The entire work of Michael Foucault is one of the most important and innovative theoretical productions of the 20th century. It has been characterized as complex, daring and often in conflict with the prevailing views of his time whereas it still rises, over twenty years after his death, many debates and controversies in the fields of philosophy and political theory (Zdoukou 2007). Hence, the theoretical framework of this research is based on his work.
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The piece of work that I analyze in this thesis is the theory of power. Drawing on this notion, I will investigate the implementation of the screening programmes not only as a quest for their necessity in order to reduce the cervical cancer incidence rates but also as a process of working on the self. Thus personal responsibility is created that deploys the discourse on self-care (Heyes 2006). In order to people adopt the personal responsibility, health education and promotion is essential. According to Foucault, power is developed around a principal axis which can be described as the analysis of objectification, forms of knowledge and power relations through which people in western societies become subjects and objects of knowledge and power. Starting from his book Discipline and punish, Foucault studies the disciplinary power and how the perception of imprisonment, for example in the Panopticon, under the disciplinary society has been established in the modern society. In the same book he proceeds to the most radical use of the concept of the body in which disciplinary power is instituted not only to control them but also to make them productive themselves. Through the continuous surveillance, the detailed collection, recording and classification of behaviors and tendencies a new subject established, the “inmate”. The inmate under the surveillance system is induced to watch over himself because he is offered the illusion that he is monitored. Thus in the theory of power, discipline and surveillance take place through the screening programmes which reflect the governance of the self and create subjected and practiced bodies. Contrary to anatomo-politics of the human body which was created in the 18th century, Foucault goes into a criticism and deals with the notion of bio-politics which isn’t concentrated on the individual bodies, but on the management of the populations. Hence, the sum of these docile bodies in the society establishes the management of the population (bio-politics) (Broer 2012).
Thus, Foucault theory of power has set a main question that this research will investigate: what are the factors that influence the female population’s decision on receiving the screening tests and ultimately become docile bodies?
The development of the National Health Systems in the UK and Greece
National Health Service (NHS)
The United Kingdom is a sovereign state located in the north-west Europe. It includes the island of Great Britain, a north-east part of Iceland as well as smaller islands and it covers a population of almost 62.5 millions of people (Chang, et al. 2011) (Currie and Guah 2007). The UK provides a national health service to all permanent residents – about 58 millions of people- which is free at the point of need and is paid out of general taxation (Chang, et al. 2011) (Gorsky 2008). The national health system of the UK is the main representative of the national health systems worldwide. It belongs to the Beveridge model whose main characteristics are the increased state intervention and state funding of health services (Yfantopoylos 2005). NHS is the first completed health system which provided universal and free healthcare for all, based on the principles of social solidarity and equal access to healthcare services (Yfantopoylos 2005).
Initially until 1900, the UK didn’t provide a social insurance system. Any social insurance, in the sense of the protection of the population, was offered by the church. Healthcare was available only to the wealthy and those who could seek treatment through charity or teaching hospitals (Chang, et al. 2011). Because of the fact that the national funding in the health sector was lacking, the hospitals were in poor financial conditions (Shortell and Gibson 1971). During the Second World War, a public health system was designed that aimed to offer services covering the whole population and its services were financed by central taxation (Chang, et al. 2011). In 1942 the Beveridge report was vital for a health system that protects the population against social dangers such as unemployment and sickness (Yfantopoylos 2005). Ultimately, the Beveridge report was the first step towards a national health service that protects the whole population. In 1948 the National Health System (NHS) was created by the Labour government following the Beveridge review (Currie and Guah 2007) and implementing the 1946 “NHS Act” regulation (Yfantopoylos 2005).
Since its inception the most challenging and notable change the NHS brought was that the health system was split into three services; the hospital services, the primary care and community services (Chang, et al. 2011). After the creation of the NHS all hospitals were under the government ownership. An additional hospital management structure of regional hospital boards and hospital management committees was designed to support the hospital services. The national health system upgraded the role of the General Practitioners (GPs) who were administered separately (Gorsky 2008) and served as gatekeepers of the primary care directing the patients to the different levels of healthcare (Yfantopoylos 2005). The primary care consists of dental, pharmaceutical and ophthalmic services and was organized by executive councils. Maternity, child health, midwifery, health visiting, home nursing and other post hospital services were administered by local health authorities (Shortell and Gibson 1971). The main purpose of this NHS structure was to provide a comprehensive, universal and free healthcare (Gorsky 2008) at the point of need focusing on the equity in the access to healthcare services.
Currently, the UK still has a state-sponsored healthcare system called NHS in which belong the National Health Service (England), NHS Scotland, NHS Wales and Health and Social Care in Northern Ireland (Chang, et al. 2011). The government funding covers the 85% of the healthcare expenditure while the remaining 15% is covered by the growing private sector (Chang, et al. 2011). The NHS organization is highly institutionalized and complex system. It consists of parliament, a secretary of state for health, other non-NHS organizations and strategic health authorities. Under these health authorities reside the NHS trusts, foundation trusts, primary care trusts and care trusts (Currie and Guah 2007) whereas NICE, an independent organization, is responsible for monitoring and reporting its performance to the parliament (Yfantopoylos 2005) (Currie and Guah 2007).
As an institutionalized environment, UK has created a public sector with universal and free healthcare coverage at the point of need. Additionally, what has developed is a “public sector ethos” which is enriched by the value of serving the public (Currie and Guah 2007). Health professionals have set this value above any finance and cost-effectiveness issues whereas treatment is provided according to medical need irrespective of ability to pay (Currie and Guah 2007). This is the reason why the NHS has been proved to be the most efficient healthcare system in terms of quality, equity and access to healthcare among industrialized countries (Chang, et al. 2011). Within this framework, the NHS has developed various policies and institutionalized mechanisms for the best performance of the organization. One area has been in the implementation of cervical cancer screening strategies.
Table 1: Current NHS Structure, July 2010 (youngfoundation.org)
Greek Healthcare system (ESY)
Alike the UK, Greece provides a national health system since 1983 which guarantees universal coverage and equity in access to healthcare services to 10 million legal residents (iefimerifa.gr, 2012) (statistics.gr, 2011) irrespective of any professional or regional conditions. In addition to the Greek population, healthcare is offered to all European and non European citizens based on multilateral and bilateral agreements (Saitakis and Papamichail 2005).
The process that Greece followed in order to establish a universal healthcare system strongly resembles the one the UK developed several years before. Since the establishment of the Greek State there has been a great attempt to create a welfare state and organize the public health services in Greece. However, as in the UK, until 1900, only 10% of the Greek population, namely the wealthiest was offered healthcare coverage. With the introduction of the Ministry of Hygiene and Social Welfare in 1922 the level of care provided by the public hospitals was considered equally advanced, compared with other healthcare systems in Europe (WHO 1996). At that time, due to changes in the political arena, the refugees’ wave coming from Turkey stressed the need to create organized health authorities in order to meet the various health problems that occurred. In 1953 the first serious move was made by the government to establish an integrated and decentralized healthcare system (Katsikari 2011) creating health regions and councils in order to provide specialized and advanced health opinions based on morbidity (WHO 1996). Twenty years later and having been through a hard political period of dictatorship, Greece was flourished in all areas and the healthcare system was one of them. New social objectives were re-defined and new policies were implemented which intended to improve the health services, to reduce the inequalities in the access to healthcare and reallocate the limited resources in favor of the poor (Yfantopoulos 2001). It was in 1983 when the government passed legislation for the implementation of a National Health Service (ESY) which is the fundamental law of the National Healthcare System (Makaronis, et al. 2010). This legislation is still characterized as a major reform achievement for the reconstruction of the health system. However, its implementation didn’t bring any changes in the management of the healthcare sector to ensure its effectiveness. This reform was based on the principle that health is a social good which has to be provided by the State to the whole population regardless of social or economic conditions (Katsikari 2011). Other basic principles of this reform included the equity in the delivery of the healthcare services, the decentralization of the health services, the importance of the primary care creating a system of referral, social security, and the mix of public-private services (Katsikari 2011).
The health policy in Greece was developed steadily over time and it was influenced but the trends of society, the human values, medicine and economy without plans and goals. Only after the Second World War did the organizing of the health authorities became essential in developed countries with a significant millstone the introduction of the National Health Service in the UK (Katsikari 2011). Currently, the welfare state in Greece is characterized as the combination of a social security system (Bismarck model) and a National Health Service system (Beveridge model) where everybody is entitled to the same healthcare treatment (Rovithis 2006). It is highly centralized and fragmented in which all the decisions are made from the central administration whereas the regional health authorities have limited power on resources and control (Rovithis 2006). Today, alongside the ESY, there is an equally powerful private sector where the biggest part of the health expenditure is concentrated (Vardaros 2008). The Regional Authorities were developed as in the UK. In order to give greater responsibility to regions, Greek primary care is provided within the Regional Health Authorities (PESY) by the outpatient section of rural centers and hospitals, polyclinics and also specialists (Saitakis and Papamichail 2005) and covers services concerning the prevention and diagnosis of a disease. The secondary care is offered either by public or private hospitals of by social insurance funds hospitals and covers services for inpatient treatment under the supervision of the Ministry of Health and Social Solidarity (Yfantopoulos 2001).
Even though the last 15 years Greece has taken some measures, the health policy still had certain problems. These problems were concentrated on the funding and the effectiveness of the health services within the ESY, the numerous sickness funds, the regional inequalities in the health services and the internal mismanagement of the public hospitals. These problems were managed by the highly centralized Ministry of health (Katsikari 2011). Contrary to the UK, Greece lacks of an institutional body that is responsible for monitoring the quality control of the health system as well as to provide national economic guidance based on the cost effectiveness principle such as the National Institute of Clinical Excellence (NICE) in the UK (Rovithis 2006). So, it isn’t surprising that Greece is among the high spenders on healthcare, spending 9% of the GDP for a doubtful quality of the healthcare services (Katsikari 2011). For that reason, the IMF implemented in 2011 austerity measures. The healthcare system in Greece has undergone major changes in order to reduce the health expenditure and improve the quality. Specifically, since January 2012 the 39 sickness funds which existed until recently have been replaced by the National Organization of Health Services (EOPYY). This organization incorporates 4 of the biggest sickness funds covering the 85% of the total population. The fact that these changes are still ongoing, doesn’t give any space to assess the effectiveness of the new healthcare system.
The idea of bio-power
In order to understand the power relations between the State and individuals, it is essential to investigate the conception of power by Michael Foucault. His perspective changes somewhere between his early work on institutions, that is the history of madness and the birth of the clinic, and his later work on sexuality and governmentality (College of Liberal Arts 2002). However the concept of power, that his work introduced, has set new dimensions to understand modern society. His genealogy of power challenges the assumption that it is a negative, repressive force that operates purely by law and practices of violence (A. Armstrong 2005) claiming that it turns the bodies into a useful and productive workforce. Power shouldn’t be considered as a phenomenon of compact domination of a group or a class over another because he strongly believes that power is something that is exercised though an organization working as a chain and it permeates every class of the society either individually or the population as a whole (Perron, Fluet and Holmes 2005).
The shift from the pre-modern to the modern forms of society involves the displacement of the sovereign power by the bio-power. Sovereign power was centralized and coordinated by a sovereign authority who exercised absolute control over the population (A. Armstrong 2005). Namely the body was central to the power upon which a detailed coercion is exercised. Anyone who challenged the monarchs’ authority triggered his wrath and this took the shape of spectacular public torture satisfying the masses (Perron, Fluet and Holmes 2005). It was the 17th century when a profound transformation in terms of mechanisms of power has undergone in the West. As the growth and care of the population became the primary concern of each state (A. Armstrong 2005), the sovereign authority wasn’t sufficient anymore to control the ever-growing population (Perron, Fluet and Holmes 2005) and the bio-power emerged focusing on the management of life. It was the moment where an art of the human body was born that makes it more obedient and useful. The violent sovereign power had been replaced by the bio-power which was invested not only in the bodies of the population (Aroni 2008) but also in the soul. This type of power isn’t a matter of life but essentially a matter of living where the bodies are regulated, trained, maintained and understood (Nettleton 2006). Instead of being exercised by means of violence celebrating death, bio-power focuses on the birth of life of individuals and populations (Ojakangas 2005) (Perron, Fluet and Holmes 2005). The bio-power concept that Michael Foucault developed is determined as a positive power over people lives which manages, multiplies, and exerts specific control and regularities to the population (Mitrossili 2008) and particularly discipline the human life, death, work, sadness or happiness of the person, mental health, sexual practices and family life (A. Armstrong 2005). So the West entered the era of biopolitics. It’s the same period that Foucault goes into a criticism and attaches to bio-power a double meaning; the anatomo-politics (Mitrossili 2008), or as Foucault labels it “disciplinary power” (A. Armstrong 2005) a form of power that addresses individuals, and bio-politics which concerns the population management (Perron, Fluet and Holmes 2005). These two poles complement each other (Perron, Fluet and Holmes 2005). Therefore, within the modern disciplinary society, social control can be achieved by means of strategies of normalization or strategies which produce self-regulated, normalized individuals (A. Armstrong 2005).
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The notion of the disciplinary power becomes clearer in his later work on the history of sexuality, where the notion of the body is central as a field to exercise power in Western countries. In the beginning of the industrialization in the 17th century, the human body had to become available and functional for the capitalism and the paid work. The impoverished, illiterate and unhealthy populations should consist of significant importance as valuable workforce for the governments. The latter created such a population policy to adapt the populations to the capital requirements (Bartky 2007). So they had to discipline in the workplace for the steadily growing production and they had to comply with the minimum standards of hygiene to avoid epidemics. In order to achieve the aforementioned, they should have stable family life. Birth rates, marriage age and sexual maturation suddenly were under strict control and bio-power was a response of that disorganized mass of individuals (Perron, Fluet and Holmes 2005). Within this concept, the importance of sexuality is displayed in Foucault’s work because on the one hand sexuality is related to body maintenance and on the other hand is related to the management of the populations (Aroni 2008). The spread of bio-power is intimately connected to the social science discourses on sex and sexuality on the grounds that these discourses tended to understand sex as an instinctual and biological process. This process has deep links to identity and thus potential effects on the sexual or social behavior of individuals (A. Armstrong 2005). Through a historical research in various communities, Foucault concludes that the conception of sexuality is considered a main expression of the disciplinary power which is central in the modern society. Power, through its directing and normalizing nature, is an instrument of control whereas surveillance and discipline procedures characterize the discourse on the care of the individuals. The establishment of the health disciplinary technology prepares the individuals for the bio-politics in modern society because the manipulation of individuals through specific practices such as diet and exercise, make the person responsible for maintaining the fitness of his body (discipline of the body) and consequently the bodies of the population (bio-politics) are controlled. Thus according to Sara Lee Bartky, sexuality operates as connecting link between the discipline of the body and the population management (Bartky 2007). As long as individuals are responsible for maintaining and controlling their bodies, new fields of knowledge are created (Aroni 2008). Surveillance and control concepts, adopt a new meaning because individuals will set their own practices such as exercise and healthy nutrition with greater discipline.
While the perceptions on the human body changed in the 20th century, their willingness to be controlled towards a proper functioning is the most important feature of the development of a public policy concentrated on health and life. So, the body becomes the objective and the target of the power. The easiest way to grasp the notion of the disciplinary power is to consider what Foucault studies in the discipline and punish. In this work he examines this new mode of surveillance which is best illustrated by Jeremy Bentham’s Panopticon (D. Armstrong 1983). The Panopticon enables the simultaneous monitoring and observation, certainty, knowledge and individualization. Specifically it was a building designed for complete, constant and anonymous surveillance of its subjects. It was arranged as a ring at the center of which was a tower. The peripheral building was divided into cells. Each cell had two windows, one allowing light to fall on the inmate and another one which allowed a guard to control the actions of the inmates, “like so many cages, so many small theatres in which each actor is alone, perfectly individualized and constantly visible” (D. Armstrong 1983). The central tower was equipped with large windows looking at the inner side of the peripheral ring (Foucault 1989). Visibility was a trap. In this model, inmates don’t interact with each other and they constantly confronted with the panoptic power (Foucault 1989). Consequently, the design of the Panopticon was such that the guard had total surveillance of the inmates’ actions. Under this surveillance, never knowing if or by whom one is being observed, the inmates were induced to watch over themselves (Nettleton 2006) and they were trained to resist any impulse of misbehavior for fear of being caught. Indeed, the inmates are offered the illusion that they are permanently monitored.
Seen through the lens of the disciplinary power, the Panopticon serves as an architectural model which successfully shows that the enforcement of rules has shifted from the spectacle of the power of violence enacted upon the body of the subjects, to the power of discipline coded into the soul of the prisoners, under the gaze of the Panopticon, focusing not on the punishment of the biological but on the social body (Bartky 2007). This way, the subject becomes the “object of knowledge” that can be studied and individualized through collecting information about all those prisoners that are contained in it (Nettleton 2006). Ultimately, the Panopticon creates a state where people police themselves unconsciously. Indeed, Bentham’s goal was to create an architectural idea that, ultimately, could function, on its own (College of Liberal Arts 2002).
In this stunning critique of the modern society, Michel Foucault highlighted the way constant surveillance isn’t only directed to control the human body, but also to discipline the mind and soul to produce the self-awareness state that the modern society requires (A. Armstrong 2005). These disciplinary practices subject the human body into continuous and constant surveillance and examination aiming to optimize the body’s capabilities, productivity and skills and to foster its usefulness and docility (A. Armstrong 2005):
“What was then being formed was a policy of coercions that act on the body, a calculated manipulation of its elements, its gestures, its behavior, the human body was entering a machinery of power that explores it, breaks it down and rearranges itâ€¦ Thus discipline produces subjected and practiced bodies, ‘docile’ bodies” (Foucault 1989).
The aforementioned complex surveillance and discipline system aims to create a type of person which urban society needs. That is the creation of a human being obedient, occupied by the feeling of being guilty and adaptable to all modern tactics. Thus, the body turns into central, transformed and improved by different techniques which monitored and analyzed it. This different way of seeing the body is the outcome of surveillance.
Screening programmes as an instrument of biopower
Since 2003 the European Council has adopted various guidelines according to which cervical cancer should be screened on population based, quality assured, organized screening tests (Anttila, et al. 2009) to achieve greater participation. These recommendations were supported by clinical trial evidence that through organized cytology the mortality rates could be reduced importantly. (Arbyn, et al. 2007) Additional recommendations describe extensively the organization and implementation of the screening tests, recommended screening age groups and screening intervals as well as policies on monitoring and evaluating the screening programmes (Anttila, et al. 2009) (Nicula, et al. 2009). The Pap test, or cytology, is the best known, most reliable and efficient test of secondary prevention (ACCP 2004) to decrease the incidence and the mortality rates by cervical cancer, highly recommended by the EU (Anttila, et al. 2009). Nevertheless, non-organized programmes have also contributed in the decreasing of the mortality and the incidence, but not to the same magnitude.
Until the early 60s, few people had heard of cervical cancer in the UK as a public concern and women were screened very rarely. In particular, they were screened only when they visited their GP, or attended obstetric or family planning clinics. This opportunistic screening led to inefficient focus on young women (Peto, et al. 2004) and women at higher risk (Eardley, et al. 1985). Although cervical cancer screening expanded steadily since 1967 at no cost, it failed to achieve high coverage rates and sufficient follow-up of women. Especially after a media storm when a woman having never received her abnormal screening results, died by cervical cancer, the opportunistic screening was overhauled (Raffle 2007). The constantly rising incidence and mortality rates in young cohorts (Arbyn, et al. 2009), boosted the NHS in 1988 to provide organized national programme for cervical cancer prevention (Bastos, et al. 2010). Eventually, it introduced the call and recall system. Since then, screening tests have reduced the average cervical cancer incidence by 33% in the period 1991-1993 and 1998-2000 (Canfel, Sitas and Beral 2006).
Using a National Health System list, women of 25-65 years old (Foley, et al. 2011) received a personal invitation in order to be offered free regular Pap smear testing, HPV testing or liquid based cytology by GPs or nurses (Linos and Riza 2000) to detect and treat cervical abnormalities. Even though screening tests were administered nationally, the personal invitations were managed regionally. (Canfel, Sitas and Beral 2006). This -call and recall-system was organized by local authorities, the Primary Care Trusts. These authorities were responsible for reminding the eligible women of the region by personal invitations their regular screening test (Canfel, Sitas and Beral 2006) with a recommended interval from 3 to 5 years, depending on the woman’s age (Bunn 2008)(Cancer Research UK, 2012) and the regional authority (Canfel, Sitas and Beral 2006). In order to ensure high participation of women in the screening tests, in 1990 a system of payments for the GPs was launched, according to which, the payment was received only if women have been screened in the previous 5 years (Canfel, Sitas and Beral 2006). This system demonstrated high participation levels where almost 80% of eligible women had been screened in the last years (Canfel, Sitas and Beral 2006). The screening coverage rose from 42% in 1988 to 85%, 6 years later (Arbyn, et al. 2009) and the overall incidence of cervical cancer in the female population of 20-29 years old shows that it has declined significantly from the onset of the organized screening tests up until 1991 (Foley, et al. 2011).
For that reason, the UK still applies this call and recall system in a target population of 14 million of women (Linos and Riza 2000) aged 25-64 years old (in Scotland from age 20) (Bunn 2008). Besides, cervical cancer screening is, and always has been, free provided and the screening costs were administered by the NHS (Whynesa, Philips and Avis 2007). However, the Pap smear method doesn’t test for cervical cancer; instead, it detects, (Bastos, et al. 2010) cell abnormalities which, if left untreated, can potentially lead to cancer. In order to perform the Pap smear method, the UK uses advanced laboratory quality assurance, training and performance standards of reporting (Canfel, Sitas and Beral 2006). Today, more that 3.5 million women in the UK are screened every year, the vast majority of which as a reply to the call-recall system (Whynesa, Philips and Avis 2007). Another significant proportion still is screened opportunistically. Nevertheless, it is surprising though that recent data demonstrate a profound increase in the incidence rates by 2.2% between 1992 and 2006 (Foley, et al. 2011) (Peto, et al. 2004). This increasing trend hints that HPV epidemic might be increased in the future.
In addition to screening tests, the HPV vaccines were introduced in many countries globally including the UK. The rapid approval of such vaccines by the European Medicines Agency (EMEA) demonstrated that decision-makers in the UK were aware of what the outcome of such a prevention strategy would be and that the reduction in the incidence of the disease would be significant. Indeed, the national HPV immunization programme prevents from cervical cancer almost 400 deaths per year (Martin, et al. 2011). In 2007, a VENICE report was conducted which, even though provided recommendation in Austria and Germany it questioned the benefits of the vaccination over the benefits of screening (Raffle 2007). In the beginning of 2008 the Department of Health in UK announced the inclusion of the HPV vaccination in the national immunization programme (Bastos, et al. 2010). The Joint Committee on Vaccination and Immunization (JCVI) in collaboration with the Department of Health decided to vaccinate girls aged 12-13 years old and additionally to promote vaccination of females only up to 18 years old because the vaccination of the female population older than 18 years would not consist of cost-effective (Bunn 2008). Male population isn’t included in the immunization programme for economic reasons (Martin, et al. 2011). Scotland was the first of the four UK countries which introduced the HPV vaccination in September 2008 at the beginning of the school year for all 12-13 year old girls (Gasparini and Panato 2009).
The power in the healthcare sector relies on the examinations (Perron, Fluet and Holmes 2005) so screening programmes could be considered the vehicle of disciplinary technology. Consequently, the organized screening programmes attract the Foucauldian approach because they are a particular version of the panoptic idea (Heyes 2006). The organized screening tests operate as the Panopticon building. This surveillance system aims to set the entire female population under a continual control and to ensure that it is subjected with respect to the requirements of the state; namely the bio-politics. Furthermore, Foucault suggests that discipline depends on the relationship between the body and its observing gaze rather than on the population. “The perfect disciplinary apparatus would make it possible for a single gaze to see everything constantly”, he notes (D. Armstrong 1983). Namely, discipline includes the strict monitoring. Diagnostic programmes, intending to promote health and prevent from a disease are the best examples to illustrate their relation with bio-politics. With the call and recall notification women are invited to arrange an appointment with their GP or their primary care
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