For years now we’ve been talking about “consumer-directed” healthcare in the US and the language of “consumerism” is steadily creeping into global health discussions as well. From conservative camps this is a way to take control of the rising costs of healthcare by forcing the “consumer” to realize the actual costs of care and the Health Savings Accounts (HSAs) are one of the primary mechanisms to place ‘control’ of financing in the consumers hands. I have nothing against the tools here but the language of the ‘consumer’ in healthcare is perplexing to many. I’m not interested in a polemic between advocates of the camps. Foucault once said that no new knowledge has ever been produced through polemics.
But I do want to raise some flags and questions. First, health and healthcare are not the same as other consumer goods. The drivers for many uses of the healthcare system are not in the consumer’s hands although we can count many ways in which behaviors of individuals do drive health outcomes. But my main concerns lie elsewhere, in the historical and political baggage that the term carries with it. If we track the geneaology of the term “consumer” we can get a window into how health, the economy and political change have come together as an assemblage over the last century in some surprising ways (I spoke about this in a keynote speech at IFTF several years ago here). The early use of the word consumer can be tracked back to John Stuart Mill and later we see the term used in London when water became a political and public health issue. “Consumer cooperatives” were formed in the late-18th century to engage in the politics of water provision. As such there ‘consumers’ were “consumer-citizens”. In the US we see similar activity a bit later but the focus was more on quackery in medicine after several famous poisonings of citizens catalyzed the movement of concerned citizens into a “consumer movement” that culminated in the creation of the FDA later on. It was not until the post-WWII era and the need to “grow” the economy, the rise of surburbia, etc. that we see the creation of the “consumer” as we know it today.
Lizabeth Cohen has documented this history brilliantly. But we must also remember that the rise of the consumer also corresponded with the rise in social movements and in health we begin to see the problematization of the relationship between physician and patient (see David Rothman and Albert Jonsen). With the growth of feminism and discourses around control of the body the power relationships in health and medicine quickly became important elements of the debate in health.
The ‘consumer’ then is a changing subject that moves with the broader changes in the economy. As we moved from the welfare state to the neoliberal state we witnessed a corresponding shift from the “patient” to the “consumer”. Now, I don’t want to overstate this as some sort of epochal shift–sure, the patient remains but I’m talking once again in terms of assemblages (see earlier blog posting below). Andrew Barry writes about how we are now increasingly seeing the citizen inscribed into a regime of “technological citizenship”. What this means is that we are increasingly expected “to make our own judgements about scientific and technological matters”. This is one of the reasons why we see more people playing an active role in campaigning, financing, innovating around their own health issues and interests. Social media are enabling people to organize in ways that were much more expensive in both time and money before. These are all fine and good and I’m very interested in the open innovation/crowdsourcing phenomenon. Barry notes that an outcome of all of this is that the “wealth of nations”, so to speak, is increasingly measure in the capacity of societies to be engaged with science and technology in a manner that drives innovation. We’re seeing genetic testing rapidly enter into the “direct-to-consumer” model of business, albeit in a rather crude fashion at the moment.
So why is any of this history and politics of the consumer important for entrepreneurs and others in the health business sector? We’re right in the middle of two major crises, one financial, the other health system focused but both are interrelated. Things that were unmentionable six months ago, such as nationalizing banks, are now everyday headlines. The consumer as we knew him or her is on life-support. Despite all of the talk about health reform we know that little more than tweaking the edges of what really needs to be done for health system transformation will be done. VCs are jumping on the wellness bandwagon and we see calls for new metrics, new business models, etc. in the wellness sphere daily. Some of this is old wine in new bottles. Of course, we all know that we have to provide better care at a lower price. Prevention is better than the sickness economy approach. But there is something deeper going on–many are talking about the great restructuring we’re in and we might want to ask how people are rethinking the relationship between the self, the body, their diseases, their social networks. If you really want to do something revolutionary in health you need to crack this nut and ask what is going on in how citizens are trying to insert their own voices in the debate on what health is about above the cacophony of wellness trinket salesman (and I’m not suggesting everyone in the space is, but just take a quick peak at “wellness” spam on twitter or your bulk mail folder sometime!), policy wonks (its all about universal payor or your HSA, etc.). Dig deeper, there is something going on with the assemblage of the economy, rationalities of consumers/citizens, technologies, somatic ethics (relationships we have about our bodies and disease or lack of disease and the so-called consumer facing health 2.0 sites are some of many sites where these concerns can be articulated), forget about what market researchers are telling you for a moment and ask some new questions about what’s going on here. I’m often surprised about the sense of speed and impatience of the business world. Don’t ask questions, show me the revenue model. And still, here we are with a system that sucks. Hurry up, get the VC to fork over the cash but let’s not do anything revolutionary but talk for the billionth time about how the system needs reforming. Never asking the right questions. Let’s try to figure out what no one is asking and diagnose the present. Then think of how we can meet those needs. I’m not going to another health conference bemoaning the present that is not asking good questions. It’s not just about health 2.0, stupid. As Ken Banks said on a blog post earlier this week in reference to mobiles in Africa, it’s about the people. I would add, yes, but what about which people can tell us something new.