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As health care fails, Part I: Power, knowledge and resistance

Recently I’ve received comments pointing out the futility of attempting to nudge medicine and public health onto the path of thermodynamically based sustainability. These comments were offered in good spirit, with one doctor telling me, “Mainstream health care’s going to crash. Are you sure you’re doing the right thing trying to reach them? I’ve stopped banging my head against the wall with medical leaders –they don’t give a damn and understand even less. Instead I’m building an alternative health care network.”

These comments have made me ponder the past six years in which there have been some “successes.” Yet they deservedly belong in quotation marks because my message has been largely ignored or, in some instances, absorbed into the culturally dominant paradigm of perpetual economic growth, which is breaking down, or, more directly, collapsing (not suddenly, but in increments of the reduction of social and technological complexity, mostly visited upon the economically vulnerable) for wont of cheap, low entropy energy (Gregor 2011).

Here I use Michel Foucault’s thoughts to reflect on the power/knowledge relationship as the first part of an answer to the question, “What to do about health care and public health as this collapse progresses?” In a subsequent essay I’ll rely upon Pickard (2010) to integrate Foucault’s perspective with complexity theory and ecological science.

I use a narrative format in this first part.

In January 2005, while working as the associate director of a center for public health practice at a school of public health, I submitted a paper, “Public Health in a Post-Petroleum World,” for presentation at the annual meetings of the American Public Health Association. Some weeks later I received notice that it had been accepted.

I informed the center director, an associate dean, via email and she in turn did two things: She walked around the office telling the staff and faculty of my good fortune; then she came to my desk and said, “Congratulations, but I don’t want you working on this paper during office time. It’s not really public health, you know.”

In subsequent months I attempted futilely to explain to her the threats peak oil poses to public health. She was consistently intolerant of my views. That summer I realized my stance had become untenable and I resigned to begin working “from the outside.” I was angry and felt ostracized and expelled from a “legitimate” position where I had access to perquisites beneficial to voicing the peak oil threat.

Now I realize that she was enforcing –quite unconsciously- what Foucault calls the dominant Regime of Truth. He writes of the relationship between knowledge (or truth) and power:

‘Truth’ is to be understood as a system of ordered procedures for the production, regulation, distribution, circulation and operation of statements [knowledge is organized into an episteme].

‘Truth’ [the episteme] is linked in a circular relation with systems of power [enforced by a regime of truth that] produce and sustain it, and to effects of power which it induces and which extend it.

Truth is a thing of this world: it is produced only by virtue of multiple forms of constraint.

In short, a regime of truth sets the boundaries of acceptable discourse and knowledge (what Foucault terms an episteme which is analogous to Thomas Kuhn’s paradigm). For Foucault knowledge and power are always interconnected; power is, however, unstable, because it is a relational product of human interaction –hence the need for regimes of truth to keep heterodoxy and destabilizing versions of reality in check or suppressed. From this perspective, my boss was acting as a sanctioned authority arbitrating public health truth, and I was resisting her authority. (The careful reader might ask, “So how did your paper get accepted?” The answer is that annual professional meetings are a safety valve where divergent ideas often are allowed expression.)

Schools of public health ostensibly identify, investigate and suggest how to mitigate or combat emerging or unseen public health concerns and threats. In reality -or at the least, according to Foucault- they address health issues (create knowledge and truths within the episteme) that do not resist or undermine the dominant regime of truth (power relationships), which, of course, reinforces the validity of the episteme. Therefore, these schools are animated not solely by scientific criteria, but by power affecting the production of knowledge -and the non-production of other knowledge. In this case power is exerted through grants –“soft money”- that support these schools. Primarily these grants come from government and secondarily from foundations. Most American public health faculty salaries are 50% or higher soft money. (The history of how AIDS got onto the public health agenda illustrates this power/knowledge relationship: the government had to be forced to address it).

My attempt to introduce –from the inside- peak oil as a public health threat illustrates how a regime of truth controls the agenda of schools of public health. My associate dean had on several occasions lamented her disinterest in “public health preparedness.” However the Federal government had awarded $1 million annual grants to approximately 26 schools of public health as a response to 9/11. One of those preparedness grants was the backbone of our center’s fiscal support, so she was –in her mind- shotgun-wedded to public health preparedness.

In our final meeting, during which I reached the decision to move on, I told her that her dislike for preparedness would be transformed if she could look ahead a few years and realize that peak oil was a qualitatively and quantitatively different public health threat than preparing for terrorism and tornadoes. “These are episodic events where we surge resources to the disaster site and then it’s back to normal,” I told her, “whereas peak oil is game-changing because it affects the entire economy and imposes long-term economic decline. We need a new model of preparedness to examine how to respond to it. Why don’t we develop it?” She gave me a stare of incredulousness and indignation and engaged in what Foucault terms self-policing, “Look, if I went to a national meeting of the preparedness center directors and told them what you just said they’d laugh at me. Why do you keep harping about this obscure energy subject?”

As I struck out on my own in late 2005 I had not connected peak oil to the larger issues of overshoot, limits to growth, the possibility of institutional collapse, and cultural sustainability. I naively believed that it could be addressed through risk assessment, a common framework in public health.

I now regard risk assessment as a form of question begging because it presumes that the status quo, of the health sciences and the larger society, is sustainable. Most important, at a philosophical level risk assessment stems from what Foucault terms the dominant Modernist episteme, which assumes that humans possess agency, that is, they have the capacity to control the social world and biosphere (Pickard 2010). Complementarily, this episteme assumes that Nature -non-human life forms, the environment, ecosystems and the biosphere- is passive and under human control. This simply means that humans are in charge of nature, either to protect it –a la the National Parks and environmental laws- or to exploit it –no examples necessary. It follows that the resources of the earth are meant to propel perpetual economic growth and technological progress. Peak oil, and now the larger issues of social-ecological sustainability, undermines this anthropocentric version of agency.

The Modernist episteme’s anthropocentric logic guides the majority of people I’ve spoken with over the past six years. They believe we can use technology to turn any problem –peak oil, climate change, water scarcity, over-consumption of resources in hospitals, waste management- into a profit-and-growth creating opportunity.

In a concise illustration of this, a few weeks ago I had coffee with a professor of sustainability whose area of expertise is energy. She acknowledges peak oil but offers this anthropocentric solution: “The problem is that the government doesn’t adequately fund alternative energy research. What’s necessary is for the Feds to turn loose entrepreneurs to solve the energy problem.”

“That’s not necessarily a sustainable solution,” I said, “Entrepreneurs want to make money, not to understand the laws of thermodynamics and the science of ecology. And the ones I’ve met have no grasp of finite resources or the consequences of exponential growth; it’s a prerequisite for them to be grandiose about their abilities and the limitless possibilities of technology. Look at how ethanol was spun as a cure all and in reality destabilizes the food system and is providing essentially zero net energy in return. And fossil fuels are directly tied to all levels of our industrial food system, which is at risk because of this dependency.”

She countered, “The food system in the US can’t really fail –it’s too sophisticated” and suggested I was cherry picking my criticisms because, “There are viable biofuel and other solutions on the horizon; we just need funding to develop them.”

“That’s just it,” I replied, “They’re always on the horizon. But do you really think science is capable of creating scalable and comparably energy-dense fossil fuel alternatives when the fossil fuels endowment required millions of years to form? If we’re going to address sustainability, we must understand how thermodynamics determines economic activity; all the rest is a derivative of this obdurate reality. What’s going on in the economy, it’s contracting, and finance, it’s a cannibal because real growth is halting, should make this clear by now. Don’t you think?”

She shook her head, “No, no you’re oversimplifying…” and I interrupted her, “Let’s say entrepreneurs would somehow create a new energy source to keep the economy expanding. Then that source will eventually reach its limits and likely cause other problems along the way –you know, like fracking for shale gas, climate change from fossil fuels or ethanol competing with food; or some other resource –like water- would become scarce. So, the nitty-gritty question is: do you think we’ve reached the limits to growth?” This elicited a recitation of facts about resource consumption, how efficiency allows less energy to do more work, a rebuke for my refusal to accept the “realistic promise of energy breakthroughs,” etc. She did not want to answer “no” yet I felt she half knew –or feared- we are at the limits. She then looked at her watch and said, “Sorry, I don’t have anymore time –lots of meetings and work today.”

There is a widening contradiction between the increasingly useless and injurious knowledge yet still ascendant power of the Modernist episteme. This points to the growing instability of human systems as exemplified by the inability of mainstream leaders to recognize the collapse that is taking place or to solve any of the problems they themselves identify, such as real estate, finance, unemployment, climate change, energy, water scarcity, Entitlements, deficits and debt, health care, and so forth.

Humanity still has options, but our degrees of freedom are shrinking. One thing is certain, I suggest: it is not for humans alone to shape their future. It will be “the result of complex interactions and relationships between environments, humans, nonhumans, technologies, biology, pathologies, ecologies and any number of other contributing factors” (Pickard 135). And this polycentric understanding of agency –which I claim is more empirically correct- must replace the rupturing Modernist episteme.

This leads to Part II of the question about what to do as the mainstream health care and public health systems crumble.


Foucault, Michel. 1970. The Order of Things: An Archaeology of the Human Sciences. Trans. Oxon and New York: Routledge.

––– 1972. The Archaeology of Knowledge. London and New York: Routledge.

––– 1973. The Birth of the Clinic: An archaeology of medical perception. London and New York: Routledge.

—–1980. Power/Knowledge: Selected Interviews and Other Writings 1972-1977. Colin Gordon et al. New York and Toronto: Pantheon Books.

Macdonald, Gregor. “Paper vs Real: Exit From Normal, Ecological Economics, and Probabilistic Regimes in One Chart.” May 7, 2011.

Pickard, E. Kezia. A Radical Relational Agency: Foucault, Complexity Theory and Environmental Resistances. University of Nottingham. JULY 2010.

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