an old-fashioned sense of community can be developed in urban communities. (24, p. 96)

I believe vehemently that health policy action must move closer to people. Rather than controlling people it must empower and protect them, it must aim at strengthening international cooperation, equity and human rights. (25, p. 11)

In each of these cases, a model of how things should be is implicit in the professionals’ attitudes. The language of enabling can have the effect of masking this premodeling. This criticism is not meant to imply a misguided “professional” approach to empowerment which can be contrasted to a “real” empowerment strategy. Rather, the intention is to raise questions about the frequently made assumption that those in an empowering role do not have an a priori agenda. Models play an important role in health education/ health promotion. For example, the PRECEDE model outlined by Green and associates (26) aims to provide a framework within which health education with behavioral outcomes can be designed, implemented, and evaluated, based on a prior needs assessment that is also conducted within a prescribed model or framework. The way in which the language and concepts of empowerment are incorporated into an individual behavior-change approach is through linking behavior change to a concept of “need” that a person experiences for a different “lifestyle,” which the person choose^" to adopt. Lifestyle in this sense has been defined as “the discretionary

332 I Grace activities which are a regular part of an individual’s daily pattern of living such as: eating (both what and how much), smoking, use of alcohol and sleeping” (27, p. 27). Those advocating behavior-change approaches can argue that the programs are developed in response to “community need,” which is assessed by surveys. But community need does not pop out of nowhere; it is not emitted in response to a survey as if the whole process of questioning does not contribute to the construction of the “responses.” Before analyzing the basis of this construction, 1 will discuss the role of empowerment within the social model of health promotion. Empowerment and the Social Model Exponents of the social model of health promotion are also interested in empowerment. The articulation of the social model represents an important step that has introduced a much-needed focus on the social and political factors influencing health. Advocates of the social model are critical of the individualistic focus of behavior change (28-32). They reject a focus on changing individual lifestyles to overcome health problems, or to promote health, and argue for the necessity of examining what are understood to be the “causes”of ill-health, or the barriers to promoting health, which are to be found not with the “individual” but in the social and economic arrangements of society, in the “environment” (7, p. 438; 32-35). Very recent developments regarding this conflict of approaches have resulted in the use of both the individual, behaviorchange, lifestyle-change approach as well as the social model, public policy approach. Instead of being viewed as an either/or conflict, both approaches are considered important and the conflicting premises disregarded. The charter for health promotion, which was endorsed at the first International Conference of Health Promotion, states that the fundamental conditions and resources for health are peace, shelter, education, food, income, a stable ecosystem, sustainable resources, and social justice and equity (36): Health promotion focuses on achieving equity in health. Health promotion action aims at reducing differences in current health status and ensuring equal opportunities and resources to enable all people to achieve their fullest health potential. This includes a secure foundation in a supportive environment, access to information, life skills and opportunities for making healthy choices. People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health.

Here, the notion of radical social change is inextricably linked with the notion of “people” being in control of the “determinants of health.” But when we examine what this means in practice, we discover again that it is the health professionals and health promotion policy advisors and decision-makers who are to control the determinants of health.’ This is evident in Milio’s work (31), which Kickbusch from the World Health Organization Health Promotion program headquarters describes as providing the conceptual underpinnings for the WHO’S Health Public Policy approach to health

’The social model approach

to health promotion can also be argued to be, at root, individualistic (37-38).

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promotion (31, back cover), an approach presumably considered to function in accordance with the Ottawa health promotion charter. In Milio’s discussion, environmental change is undertaken “for” people. This orientation is evident in statements such as “there is a clear implication in here for those who have responsibility and concern for the health of Americans” (31, p. 166). In reading Milio, it is possible to detect, not a taking control by the people, but rather a pseudoparticipation of the people (consumers) in the processes of those in authority manufacturing an environment that, within its own construction, controls people extremely well and is construed as being in their own interests (whether they like it or not). The framework proposed by Milio is a simulation based on a model of health and a planned process to achieve an outcome. It is a world of production and consumption operating in accordance with incentives and disincentives, with measurable inputs and outcomes, and a discourse of rational individuals using cost-benefit decision-making. The dichotomy of individual and environment implicit in the model means there is a world outside the individual that can be controlled by policy and shaped to create an environment to which people respond with a successful outcome: health. An emphasis on the primacy and importance of policy is repeated frequently in health promotion discourse (20,23,25,27,29,31,39-44). Although Kickbusch advocates an “ecological vision of public health” that “does not aim at a division between individual and environment but sees them as a totality” (45, p. 324), the discourse of the social model has yet to articulate an approach to health promotion that genuinely transcends the individual/ environment dualism and that is not managed by professionals, even though backstage. This discussion of empowerment raises the following problems. Genuinely positioning control in the hands of the people within a discourse of health promotion eludes both the behavior-change and social models of health promotion. Why do we seem to be faced with this inevitable premodeling or construction by health professionals, even with every good intention to avoid it? If health professionals are sincerely attempting to respond to people’s needs in accordance with their best interests, to promote health and prevent disease, what are the obstacles in the way? Why does the discourse seem to get sabotaged and be unable to genuinely reflect its intentions? Why does this contradictory position of being both empowering and controlling infiltrate the health promotion initiative? EMPOWERMENT PICKING UP THE CHALLENGE OR RECONSTRUCTTNG THE TERRAIN? A closer examination of the health promotion discourse reveals a contradictory structure. In this study, 21 individuals were interviewed, all of whom were working directly in, or in close connection with, health promotion in New Zealand. The interviews were open-ended with the intention of generating a discourse of health promotion that focused both on ways of understanding health promotion and on activities pursued under the title of health promotion. The interviews were taped and transcribed in full. The transcripts provided the basis for the following analysis of the notion of empowerment. (The discourse was analyzed using a lexicological method. Lexicology entails a process of discovering a structural logic within a discourse, a logic that might be involved in structuring the discourse but, at the manifest, surface level is not apparent.

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This is a logic that goes beyond the discourse itself and could highlight the politics involved at the extra-discursive/discursive interface that contribute to this structuring.) Two distinct themes emerged from the discourse analysis. There is one theme of providing and serving, which exists alongside a second theme of planning, changing, and confrolling.The first theme implies that the control is with “them,” that “their” needs, wishes, wants, and desires precede the provision. The second theme implies that the control is with “us,” that “our” plan or vision determines the course of action. On the one hand, the discourse is positioning the object of the discourse as being in control; on the other hand, it is simultaneously articulating a controlling position on the part of the health promoters. A model that exhibits this duality in precisely this form is that of marketing. It is always “them,” the consumers, who have needs, wants, and desires and “us,” the providers or marketers, who have plans, targets, and goals. For the consumers to have needs, wants, and desires it is necessary for them to experience a lack. “Health status” is a construct that, in accordance with the marketing discourse, the health consumer must have in order for a lack to be experienced; health status is something the health consumer must monitor and evaluate (or have monitored and evaluated) to be made aware of his or her health needs. This model provides for the construction of the consumer as a needing, wanting individual who can assess his or her own needs and wants and can take steps to fulfill these by purchasing or otherwise obtaining the goods and services required to satisfy these needs and wants. The structural form of the health promotion discourse, the concepts and underlying assumptions about the relations between “objects” and the logic of how they are produced, needed, and exchanged, parallels that of marketing. The implications of this parallel for an analysis of the contradictions of empowerment and control reveal the influence of the ideology of marketing within the broader logic of consumer capitalism. Is the empowering intention of the health promoters to be understood as a genuine response to the challenge of the health movements? This question arises because of the contradictions within their discourse. An analysis of these contradictions shows how the articulation of an empowerment discourse may be a reconstruction of the grounds upon which the relationship between the health movements and the health professionals is negotiated. The relationship of provider to consumer effectively dissipates the political antagonism of resistance; it shifts the ground from the sphere of political challenge and struggle to the ground of market relations. On this latter terrain the demands of the health movements become commodified. Captured and absorbed by the relation of consumer and provider, the demands of the health movements become many additional needs that can be fulfilled by a proliferation of the market. McKnight was critical of this development: “The sign of commodification is the ‘health consumer.’ There is, of course, no possibility that health could be consumed. There never has been a ‘health consumer.’ Nonetheless, this medically engineered mythical being has entered the fantasy life of modern society and emerged as a client” (46, p. 78; emphasis in original). Health promotion can be understood as an expansion of the medicalhealth provision to provide for “needs” for “empowerment,” “individual responsibility,” “information,” and “health.” This expansion is not a simple relationship in which a particular class or elite group controls the process of change to secure its own benefits. Rather, the

A Critique of Health Promotion / 335 phenomenon of proliferation of provision in accordance with a marketing ethos is determined by complex generative processes that cannot be traced to a single source or mechanism. To understand further the sources of the contradictions surrounding the notion of empowerment, it becomes a matter of explaining the way in which people are positioned both as providers and consumers. An analysis of the prevalent management terminology and concepts in the interview material advances this understanding. The major way in which the form or structure of marketing is apparent within the discourse of health promotion is through the discourse of management. MANAGEMENT AS A SUBDISCOURSE OF MARKETING It’s very difficult to promote health-take for example the gala, now there’s free tank rides, free helicopter rides, and here we’re going to be with our tent. Now what the hell could we offer that’s going to compete with that? . . . We’ve got to make it interesting. Now, we’ve got to get people in our tent. Interviewee

Marketing is a process that forms the central discourse of exchange operating within the form of political economy that is dominant globally. The two themes evident in the discourse of health promotion (one of providing and serving, and one of planning, changing, and controlling) characterize roles assumed within a market-based transaction. A seller of a product has both a discourse that positions the purchaser as a chooser and a discourse that positions the purchaser as a potential buyer, a buyer “made” by the marketer. The first positions the seller as provider who exists purely to serve (to a standard of excellence) the customer’s wish, desire, or need; the second positions the seller as an agent of persuasive techniques who attempts to fashion the customer into precisely that chooser with particular wishes, desires, and needs. The two apparently contradictory discourses are reconciled, albeit inadequately, by assuming the prior construction of the subject-as-customer. According to this philosophy, the customer is an individual with needs, wishes, desires; she or he has the freedom to choose, is a decision-maker, is a “private individual.” The marketing agent merely describes and displays the goods and services; the individual potential customer is free to resist persuasion and to make up her or his own mind. There is no coercion, and the marketplace is “free.” Echoes of this philosophy appear in these statements taken from the interviews: And that’s an area where I think we have a great deal of need, is in marketing of health. I think it’s like everything, you’ve got to sell it, it needs to be advertised, people want to know why it’s of value, why they should have it, what’s beneficial about having it, how they’re going to benefit by doing something, what good is it going to do to them. And they need to see it, that they are going to gain something out of it, practicing whatever habit it may be. You have to be sure that what is being promoted is a very good thing, is a good idea, and presumably one likes to think that all gets checked o u t before the program is established, and then the next thing is for the consumer to be aware of it, and there’s still an allowance for that person to decide, given all the information they need. So it’s not just something the government says-it’s a good idea, do it-because if it’s your own decision you’re more likely to act on it than if you’re just being told, in fact you’re more likely to act on it probably.

336 / Grace Drucker (47) placed a strong emphasis on the role of management in the development of the contemporary global economic struct~re.~ He claimed that we simply would not have the current modes of production and workforce structureswithout the management practices that have been developed and expanded over the last century, particularly since World War I. He claimed that management has in fact been so central in this process that it is management that has “created a global economy” (47, p. 65). As this transformation has progressed, management itself has undergone considerable changes. Drucker continued: The fundamental task of management remains the same: to make people capable of joint performance by giving them common goals, common values, the right structure, and the ongoing training and development they need to perform and to respond to change. But the very meaning of this task has changed, if only because the performance of management has converted the workforce from one composed largely of unskilled laborers to one of highly educated knowledge workers.

It is only recently that the knowledge needed to capitalize on this particular transformation has been developed-knowledge of ways to “put people with different skills and knowledge together to achieve common goals” (47, p. 66). Drucker claimed that without this form of management it would not be possible to make effective use of the explosion of educated and knowledgeable workers: “The emergence of management has converted knowledge from a social ornament and luxury into what we now know to be the true capital of any economy” (47, p. 67). In Drucker’s terms, it is knowledge that has become the center of capital investment, not “bricks and mortar” as it was in the earlier stages of the development of capitalism, and it is management that is the key to accomplishing the effects. There is nothing new in the observation that more may be achieved by combining the labor of numbers of people. This phenomenon has been documented throughout history and across different cultures and continents; warfare and other forms of combat are the paradigmatic example of how power accrues with organizational capability. However, what is new-and this is what Drucker drew attention to-is the change in management processes required to manage “knowledge workers” as opposed to soldiers or factory workers. The same basic features persist: the importance of setting objectives, having common goals, planning, training people for specialized roles, coordination action, and evaluating outcomes/measuring performance. But the style and the content have changed. We are now talking about information-based organizations in which teamwork is more efficient and necessarily has replaced the hierarchical management structures of the past. This process goes hand in hand with the automation of mechanical production, which is the equivalent of the restructuring of production around information (47, p. 70). The form of management associated with the expansion of knowledge over the last few decades locates “knowledge”within an information-based, cybernetic formulation (48). Management, a discourse having a central role in the marketing processes of the contemporary political economy, figures prominently in the discourse of health Although Drucker does not provide a critical analysis of contemporary global economy, this does not mean his astute descriptions of economic and managerial processes are inaccurate. Drucker is such a successful author in these fields precisely because of his insight into the way the system operates.

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promotion. Although an enterprise such as health promotion is not necessarily profitmotivated, that does not mean management principles cease to be central to its operation. Drucker wrote of nonprofit managers as well as profit managers, noting that most of their responsibilities are the same: “among them, defining the right strategy and goals, developing people, measuring performance and marketing the organization’s services” (47, p. 69). The discourse of health promotion generated by the interviews reveals a strong emphasis on management principles. This is particularly apparent with the metadiscourse of the second theme: plan, change, and control. The pervasiveness of management principles in the interview material is apparent in three ways: first, in the repetition of keywords such as objectives, coordination, and evaluation; second, by virtue of the sheer amount of the discourse that focuses on outlining planning procedures, problems of resources, and discussing structural features of organizational processes that enhance or impede action; and third, the presence of management concepts as a context in which action and analysis of action are discussed. Those interviewed tended to stress the importance of setting priorities because of scarce resources and the need to be efficient. What the agency actually did, whether it was a governmental or quasi-governmentalorganization or large voluntary agency, was frequently couched in terms of setting objectives, implementing policy or programs, evaluating outcomes, and coordinating efforts. An alternative approach involved “seizing the political moment,” which was voiced by those who adopted more of an advocacy role. But in each instance, strategies were central, evaluations integral, and a planning or management discourse predominated. Interviewees talked of the importance of goalsetting at all levels: national (“the need for a set of national health goals”), regional, at the level of projects and programs, and within organizations. The most frequent words used for goal-setting were objectives and goals; others included targets, vision, mission. Goals and objectives appeared in the work plan, management plan, operational plan, strategic plan, or mission statement(s). Funding and issues associated with the allocation of resources and the problem of planning within the available resources assumed a prominent place within the discourse. Some interviewees continually returned to issues of funding, referring to the processes of the division of funds within the bureaucracy or organization; the proportion of money going to this or that program, section, or group; how they were repeatedly hindered by lack of funds, personnel, or resources. The processes of deciding appropriate courses of action were talked about in a language of strafegy-assessing a problem or needs (again at the national, regional, local, community, and/or individual levels), figuring out the most likely course of action to solve, resolve, change, transform the problem or fulfill the needs, and then mobilizing the resources necessary to successfully accomplish that action (program, policy, campaign). To evaluate the success or otherwise of this small and “local” or “massive” and national intervention, the importance of having measurable objectives, and hence also an interest in the development of measures, was frequently mentioned. The way in which people went about achieving their goals was central to the discussion. Usually a series of steps was followed according to a model (such as the PRECEDE model). The relative value of different models would be assessed and strategies debated at workshops, seminars, conferences, and ongoing training sessions.

338 I Grace The degree of formality believed necessary in adhering to a particular model varied. There was a strong emphasis on the importanceof flexibility, of being innovative, which at times had the flavor of a kind of “Zen of management.” The importance of management was also apparent in the focus on roles; the labels for individuals’ roles were related to the specificity of their particular positions within the organization and would change as subtle changes of roles occurred. A group of people, each with different roles, was frequently called a team-management teams, health teams, multi-disciplinary teams-and the process of coordinating roles is of course the process of management referred to above. Decision-makingprocesses were outlined in detail by interviewees who occupied positions in more complex bureaucratic structures, frequently accompanied by a description of those structures with references to a structural organizational chart showing roles, lines of responsibility, and decisionmaking powers. There was evidence within the discourse of a process involving a shift from the hierarchical management structure to the team management structure, which Drucker highlighted as being so central to the development of the current form of global economy. Interviewees from government agencies had experienced a major “restructuring” of the Department of Health just prior to the interviews. The following interview statement could be interpreted as a reflection of a person used to a hierarchical management style who is trying to understand a transition to a new type of management: [XI’S particular management style is sort of a collegiate thing that everyone has a say. But ultimately the decision is hers. . . . I used to work in industrial relations and consultation for me is-you can consult everyone but you don’t necessarily need to take account of their views. You listen to what their views are and you either accept them or reject them or whatever you do with them, and that to me is her style, although other people may see it slightly different because she does, she attempts to take into account other people’s views.

And a little later, talking of the same manager, the same interviewee said: “People within the program like her style. . . . It’s probably the first time that their views have really been taken into account.” This change in management is also echoed in this statement made by another interviewee: “The thing about the Health Department is that they’re all so bloody slack. . . . I don’t think they are very professional or very sort of organized or efficient and I think with [XI’S leadership our section anyway can probably motor faster in that direction, a lot faster than a lot of the other departments.”& another interviewee put it: “It’s in the nature of things that you have managers who manage the status quo and you have managers who manage change, and we’re very much more into a managing change situation, whereas before it was maintaining the status quo; it was control which was the name of the game.” The nascent quality of the introduction of managerial skills of the type Drucker outlined is evident also in the following statements, this time from an area health board: One of my objectives as manager is to bring the team concept into the division. We are not structured in these three or four different areas but we are a team. Our roles within the team may be seen as not similar. . . but by the same token your objectives are the same.

A Critique of Health Promotion I 339 The team manager and me, we try and bring things together.

I think that until we get our structure right and our objectives clear as a division . . . This is an outside organization that at present I am negotiating with in terms of management training . . . ,so that’s giving people skills to write precise, clear objectives, to have good skills in questioning and listening and what have you, just management skills we want the division to have. Once we’ve got them we can apply ourselves a lot more to what I see the main objective of the division-[health] promotion and prevention.

Reorganization and restructuring were often discussed in the context of increasing communication, clarifying expectations and roles, and improving coordination and cooperation. A new kind of paternalism is apparent in this discourse: there is still a “provision for.” New management techniques require participation and involvement of team members with different skills; to be able to participate in a way that enhances efficiency, workers have to be trained. The demand by an increasingly sophisticated workforce for participation in decision-making dovetails neatly with the new management imperatives. Again, it is possible to see a shift of ground in this process from one of challenge and political antagonism to one of provision. Participation in decisionmaking is demanded-it can be “given” or provided for, in fact it is necessary to the running of the organization in accordance with contemporary management methods. Lasch (49) has commented on the ideology of “benevolent management.” The particular form of political struggle that depended on a clear distinction of roles within a hierarchy, roles associated with power to decide and determine, becomes dissipated. In conjunction with this focus on planning and management procedures in the interview materials, there was copious mention of structural features of relationships between various organizations, agencies, departments, and committees and how these relationships affected the implementation of plans, programs, and other activities. The prevalence of the management discourse and its link with marketing reveals a structural form that provides a basis for explaining the relationship between the two themes identified within the discourse. To “manage” in the interests of people’s “needs,” for the purpose of “efficiency,” is a discourse that masks the ideology of marketing and couches it in an “empowering” frame of reference. If a market-based form of exchange, and the logic associated with that exchange, can be seen to underpin the discourse of health promotion, the discourse of management can be seen to play a role in masking the contradictions and literally “managing” the success of the hegemony of a market-based political economy. THE CONSTRUCTION OF THE HEALTH CONSUMER It is in the context of the second theme-planning, changing, and controlling-that we can see how health promotion actually models the individual subject as a consumer. The consumer is constructed to act according to a model. This construction occurs within a process of predetermining and constructing “needs.” The entire discourse of the second theme illustrates this modeling process. Within the interviews it is possible to see a dual construct: on the one hand, “we” provide according to “their” needs, yet on the other hand “we” tell “them” their needs.

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Consistent with the first, the health promoters interviewed were concerned to “ascertain what community needs are and to fulfill them appropriately.” We see the importance of “groups looking at their own needs in their communities,” of “putting consumers on service development groups,” of “people setting their own goals.’’ Health promoters claimed that “it is presumptuous to decide on their behalf” and insisted that “they change because they wish to, not because they’re told to.” As one interviewee put it: “I subscrib to the self-assessment needs assessment approach, and that we should be working on, as a part of the balance, those kinds of things that people in their own communities want to achieve for themselves.” The test of success for a health promotion program is “whether or not programs are having any impact and cooperation from the community, or in fact are they meeting community needs to begin with?” or “whether we get a request again.” On the one hand, statements appear such as “We want them to come to us and say well, this is a problem, these are the resources we need to promote this particular problem, and then we’ll sit down with them and plan the objectives of how best we can meet their needs.’’ On the other hand, and consistent with the second aspect of the dual construct, the process of the construction of these “needs” appears to result from a prior interaction with a dominant discourse. The role of “we” in the construction of “needs” is evident in the following statements: We did a survey in Auckland . . . to get a picture of what was happening and what the problems were. Then we look at the needs of the district depending upon what statistics they have gathered. The top priority is fitness, that really came out top, then weight, then stress management, and in about five different community surveys we found about two-thirds of the population, adult population, interested in one or more of these.

You look at the demographic projections, you see that the population is aging, you look at the research that shows that caregivers of people with severely deteriorated relatives . . . are very much at risk in terms of mental health problems of a range . . . so you then look around and say well what can we do about it?

There is a discourse of “finding out community needs,” which involves doing a survey of “individuals”; these data are interpreted according to a “population” basis and the “community” is then told what its needs are: “The public as a whole can best manage their own affairs if they know how well they are doing, and they need to know how they’re doing as a nation.” The starting point is a survey that originates from the premises of the health professionals: “The biggest problem is that we don’t contact the people who we are going to change. They have no idea that they have a problem and most of the time they don’t even care.” Numerous statements made by interviewees show a consistency with the second aspect of the dual construct proposed above: “we tell them their needs.” Health promoters “shape public opinion through the use of the mass media” and find that this is a useful way to “put issues on the public agenda.” It is their job to “state the physical or behavioral requirements for change for the nation,” then “the first step is to make people

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aware” (all quotations from interviews). Health promotion professionals do the research and therefore know what changes are necessary. They focus on: “political analyses of health problems and alcohol problems. . . [and] other factors that are very important for people’s health status including their income level and their environment.” On the subject of diet and cancer, one interviewee stated: . . the best guess at the moment, according to Doll, is about 33 percent of cancers. We don’t know really which food it is; the data are still extremely soft. There are good grounds for thinking that diets which are low in fiber and high in fat contribute to the so-called Western cancers.” Those interviewed talked of the importance of “keeping the public informed” and of “monitoring social trends that affect health”; “We have to monitor the health behaviors, or the unhealthy behaviors, that contribute to those outcomes.” So the public is told by the professionals what the problems are, what the needs are; the public is given a language of health needs: “We knew that there was a need from previous blood tests and diabetes tests that their lifestyles needed altering if possible. . . . They’re [community nurses] looking at blood pressures, they’re measuring their blood sugars, looking at their snack breaks.” The dual construct of surveyinglmeeting needs and constructinglmodeling needs corresponds to that of the market model. As long as there are providers and consumers positioned within an interactive process of constructing demands and needs, and producing services and goods to fulfill those demands, this aspect of the structure is reproduced.

“.

CONCLUSION An analysis of the contradictions and inconsistencies surrounding the use of the notion of empowerment within the discourse of health promotion shows a revealing parallel with marketing and management discourses. The institution of “health promotion” produces an ideology of empowerment that, it can be argued, effectively masks its collusion with the contemporary form of political economy, consumer capitalism. This critique provides an understanding of the process whereby demands made by the health movements for “empowerment” are recaptured and transformed within the health promotion discourse and contribute to the construction of the individual as a “health consumer.” This construction precludes a transformation of health-related social processes that could result from the challenge of the health movements. The health promotion discourse dissipates the dynamism of these movements for change. It is ironic that a discourse articulating a concern to promote health in the name of freedom and “wholeness” functions to alienate people from their capacity to engage in protest, and effectively operates to subject them further to the political and economic order.

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