Introduction
Since 2011, national and local television channels in Turkey have been flooded with short media clips lasting less than a minute, called “public spots” (kamu spotu). They are prepared exclusively by government ministries and NGOs and are aired pro bono by television channels during commercial breaks.Footnote 1 Their purpose is, by definition, to “inform and educate” the public on a wide spectrum of issues, including proper usage of stoves, blood donation, smoking, driving speed, mugging, efficient energy use, the abuse of children via the Internet, occupational accidents and safety, obesity, food safety and hygiene, herbal medicine, organ donation, breastfeeding, and so forth. As different as their contents are, these spots all have a certain likeness in terms of being informative in their language, serving as guidelines in their claim to be educational, and being plain and direct in conveying their message to the individual. Focusing on the content of public spots—rather than on their form, format, or style—we argue that they all share a common feature that lies in their mode of operation: as risk caveats, public spots warn individuals about potential dangers and threats surrounding them in everyday life and expect individuals to then engage in various proactive measures by assuming responsibility for their conduct through constructing a lifestyle free of such risks. Among the large pool of public spots, we will specifically focus on and observe this trend and these emphases in those spots related to smoking and obesity produced by the Ministry of Health (hereafter MH; Sağlık Bakanlığı).
Since the introduction of the Health Transformation Program (HTP; Sağlıkta Dönüşüm Programı) by the MH in 2003, Turkey has undergone a series of neoliberal health reforms. Designed to meet the health standards and regulations of the European Union and OECD countries,Footnote 2 the HTP brought fundamental changes to the management and organization of Turkey’s health care system. One of the key changes was the merger of four major health insurance schemes (the Social Insurance Organization [Sosyal Sigortalar Kurumu, SSK]; the Social Insurance Agency of Merchants, Artisans, and the Self-employed [Bağ-Kur]; the Government Employee Retirement Fund [Emekli Sandığı]; and the Green Card Program [Yeşil Kart]) into a Universal Health Insurance (Genel Sağlık Sigortası) system. This system introduced statutory health services for the entire population, with additional voluntary health insurance offered by private insurance companies.Footnote 3 Public hospitals became semi-private enterprises with financial and administrative autonomy in securing and spending resources, contracting out services, and staffing.Footnote 4 A performance-based payment system was introduced for public health services personnel, which allowed them to receive supplementary payments from a hospital’s revolving funds.
Within the scope of the HTP, the MH has also been subjected to a functional restructuring as a “planning and supervising authority” for health.Footnote 5 With public hospitals operating as autonomous enterprises, the MH has gradually withdrawn from providing health care services directly to the public.Footnote 6 It instead came to perform a “stewardship” function, described in the program as the “careful and responsible management of everything related to health care,”Footnote 7 including policy-making, assuring the effective functioning of the health care system, raising health awareness, and promoting a healthy lifestyle.
Following this functional restructuring, the MH began to produce public spots on smoking and obesity. In 2008, it introduced a Health Promotion and Development System (Sağlığın Teşviki ve Geliştirilmesi Programı) to “ensure the public display the correct [health] behaviors.”Footnote 8 Identifying obesity and tobacco use as significant risk factors and thus priority areas for behavioral change, the MH established nationwide programs (the Obesity Prevention and Control Program of Turkey [Türkiye Obezite ile Mücadele ve Kontrol Programı] and the National Tobacco Control Program and Action Plan [Ulusal Tütün Kontrol Programı ve Eylem Planı]) in order to promote their prevention. As part of these programs, the MH’s General Directorate of Health Promotion (Sağlığın Geliştirilmesi Genel Müdürlüğü) launched two national media campaigns called the “Fight against Obesity” (Obezite Mücadele Hareketi Kampanyası) and the “Fight against Tobacco and Tobacco Products” (Tütün ve Tütün Mamülleriyle Mücadele Kampanyası). These on-going campaigns involve the production of communication materials—public spots as well as billboards and brochures—in order to encourage individuals to adopt smoke-free, active lifestyles with balanced nutrition.
Scholars have discussed these changes in Turkey’s health care system predominantly via the concept of neoliberalism.Footnote 9 What has been stressed in these studies have broadly been the transferring or externalization of state services to the private sector; the reregulation of the health sector in line with the principles of the market, resulting in the prioritization of efficiency, cost reduction, and profitability, in contradistinction to the previous welfare system; and the conceptualization of individuals as consumers rather than citizens. Our problematization in this article, which rests on the framework of neoliberal governmentality, acknowledges these processes. Within the confines of this framework, these processes are viewed as signalling the emergence of multiple power centers in neoliberal societies, particularly due to the growing externalization of the state’s functions, activities, and responsibilities not only to the private sector, NGOs, and international institutions, but also to individuals, through mechanisms of deregulation, privatization, and decentralization. The neoliberal governmentality literature reads these processes of externalization primarily as a technique of indirect “governance at a distance.” It argues that, above all, this technique seeks to responsibilize individuals for self-governance, which results in the emergence of more enterprising, active, and responsible beings who are more suited to taking charge of their own well-being and making rational decisions.Footnote 10
In following this framework, we will neither approach the structural changes in neoliberal health reform as expressed by those favoring the concept of neoliberalism, nor will we discuss their perception by the wider public.Footnote 11 We share the critique of those scholars who deploy a certain level of skepticism toward the analytical usefulness of the concept. In that sense, we welcome Mitchell Dean’s statement that neoliberalism has been an overblown notion and, if it indeed does need to be employed in any analysis, its use should be circumscribed.Footnote 12 We also agree with John Clarke’s critique that neoliberalism has become an omnipresent and promiscuous concept that “is evident everywhere, and applies to a variety of economic and social phenomena.”Footnote 13 Similar to Dean, Clarke suggests that the social field that is said to be constructed by neoliberalism needs be shown as a disorderly space full of contradictions and antagonisms.Footnote 14 Combining these cautionary remarks with the emphasis of the neoliberal governmentality approach on the rise of the individual self-governance discourse, we argue that public spots on obesity and smoking convey a discourse of self-governance in contemporary Turkey, one where individuals are responsible for their own well-being through the supervision and care of their own health.
In looking at these spots, we aim to probe the mechanisms and techniques of self-governance, rather than focusing on the processes of the externalization of the state’s functions. Highlighting mechanisms rather than processes brings the techniques of neoliberal governmentality to the fore. Furthermore, concentrating on the mechanisms allows us to focus more on how the subject of neoliberal governmentality is formed, rather than on which particular functions of the state have been reassigned to the individual. In this endeavor, we diverge slightly from the neoliberal governmentality literature that focuses specifically on the transference of state power to individuals.Footnote 15 While this literature acknowledges the formation of a self-governed—or rather self-responsibilized—subject as a result of indirect governance and discusses the historical, social, and economic conditions that led to this formation, we observe that the what and the how of this new form of subjectivity have been relatively less studied. This has recently begun to change, however, with the publication of Foucault’s 1978–1979 lectures, The Birth of Biopolitics, where he introduces the self-entrepreneur homo œconomicus as the quintessential subject of neoliberalism.Footnote 16 Following Foucault’s conceptualization of neoliberalism as not merely a product of state power or class antagonism, but first and foremost as an “inevitable aspect of the human condition” materialized as homo œconomicus,Footnote 17 neoliberal governmentality scholars came to think more about the particular social ontology of this self-governing subject of neoliberalism.Footnote 18
As a domain where these discussions on neoliberal governmentality took precedence, studies concerning health focus on its reregulation in line with market logic and signal the emergence of a self-entrepreneur homo œconomicus that takes responsibility for the management of her/his well-being. An emphasis on the “individualisation of responsibility”Footnote 19 began to appear in especially those studies that critically engage with the widespread commonsensical images and conceptualizations of obesity and smoking.Footnote 20 In their critique, they survey current discursive systems and, by highlighting specifically how obesity and smoking are constructed as unhealthy and seen as an “individual’s risk behavior,” question the ways in which their medicalization and stigmatization are justified, rationalized, and politicized.Footnote 21 In other words, these studies discuss how both the processes and the mechanisms of avoiding smoking and preventing obesity become a matter of individual responsibility. Seen through the lens of neoliberal governmentality, they define the self-responsibilized health entrepreneur as one who takes care of her/his health by making the rational choice of not smoking and preventing becoming obese. As will be demonstrated below, our research into the public spots of the MH revealed a similar problematization wherein both smoking and obesity emerged as major health risks that could be effectively managed with the active participation of individuals.
In studies concerning risk, the neoliberal governmentality approach is also directed against realist epistemologies, and specifically against a Beckian approach to risk.Footnote 22 Risk is seen by Beck as the fundamental feature of contemporary societies, both in and of itself and through its wider social, political, and economic implications.Footnote 23 Risks not only increase quantitatively and multiply rapidly, but are also brought about by human activity, thereby making them inescapable and routinized features of contemporary societies. The neoliberal governmentality framework alternatively approaches risk as a tactic, strategy, and technique and/or as a form of governance, and it studies the multiple ways in which risks are calculated, administered, overseen, and responded to.Footnote 24 In this sense, the governance of risks no longer plays the central role, but is instead replaced in contemporary societies by a governance by risks.Footnote 25 While we acknowledge Beck’s contribution to risk studies, his quintessentially realist methodology, which leads him to reduce risks to their quantitative arrangements and assign them ontological status, does not translate well into our analysis. As such, we do not discuss obesity and smoking as “objective” or “real” risks that exist out there, but as part of a neoliberal governmental strategy through which individuals, as health entrepreneurs, are responsibilized to engage in self-governance.
In what follows, we will first address the formation of subjectivity as homo œconomicus under neoliberal governance. Then, drawing on interviews with personnel from the MH’s Health Communication Head Office (Sağlık İletişimi Daire Başkanlığı)Footnote 26 and using a number of examples from the MH’s public spots on obesity and smoking, we will discuss how these spots both expect and encourage individuals to care for their own well-being and manage their own health by governing risks. We group public spots, based on their content, into two different styles: pedagogical and self-motivational. We argue that both styles speak directly to individuals and aim to induce a particular behavioral change as guidelines by encouraging each individual to adopt and maintain a healthy lifestyle with a balanced diet, regular activity, and no smoking. At the same time, however, each style points toward a contradictory relationship with the health-entrepreneur homo œconomicus. While self-motivational spots address an already existing self-responsibilized entrepreneur who is willing and able to manage her/his own health risks through her/his own resources, pedagogical spots aim at the production of such an entrepreneur by claiming to “inform” and “educate” individuals about personal health risks. We mark this coexistence as a somewhat defining contradiction of the public spots under analysis and conclude by proposing that, while these spots ultimately treat health as a matter of personal conduct and the responsibility of the neoliberal subject homo œconomicus, the social ontology of this new subject remains ambiguous.
Neoliberal governmentality and the self-entrepreneur homo œconomicus
Contrary to its dominant conceptualization as a capitalist economic process,Footnote 27 in Foucault’s usage neoliberalism refers to a much more extensive strategy of governing human action across a multiplicity of domains.Footnote 28 Foucault implies this when, in The Birth of Biopolitics, he defines neoliberalism as a “new art of government” or a form of governmentality, countering the arguments that conceptualize it merely as the “pure and simple consequence and projection of the current crisis of capitalism in ideology, economic theory, or political choice.”Footnote 29 The political rationality of this new art of governance closes the gap between economy on the one hand and society and politics on the other, a gap established by classical liberalism. In reference to its diffusion and breadth as a governance strategy, neoliberal governmentality becomes a generic term in Foucauldian scholarship, one whose frame reaches beyond pure market relations and financial networks to designate a specific economic rationality that cuts across multiple domains of life.Footnote 30
One of the novelties of neoliberal governmentality is the new subject, homo œconomicus, that it brings along with it. While Foucault borrows this term from classical liberalism, where it designated a “man of exchange” or a “partner of exchange,” in neoliberal governmentality homo œconomicus transforms into “an entrepreneur of himself,” becoming his own capital, producer, and source of earnings.Footnote 31 Even though this new subject engages in perpetual cost-benefit calculation and rational choice,Footnote 32 he does not reserve this exclusively for financial or profit-generating matters. In Foucault’s own words:
[C]onsidering the subject as homo œconomicus does not imply an anthropological identification of any behavior whatsoever with economic behavior. It simply means that economic behavior is the grid of intelligibility one will adopt on the behavior of a new individual. It also means that the individual becomes governmentalizable, that power gets a hold on him to the extent, and only to the extent, that he is a homo œconomicus.Footnote 33
That is, only when man becomes an entrepreneur of himself, constituting himself as homo œconomicus, does he become a subject of neoliberal governance. What subjectivizes man as homo œconomicus, however, is not simply the economic transactions he conducts, but also the entrepreneurship mentality that he develops in his relations, which expands into all spheres of life, making life itself a cost-benefit calculation.
This self-entrepreneurship, we suggest, particularly manifests itself in homo œconomicus’ relationship to risk governance, where risk emerges as the primary concern that mediates her/his position in life, regulating her/his actions, decisions, and relations. Scholars studying risk from the perspective of neoliberal governmentality acknowledge that risk governance proceeds through individualizing risks and responsibilizing individuals concerning their management. Early accounts of responsibilization as the key feature of neoliberal governmentality were put forth in the works of Graham Burchell, Pat O’Malley, and Mitchell Dean, who highlighted the role of actively responsible individuals managing risks on their own. Risk calculation has always been a matter of cost-benefit calculation. What is peculiar to neoliberal governmentality is the relegation of responsibility for this calculation to the individual, making her/him an entrepreneur of risk governance in multiple social domains. Dean’s elaboration furthers this point by arguing that risk management currently occupies a central position in an individual’s every choice: “[W]e witness the multiple ‘responsibilization’ of individuals, families, households, and communities for their own risks: of physical and mental ill-health; of unemployment; of poverty in old age; of poor educational performance; or of becoming the victims of crime.”Footnote 34
This individualization of responsibility has recently been taken up by scholars to look at how it operates on a wider scale, covering areas including but not limited to citizenship and immigrant integration policies,Footnote 35 environmental and biodiversity conservation,Footnote 36 contemporary consumption practices,Footnote 37 security and crime prevention,Footnote 38 and health and body politics.Footnote 39 Responsibilized individuals regulate their own behavior in environmentally friendly ways; they responsibilize themselves in order to achieve membership in a national community or, as an immigrant, they integrate their own selves through education and training programs; they take responsibility for creating security by preventing crime in their own environment; and they bear the responsibility for leading a healthy lifestyle by choosing to eat well, exercise regularly, drink less, and not smoke. In all of these areas, the responsibilized individual becomes an entrepreneur of her/his own life by investing in “individualized and self-regulating entrepreneurial behavior” while taking up the management of life risks.Footnote 40 To express this in strictly Foucauldian terminology, it is through the problematization of risk governance in each of these areas—constructed fundamentally as a matter of individual choice—that the subject of responsibility is constructed as the individual.
Taking on responsibility brings with it self-governance, where risks relate to an individual’s self-knowledge, self-control, self-improvement,Footnote 41 and self-empowerment.Footnote 42 These characteristics are apparent in Foucault’s portrayal of the neoliberal homo œconomicus as a governable individual, one “who accepts reality or who responds systematically to modifications in the variables of the environment […] someone manageable, someone who responds systematically to systematic modifications artificially introduced into the environment.”Footnote 43 We read this statement as placing more emphasis on the governability of homo œconomicus and less on the systematicity of environmental modifications or interventions in life itself. However, such governability does not follow a specific agent’s or agents’ making homo œconomicus governable. What we are particularly interested in as part of our discussion is the inclination of homo œconomicus to self-responsibilize in the face of health risks, which may or may not be foreseen, predicted, or prevented.
Responsibilizing individuals in public spots
Public spots on smoking and obesity are solid cases pointing toward the designation of the individualization of responsibility as concretized in the figure of the self-entrepreneurship of homo œconomicus. They were introduced as part of nationwide programs on anti-smoking (the National Tobacco Control Program and Action Plan, NTCPAP [Ulusal Tütün Kontrol Programı ve Eylem Planı])Footnote 44 and anti-obesity (the Obesity Prevention and Control Program of Turkey, OPCPT [Türkiye Obezite ile Mücadele ve Kontrol Programı])Footnote 45 launched by the MH in 2008 and 2010, respectively, and meant to encourage individuals to adopt a healthy lifestyle. Both programs stemmed from the World Health Organization (WHO) summits that designated obesity and smoking as major health risks in the contemporary world. In 2004, Turkey became a party to the WHO’s Framework Convention on Tobacco Control, which was developed in response to the organization’s concerns over the “globalization of the tobacco epidemic.” Two years later, Turkey prepared an action plan to reduce the demand for tobacco and avoid diseases stemming from its use. The same year, Turkey hosted WHO’s European Ministerial Conference on Counteracting Obesity, which this time drew attention to the global increase in the “obesity epidemic.” The conference adopted the European Charter on Counteracting Obesity, according to which the MH prepared the OPCPT for decreasing the obesity risk in Turkey.
The common point in both programs is the conceptualization of obesity and smoking as what Evans calls “risk factors”Footnote 46 for major illnesses such as cardiovascular diseases, cancer, hypertension, and diabetes. Concentrating on these risk factors, first of all, points toward a pre-emptive strategy aimed at annihilating potential future illnesses; i.e., it signals a “broader policy shift to manage and ‘treat’ risk rather than symptoms.”Footnote 47 Furthermore, through such a strategy, risk—rather than designating a “potential harm”—has gradually become synonymous with “actual harm,” and as such, it has come to emphasize danger in contemporary understandings of risk.Footnote 48 During our interviews, MH personnel drew attention to this issue by arguing that these programs are not concerned with obesity or smoking as “diseases” in themselves, but rather with the health risks they embody, which they summarized under the concept of “disease burden.” The personnel argued that obesity and smoking carry “disease burdens,” and emphasized that, through these burdens, they are able to generate a series of malfunctions in the body. For instance, in the words of one of the interviewees, obesity may “impede the working of your organs, which may lead to systemic malfunctions and may thus become a cause for many future diseases.” Through such a conceptualization, fighting health risks translates into fighting the actual harm they may inflict upon the body.
While the NTCPAP and the OPCPT view the individual as the most crucial responsibilized actor, they also assign to various state agencies responsibility for dealing with the risks caused by smoking and obesity and deterring the harms they might cause. First of all, both programs assign a supportive role to the MH for providing services (establishing smoking cessation hotlines and polyclinics, distributing free nicotine patches, setting up exercise equipment in public parks, and providing counselling services in local clinics against obesity) and regulation (controlling cigarette prices, banning smoking in closed spaces, and removing fatty foods from school cafeterias). Secondly, the Ministry of Finance is responsibilized for the taxation of cigarettes and the determination of cigarette prices, controlling the illegal tobacco trade, creating opportunities for physical activity at workplaces and schools, and creating sport centers and recreational areas in urban neighborhoods. Finally, the Ministry of Education is responsibilized for educating teachers on the causes of obesity, giving school children information about the significance of a balanced diet and physical activity for the prevention of obesity, and delivering fresh fruit and milk to schools.
Nonetheless, in order to fight the aforementioned harm, these programs specifically require the participation of a health-responsible individual as the key actor. The then Minister of Health, Recep Akdağ, stressed this concisely in the preface of the OPCPT: “A healt[h]y life can not be provided only by increasing the quality of the health services presented to the public. It is required that the individual should be aware of his/her health, should demand services and should develop behavioural changes in the positive direction [sic].”Footnote 49 During our interviews, MH personnel also emphasized the health-responsible individual as a major agent in the fight against obesity and smoking. All of them remarked, quoting one after the other, that no matter how widespread the services provided and how effective the regulations set up by the MH or other government agencies might be, at the end of the day it is the individual who is responsible for her/his health. Interventions such as the NTCPAP and the OPCPT, they argued, would not be successful unless individuals adopted “positive” behavioral changes as part of their daily routines, with a balanced diet, regular activity, and no smoking.
Public spots on obesity and smoking make the individual the main point of implementation for these nationwide programs, and originally emerged so as to encourage her/him in developing the proposed behavioral changes. MH personnel repeatedly compared the public spots with such other conventional means of information as documentaries, brochures, posters, booklets, and billboards, and they praised the public spots as a new, creative, and highly effective means of bringing out change in the health conduct of individuals. For them, it is the appeal and accessibility of television to the broadest possible national audience that makes public spots an especially desirable medium. In the words of one interviewee: “[The individual] watches TV with her/his defence mechanisms down; s/he believes whatever s/he sees on TV and takes no heed of her/his family practitioner.” Whereas other mediums are rarely seen, read, or observed, public spots are aired on every television channel for 90 minutes a month (30 minutes of which must be during prime time), and as such they are able to reach individuals from different social backgrounds, ages, educational levels, and regions. MH personnel also remarked that many individuals do not read brochures because they find them too long and overloaded with information, and they do not watch informative television programs on health, such as documentaries, because they simply find these programs boring. We were told that public spots are paid attention to by a much wider audience because, by imitating the format of a television commercial, they could deliver the desired information in a condensed manner, without exhausting or frustrating individuals. One interviewee, for instance, observed that individuals are not intimidated by doctors when they see them on television, as opposed to the daunting experience most of them have when faced with a doctor during consultation. “Therefore,” she added, “when in front of the TV s/he listens more, applies [the principles] better, and alters her/his behavior significantly.”
The recurrent stress upon individual participation and the efforts made through public spots to include her/him as a responsible party in the anti-smoking and anti-obesity programs point toward a particular conceptualization of health that privileges a neoliberal participant; i.e., an “entrepreneurial self actively engaged in maintaining his or her own health.”Footnote 50 This neoliberal participant—the individual as a health entrepreneur expected to take responsibility for eliminating health risks and governing her/his own well-being—emerges wherever health is problematized from the perspective of neoliberal health governance. In this particular problematization, health is a matter of individual lifestyle choice. Eating well, exercising regularly, and not smoking—and thus preventing major illnesses that damage health—all become a matter of what kind of life the individual chooses for herself/himself. The health entrepreneur, enmeshed in a net of numerous possibilities, is expected to calculate the costs and benefits of each choice, find the most rational one among them, and construct her/his life around it. Within this context, public spots on obesity and smoking appear as guidelines for health risk management, produced not only to direct the attention of health-entrepreneur individuals toward certain health risks, but also to suggest to them, rather than imposing on them, the most “rational” and “cost-beneficial” ways of avoiding, eliminating, and managing these risks.
As of January 2015, the MH has produced fourteen spots on smoking and eight spots on obesity. We have grouped these spots into two different styles according to their contents: whereas one has a pedagogical style providing descriptive and technical information, the other is self-motivational in that it presents real-life narratives of individuals who quit smoking or overcame obesity. The pedagogical public spots, being by definition informative and educational insofar as they are produced so as to make individuals “internalize” the information provided—rely explicitly on expert knowledge. Instead of appealing to the audience’s emotions, they use a dry language expressing technicalities and describing the effects of smoking on the body or showing how to calculate and prevent obesity. One such public spot concentrates on the negative effects of tobacco smoke on the lungs. It describes the damage smoking causes by displaying a hand squeezing a sponge filled with a muddy liquid. The sponge acts as a metaphor for how air pores in a smoker’s lungs become filled with tar. As viewers are exposed to this image, an authoritative male voiceover states: “Our lungs are like sponges that take the air in. When we inhale cigarette smoke into our lungs instead of air, it accumulates as cancer-causing tar.” After this statement, we see a jar being filled with a muddy liquid, and from the voiceover we learn that the liquid in the jar equals the amount of tar accumulated in one year in the lungs of a one-pack-a-day-smoker. An intimidating statement accompanies this image: “This much tar is enough to make you sick.” Another pedagogical public spot begins by informing the viewer that “cigarettes harm you with each puff,” showing once more how the inhaled smoke damages one’s lungs through yet another sponge that undergoes deterioration in texture and color, gradually turning from yellow to gray and gray to black as its pores decompose and eventually vanish. In the meantime, we are told by the authoritative male voiceover: “Our lungs are made up of millions of air pores, just like sponges. The cigarette smoke that is inhaled damages these air pores. This is why smokers experience shortness of breath.”Footnote 51
In obesity spots, a similar pedagogical style is observed, but the images used are less graphic and the voiceover less authoritative. One public spot introduces BMI (body-mass index) as the only reliable source for calculating obesity. The viewer sees a red and white animation showing a man measuring his height and calculating his weight in order to find out his BMI number. The voiceover informs us: “Everyone has a body-mass index. We learn our height-weight ratio from this index and see whether or not we are fat.” Then the spot explains how BMI is calculated and advises individuals to seek medical help should the figure be over 25. It finishes by stating, “Come on Turkey: start moving.” Another public spot on obesity cautions individuals against the “great risk” of obesity, “the most important threat of our era,” by pointing out how an unhealthy diet and sedentary lifestyle leads to it. It directly calls for individuals to exercise regularly every day and shows different people across Turkey—young, old, men, women, overweight, thin, fit—walking or running in their neighborhoods, in parks, in forests, on beaches, over bridges, on streets, at historical sites, and so forth. The spot concludes by informing the viewer: “The Ministry of Health has started a fight against obesity and calls for you to walk, run, move at least thirty minutes a day. Come on, stand up: you, too, move against obesity.” Finally, one recent pedagogical campaign on obesity—namely, the “Live Healthy, Grow Healthy” campaign, which consists of three separate yet connected series—addresses children. Shot as animation, it shows the daily life of a “robust child” (gürbüz çocuk): after a decent night’s sleep, he leaves the house, takes the stairs (rather than riding the elevator), does his daily walking exercise, plays with his friends, eats the healthy foods his mother has cooked for him, drinks his milk so as to ensure the healthy growth of his bones, and throughout this entire process, he refrains from processed foods. This last point is also heavily emphasized as part of the “Eat Well, Move, and Live Happy” campaign in two other public spots on obesity. One of them shows an inactive and overweight young boy eating processed food at home while his friends play outside. The spot calls for parents to keep their children away from junk food and to encourage them to engage in physical activity. The other one follows a young male overconsuming sugar and foods rich in carbohydrates. The male voiceover finishes this public spot by stating, “Obesity is not your destiny—it is your choice.”
The pedagogical public spots are specifically directed at informing and educating individuals about health risks. The spots on smoking graphically display its damaging effects on the body, while those on obesity present it as a major health problem that could happen to us all. In this way, they encourage individuals to quit smoking and to preemptively act against obesity. In this pedagogical style, the individual is designated as the main target of the proposed actions and consequently responsibilized as the primary agent of health management. Smoking is problematized through its negative effects and the explicit health risks it poses to the smoker’s body, and the smoker’s body only. By displaying the harm and damage cigarette smoke causes to one’s lungs and indicating the potential illnesses—such as lung and throat cancer and chronic obstructive lung disease—that might result, these spots invite the individual to quit and make the right decision by “choosing health.” On the other hand, unlike the spots on smoking, pedagogical spots on obesity do not concentrate on the potential harm and damage awaiting an obese individual, but they do still envision her/him as the responsible agent. They do this by placing the burden upon individuals to learn and decide for themselves whether or not they are obese by calculating their own BMI and calling preemptively for them to avoid becoming obese.
These pedagogical spots attempt to produce a self-entrepreneur, one who will make the right and rational choice of avoiding the risks of smoking and obesity. With their distinctive style—i.e., the authoritative voiceover, the oversimplified language, and the clear-cut differentiation between right and wrong conduct—they aim to generate in individuals the trait of rational decision-making, cost-benefit calculation, and self-responsibilization. Moreover, what is understood as a healthy lifestyle (marked by eating well, not smoking, and exercising, and thereby eliminating the risk factors that could harm an individual’s body) is an already established fact for the NTCPAP and the OPCPT, and the pedagogical public spots intend to direct individuals toward such a lifestyle. Similarly, during our interviews, we were repeatedly told that public spots play a key role in the advent of a “self-aware” and “health-conscious” individual, guiding her/him toward “internalizing” a healthy lifestyle. This guiding process was called “fostering health literacy” by the MH personnel. This designation imagines the individual as a potential student of health, and the ideal individual that would emerge from this educational process is one who has “learned and internalized the basic language of health,” or, to express it in the terms of neoliberal governmentality, one who is a responsibilized self-entrepreneur.
We encounter the individual as health entrepreneur once more in the second style of public spot, the self-motivational type, which features the narratives of real individuals who successfully quit smoking and/or fought obesity. However, unlike the pedagogical public spots, the self-motivational spots assume that their audience is already a self-entrepreneur, and thus able to make the rational choice through cost-benefit calculation. Addressing this self-entrepreneur, these spots adopt a style that is indirect, inviting the audience to associate themselves with the story told on the screen. One MH personnel argued that it is much easier for individuals to adopt a particular behavior if they see it done in real life by real persons (i.e., by someone who really did quit smoking or lose weight): “I can do it if she can” is the motivation these stories mean to provide. These spots all follow the same storyline: a former smoker or an overweight individual, usually in a very casual environment and sometimes in the presence of significant others or relatives, tells her/his story of why, how, and when s/he decided to quit smoking or lose weight. While these individuals come from different social backgrounds and have varying demographic characteristics, their stories share common themes. Firstly, they all begin by stressing the negative effects of smoking or obesity. These are described as troubled breathing while walking, working, or running; insomnia; wheezing lungs; shortness of breath; dry cough; a sudden rise and fall in blood sugar; and laziness—all of which disappeared after the narrator quit smoking or lost weight. Secondly, all the individuals express an exuberant joy about their restored health, using phrases like: “I’ve been saved from laziness, now I’ve got energy;” “I grew younger, no more shortness of breath or insomnia;” and “I started exercising; I’ve never felt better.” Thirdly, in these self-motivational public spots what we hear about is not how smoking and obesity were fought against with professional help. For instance, none of the speakers achieved success through nicotine patches, medication, placebos for cigarettes, weight-loss programs, or frequenting gyms and beauty centers. Instead, it is their own will power and self-motivation that is put forward as what enabled success: “I wanted it from the bottom of my heart and I succeeded;” “I decided once and for all, end it, and I haven’t smoked from that day on;” “I personally saved myself;” “What you need is […] will power and perseverance […] to successfully lose weight.” What these real-life stories ultimately emphasize is the figure of a self-sustaining individual who takes personal responsibility for her/his own health, or a health entrepreneur who fights risks in a determined manner using her/his own resources and governing her/his own life. In other words, these spots portray an individual choosing the right conduct as a result of being able to make a rational choice: “It’s your choice—while it’s not too late;” “Your life, your choice;” “It’s your choice;” “Call 171 to choose health;” “I saved myself—and you can save yourselves;” “She chose health before it was too late.”
Public spots as a technique of neoliberal governmentality
The mentality of neoliberal governance and its perpetual cost-benefit calculation constructs public spots as the most effective way to both produce and address health entrepreneurs by encouraging them to internalize and put into practice the guiding information provided in the spots. In trying to induce a particular behavioral change by promoting the adoption of a healthy lifestyle—which basically means knowing how to manage the health risks that smoking and obesity might generate—the public spots portray a model of homo œconomicus, the subject of neoliberal governance. Homo œconomicus emerges in these public spots, where s/he is made the target of proposed actions on managing health risks in order to achieve a desired behavioral change through an induced association with real individuals; where health risks are conceptualized as being inflicted by the individual upon her/his own body; where health is problematized as an individual’s own lifestyle choice; and where the individual ultimately is expected to act upon her/his body, her/his health, and her/his life. Thus, public spots reveal the mentality in which the state—however efficient it may be in its management of health through the provision of services and the implementation of regulations—can only facilitate health improvement and risk management to a certain extent. Unless the individual takes it upon herself/himself to decide to quit smoking, start exercising regularly, and follow a balanced diet, the state’s efforts will remain all in vain. As Gilbert puts it concisely, “the ill-health effect is avoidable, if individuals master their own lives.”Footnote 52
The ontology of this new subject, however, is rather ambiguous: it is unclear if the responsibilized individual or health entrepreneur in question already exists as the target, or if it only comes into existence through the intervention of public spots. It seems that public spots are attempting to move in two completely opposite directions at the same time, giving rise to a contradiction: while the real-life narratives of “successful” individuals hint at an already existing health entrepreneur, those spots that adopt a pedagogical style aim to produce that very entrepreneur. Whether this contradictory character of the public spots represents the ontology of a new subject needs to be further elaborated.
What we find particularly interesting in this formulation is that the responsibilized individual, the health entrepreneur, or the subject of neoliberal governance emerges in the public spots as a self-focused subject, not as part of a community, society, or environment. Rather than stressing the risks of obesity and smoking on the whole population, these spots choose to focus on how these risks affect the individual’s body, and the individual’s body alone. Thus, excepting only one public spot—which cautions parents about child obesity—health is problematized neither through its weakening and deterioration, nor through its improvement and amelioration as regards current and/or future populations. However, this does not mean that such a problematization is entirely absent from the nationwide programs NTCPAP and OPCPT. These programs, in responsibilizing multiple government institutions toward managing smoking and obesity by providing services and regulations at the national level, do not disregard the social dimension of such risks. They target the entirety of the population and highlight mortality, morbidity, and the disease burden as risks that can potentially decrease the quality of life and the life expectancy of the whole population. The public spots, on the other hand, take a different tack: they do not steer toward the social dimensions of smoking and obesity risks by, for instance, emphasizing the damage caused by passive smoking; the possible negative impacts of smoking and obesity upon life expectancy, mortality, and morbidity; or the social costs and implications of the disease burdens they carry. In short, public spots do not portray an individual with social concerns, within a social environment, or as part of a community, and thus they do not portray an individual who is also responsible for the health of others. Instead, they target the more self-centered and self-absorbed individual. On this point, we agree with Crawshaw to the extent that he sees in regimes of neoliberal health governance a lack of engagement with communities or a disinterest in improving the environment and, instead, an emphasis on self-discipline in self-conduct (such as dieting, exercising, and regulating tobacco and alcohol as risky substances), thereby making the individual, not the social, the implicit target of intervention.Footnote 53 It is this implicit target that makes these public spots a technique of neoliberal governmentality in the management of health in contemporary Turkey.
