Risk Ritual and the Management of Control and Anxiety in Medical Culture
Identifieur interne : 002132 ( Istex/Corpus ); précédent : 002131; suivant : 002133Risk Ritual and the Management of Control and Anxiety in Medical Culture
Auteurs : Robert CrawfordSource :
- Health [ 1363-4593 ] ; 2004-10.
English descriptors
- Teeft :
- Breast cancer, Conduct life, Contemporary anxiety, Contemporary health consciousness, Contemporary life, Crawford, Critical theory, Cumulative message, David ropeik, Distinctive feature, Early stages, Endangerment, Epidemiological knowledge, Expert knowledge, Expertise, Fear factor, Genetic predisposition, Genetic risk, Harvard center, Health consciousness, Health education, Health educators, Health hazard information, Health hazards, Health policy, Health promotion, Health status, Individual efforts, Insecurity, Institutional practices, Instrumental control, Lifestyle, Lifestyle changes, Lifestyle hazards, Lupton, Medical authority, Medical centers, Medical culture, Medical knowledge, Medical monitoring, Medical supervision, More knowledge, Other hand, Other words, Personal control, Political rationality, Potential harm, Prescriptive advice, Prevention paradox, Professional health promotion, Psychosomatic subjects, Rationality, Recent advances, Risk, Risk analysis, Risk assessment, Risk communication, Risk communication experts, Risk discourse, Risk experts, Risk factors, Risk management, Risk professionals, Risk rationality, Risk ritual, Risk ritual features, Risk society, Risk technologies, Risk technology, Robert crawford, Ropeik, Safe passage, Sage publications, Social production, Social science, Symbolic order, Symbolic power, Symbolic practice, Symbolic substance, Technical control, York times.
Abstract
Medical culture in advanced technological societies is characterized by an abundance of warnings about health hazards, along with an equally abundant flow of prescriptive advice for protecting individuals against them. Knowledge of health hazards also defines living and working environments and has spawned a politics of regulatory control. These features of contemporary health consciousness and action, along with deepening insecurities in the larger body politic, precipitate a spiral of anxiety and control. The spiral disrupts the presumed security derived from medical knowledge and medically informed behaviors and threatens to erode the boundaries of sanctioned action for health protection. In the context of the volatile political economy of health, the spiral, with its excesses of anxiety and demands for unauthorized controls, elicits efforts to contain it. I explore the symbolic dimensions of risk, what I call ‘risk ritual’ - the prevailing form of managing this troublesome contradiction.
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DOI: 10.1177/1363459304045701
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ISTEX:201156BA33654076CAC6B9D6DEB98C19F5B36D8DLe document en format XML
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(1991)</json:string><json:string>Lupton (1999)</json:string><json:string>Beck, 1992</json:string><json:string>quoted in Robertson, 2001: 294</json:string><json:string>Lupton, 1999</json:string><json:string>Tulloch and Lupton (2003)</json:string><json:string>Ropeik, 2002: 2</json:string><json:string>Gray and Ropeik, 2002: 112</json:string><json:string>Ferudi, 1997</json:string><json:string>Davison et al. (1992)</json:string><json:string>Lupton, 1993</json:string><json:string>Novas and Rose, 2000</json:string></ref_bibl><bibl></bibl></unitex></namedEntities><ark><json:string>ark:/67375/M70-WF8KB9V8-4</json:string></ark><categories><wos><json:string>1 - social science</json:string><json:string>2 - social sciences, biomedical</json:string><json:string>2 - public, environmental & occupational health</json:string></wos><scienceMetrix><json:string>1 - health sciences</json:string><json:string>2 - public health & health services</json:string><json:string>3 - public health</json:string></scienceMetrix><scopus><json:string>1 - Social Sciences</json:string><json:string>2 - Social Sciences</json:string><json:string>3 - Health(social science)</json:string></scopus><inist><json:string>1 - sciences humaines et sociales</json:string></inist></categories><publicationDate>2004</publicationDate><copyrightDate>2004</copyrightDate><doi><json:string>10.1177/1363459304045701</json:string></doi><id>201156BA33654076CAC6B9D6DEB98C19F5B36D8D</id><score>1</score><fulltext><json:item><extension>pdf</extension><original>true</original><mimetype>application/pdf</mimetype><uri>https://api.istex.fr/ark:/67375/M70-WF8KB9V8-4/fulltext.pdf</uri></json:item><json:item><extension>zip</extension><original>false</original><mimetype>application/zip</mimetype><uri>https://api.istex.fr/ark:/67375/M70-WF8KB9V8-4/bundle.zip</uri></json:item><istex:fulltextTEI uri="https://api.istex.fr/ark:/67375/M70-WF8KB9V8-4/fulltext.tei"><teiHeader><fileDesc><titleStmt><title level="a" type="main" xml:lang="en">Risk Ritual and the Management of Control and Anxiety in Medical Culture</title></titleStmt><publicationStmt><authority>ISTEX</authority><publisher scheme="https://scientific-publisher.data.istex.fr">Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><availability><licence><p>sage</p></licence></availability><p scheme="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B"></p><date>2004</date></publicationStmt><notesStmt><note type="research-article" scheme="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</note><note type="journal" scheme="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</note></notesStmt><sourceDesc><biblStruct type="inbook"><analytic><title level="a" type="main" xml:lang="en">Risk Ritual and the Management of Control and Anxiety in Medical Culture</title><author xml:id="author-0000"><persName><forename type="first">Robert</forename><surname>Crawford</surname></persName><affiliation>University of Washington, Tacoma, USA</affiliation></author><idno type="istex">201156BA33654076CAC6B9D6DEB98C19F5B36D8D</idno><idno type="ark">ark:/67375/M70-WF8KB9V8-4</idno><idno type="DOI">10.1177/1363459304045701</idno><idno type="article-id">10.1177_1363459304045701</idno></analytic><monogr><title level="j">Health</title><idno type="pISSN">1363-4593</idno><idno type="eISSN">1461-7196</idno><idno type="publisher-id">HEA</idno><idno type="PublisherID-hwp">sphea</idno><imprint><publisher>Sage Publications</publisher><pubPlace>Sage CA: Thousand Oaks, CA</pubPlace><date type="published" when="2004-10"></date><biblScope unit="volume">8</biblScope><biblScope unit="issue">4</biblScope><biblScope unit="page" from="505">505</biblScope><biblScope unit="page" to="528">528</biblScope></imprint></monogr></biblStruct></sourceDesc></fileDesc><profileDesc><creation><date>2004</date></creation><langUsage><language ident="en">en</language></langUsage><abstract xml:lang="en"><p>Medical culture in advanced technological societies is characterized by an abundance of warnings about health hazards, along with an equally abundant flow of prescriptive advice for protecting individuals against them. 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<p>Medical culture in advanced technological societies is characterized by an abundance of warnings about health hazards, along with an equally abundant flow of prescriptive advice for protecting individuals against them. Knowledge of health hazards also defines living and working environments and has spawned a politics of regulatory control. These features of contemporary health consciousness and action, along with deepening insecurities in the larger body politic, precipitate a spiral of anxiety and control. The spiral disrupts the presumed security derived from medical knowledge and medically informed behaviors and threatens to erode the boundaries of sanctioned action for health protection. In the context of the volatile political economy of health, the spiral, with its excesses of anxiety and demands for unauthorized controls, elicits efforts to contain it. I explore the symbolic dimensions of risk, what I call ‘risk ritual’ - the prevailing form of managing this troublesome contradiction.</p>
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</kwd-group><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value> Risk ritual and the management of control and anxiety in medical culture Robert Crawford University of Washington,Tacoma, USA ABSTRACT Medical culture in advanced technological societies is charac- terized by an abundance of warnings about health hazards, along with an equally abundant flow of prescriptive advice for protecting individuals against them. Knowledge of health hazards also defines living and working environ- ments and has spawned a politics of regulatory control. These features of contemporary health consciousness and action, along with deepening inse- curities in the larger body politic, precipitate a spiral of anxiety and control. The spiral disrupts the presumed security derived from medical knowledge and medically informed behaviors and threatens to erode the boundaries of sanctioned action for health protection. In the context of the volatile political economy of health, the spiral, with its excesses of anxiety and demands for unauthorized controls, elicits efforts to contain it. I explore the symbolic dimensions of risk, what I call 'risk ritual' the prevailing form of managing this troublesome contradiction. KEYWORDS anxiety; control; culture; health; risk ADDRESS Robert Crawford, Interdisciplinary Arts and Sciences, University of Washington, Tacoma, 1900 Commerce, Tacoma, WA, 984023100, USA. ACKNOWLEDGMENTS I am grateful to William Arney, Isaac Balbus, Phillip Cushman, Peter Marshall, June Lowenberg and the referees of health: for their careful critiques and editorial suggestions on earlier drafts of this article. Health consciousness and individual action to protect and improve health have become integral to the quest for security. The fear of disease, untimely death and perhaps the fear of death itself, can be stilled, or so it is hoped, by becoming informed about hazards to health and by taking steps to minimize and monitor dangers. As Susan Sontag (1978) suggests, disease, death's cognate, is modernity's angel of darkness against which a technical war a spiritual war, in fact must be waged. Death, Zygmunt Bauman (1992) argues, 'scandalizes' modern ambitions. Not to be deterred, we 'deconstruct' death by converting it into innumerable 'specific causes'. 505 health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine Copyright © 2004 SAGE Publications (London, Thousand Oaks and New Delhi) DOI: 10.1177/1363459304045701 1363-4593; Vol 8(4): 505528 Combating these specific causes becomes our daily task. Indeed, the improvement of health is among modernity's principal symbolic practices. In mobilizing anxieties and energies related to life and death, social action in the name of health validates or fails to validate forms of knowledge and institutions held responsible for individual and collective well-being. Moreover, the quest for health has become a distinctive feature of middle- class identity and belonging. To the question, 'How should I live?', the denizen of medical culture answers, 'Healthfully'. Behaviors are modified and lifestyles constructed in response to information about dangers to health. Often enough, as with smoking, diet and exercise, preventive action delivers on its promise, resulting in improved health status, and with it, apparently, enhanced security. Or does it? Does making health an important life goal, requiring sustained attention to medical information and medically informed, instru- mental action increase security? I will argue that in health, as throughout contemporary social life, western scientific and technical rationality, in the context of a predatory global capitalism, cannot deliver the security it promises. The dream of security is confounded by the insecurity of contem- porary social conditions and, ironically, by insecurity generated by efforts for protection. Following Arthur Barsky's (1988) pioneering work, I explore a contradiction at the heart of medical culture: the continuing expansion of knowledge about threats to health, the prolific communication and insatiable consumption of that knowledge and the professional and lay mandate to protect and improve health together aggravate the very inse- curities they are designed to quell. The preoccupation with safety engen- ders alarm, a heightened sensitivity to danger and a sense of personal vulnerability. My topic, then, is the nexus of control and anxiety the control of anxiety but also the anxiety of control in contemporary health practice. Anxiety about health, though over-determined, is aggravated by a medical culture compelled to identify dangers in order to control them. Anxiety is the collateral damage of a boundless ambition to extend life and eliminate the sources of corporeal harm. Control and anxiety are the twin siblings of health consciousness and action. We do not dwell in one state without dwelling in the other. If we are to understand contemporary health consciousness, its articulations with other experiences of insecurity in the present era and its implications for the politics of 'risk society', we must attend to the cultural formation of anxiety and control and the experien- tial distress associated with its volatile dynamic.1 My contention is that a distinctive feature of contemporary medical culture is an escalating spiral of control and anxiety. The drive to achieve security through the acquisition of medical knowledge and the adoption of individual, self-protective practices motivates more finely tuned awareness of contingency and still more elaborate efforts in pursuit of an enigmatic health. The more that is controlled, the more apparent becomes that which eludes control. Each advance in medical knowledge and practice opens new health: 8(4) 506 horizons of complexity, unpredictability and tasks, the first of which is the acquisition of more knowledge. As Barsky (1988) emphasizes, overall improvement in health status is accompanied by a declining satisfaction with health and an increased sensitivity to symptoms. And as Renee Fox (1980) contends, the rising expectations that accompany every medical advance engender greater intolerance of uncertainty. In other words, dangers to health, continuously disclosed and tethered to practices of control, capture our anxious attention and motivate endeavors for still more knowledge and control. The efficacy of action cannot keep pace with know- ledge acquired and knowledge itself becomes increasingly problematic. We now live in a society in which ambient but invisible hazards are understood to corrupt bodily health, their dreaded outcomes projected onto an uncer- tain future. The fruit of knowledge appears to require of us an exile from the garden of presumed safety. If the pursuit of health cannot deliver on its promise of enhanced security, the moral certainty and strategies of distinction invested in the quest may also be put into question. I am suggest- ing that the disjunction between the symbolic order of health its moral imperative, its affirmation of western scientific knowledge and practice, its validation of institutions and persons and the disordered experience of its attempted achievement is a contradiction that a critical theory of health must take into account. How has such a state of affairs come about? Danger and control in contemporary health consciousness The constituting moment of health consciousness is acquiring or being exposed to information that conveys a sense of endangerment, along with a mandate to undertake instrumental actions for protection. Dangers are problems and problems the birth of solutions; or as Foucault put it, 'If everything is dangerous, then we always have something to do' (quoted in Robertson, 2001: 294). Yet, actions undertaken to protect health fall short. Health-conscious people live with the knowledge of a gap between prescrip- tive advice and what one actually does or can do. They also live with the knowledge that, no matter how much one complies with the rules of health, dangers far exceed the personal capacity for protection through lifestyle changes or other preventive actions and that still more dangers remain hidden or are soon to be discovered. Six characteristics of contemporary medical culture contribute to the spiral of control and anxiety. Media and other forms of mass communication should be considered as integral to each and will not be discussed separately. The identification and politicization of environmental and occupational hazards An enormous body of evidence about the social production of health hazards has been continuously communicated to the public, spawning health and safety movements, a vast expansion of government regulation Crawford: Risk Ritual and the Management of Control 507 and decades of controversy. Over 20 years ago, Mary Douglas and Aaron Wildavsky (1983) famously complained that North Americans had become a people who distrusted the world in which they lived. Americans, they wrote, have come to fear nothing much really, except the food they eat, the water they drink, the air they breathe, the land they live on, and the energy they use. In the amazingly short space of fifteen to twenty years, confidence about the physical world has turned into doubt. (1983: 10) The politics of imposed hazards and their regulation have become a central feature of public debate about the role of corporations and government in American life, a key dimension of Ulrich Beck's 'risk society' (1992) and what other commentators describe as a 'culture of fear' (Ferudi, 1997; Glassner, 1999). The proliferation of 'excessive' fears has also become a familiar complaint voiced by representatives of hazard-producing indus- tries, such as Elizabeth Whelan, President of the American Council on Science and Health: 'I am now convinced that one of the major problems is that scientists are unwilling to use the four-letter word, "safe"' (quoted in Kolata, 1999: A16). The growth of professional health promotion and health education aimed at raising awareness of 'lifestyle hazards' and inducing changes in behavior Since the 1950s, physicians and health educators, backed by a wealth of epidemiological knowledge, have made 'lifestyle hazards' or 'at-risk behav- iors' a matter of public awareness. Boosted by the ideological turn toward individual responsibility, professional health promotion took off in the 1970s and 1980s and is now supported by government policy, integrated into school curricula, become standard practice for patient education in clinical and institutional settings, disseminated through mass and special- ized media and, not least, enthusiastically taken up by the professional middle class. Indeed, Douglas and Wildavsky's classic remark should be updated. Americans have come to fear 'nothing much really', except the amount of 'good' and 'bad' cholesterol in their blood, the passive smoke they inhale; the vitamins, food supplements, hormones or other protective drugs they are missing; the detrimental effects of those same products; the length of time since the last cancer check; which 'routine' tests are overdue; various genetic 'time bombs'; the dangers of obesity and too little exercise; the exposure of skin to sun; low bone density; every instance of failed memory; the truthfulness of sexual partners; etc. An essential component of health education is the pedagogy of danger. The task confronting health educators (journalists, advertisers and lay health advocates face a similar problem) is not simply the identification and communication of the existence of a hazard; the challenge is to get people to take seriously the threat. Effective communication cannot be emotionally health: 8(4) 508 neutral; it must exaggerate the danger and emphasize the consequences of failing to heed warnings. As feelings of endangerment decline, so does compliance with health promotion recommendations. Motivating 'at-risk' people to give up behaviors that are psychologically useful, socially supported, peer-pressured, habitual, or to adopt behaviors that require continuous effort over a lifetime and continuous fine-tuning, compels the messenger to shake loose defenses by whatever scare tactics can be devised. The humane goal of reducing future suffering, a professional obligation, authorizes extreme measures. Health promoters and advertisers must continually discover new ways to subvert the human longing to feel safe and the penchant for discounting danger (Lupton, 1993; Forde, 1998). The cumulative message of health promotion is that contemporary life is lived in the danger zone (Armstrong, 1993) and that a person will be sick unless over a lifetime prevention is made an essential part of everyday practice and asymptomatic bodily signs are regularly monitored for their morbid implications. The task is demanding, and competing values and desires limit willing- ness to go along with medical recommendations. Though a rising star, health is not the only light in the sky. Life-long renunciations go against the American grain and the mandates of a consumer society. For those attempting to live a healthy lifestyle, behavior changes come slowly and are subject to relapse or 'deserving remissions' (Crawford, 2000). Whether in the name of pleasure, freedom from the 'health police', lack of time or money or insufficient will power, the commandment of health is violated with full knowledge of the transgression. Those inclined to reject the stiff collar of perfectly disciplined action, which means most of us, are continu- ally reminded of the future consequences that await the disobedient. Given the magnitude of the task, we come to live with the realization that indi- vidual acts of protection do not remove us from harm's way. Efforts to reduce risks are the occasion for a more finely tuned awareness of danger and doubt about the adequacy of measures undertaken. Advancing technologies for identifying risk factors and early states of disease Detection and monitoring of disease are pushed toward earlier stages, hidden pathology, predispositions and susceptibilities. In the last 30 years, the recommended number and frequency of tests in order to screen for early signs of disease have greatly expanded. Diagnostic technologies (e.g. X-ray, ultrasound, echocardiography, amniocentesis, biopsies, CAT-scans, MRI-scans, mammography, pap smears, colonoscopies, PSA tests and an array of other tools for detection of cell, blood, chromosomal, genetic and other abnormalities) make possible an unprecedented level of medical monitoring and early intervention for an increasing number of diseases, the definition of which has broadened accordingly to include 'early stages'. Recent advances in genetic testing and screening radically extend the scope Crawford: Risk Ritual and the Management of Control 509 of medical surveillance and the number of people who now live with the knowledge of their individual susceptibility to disease (Novas and Rose, 2000). Symptom-free, health-conscious people face a dilemma. On the one hand, the promise of slowing or stopping the progression of disease through controlling known risk factors or through early medical intervention can be reassuring: 'Better to catch it early so you can do something about it'. On the other hand, the experience of testing the decision to be tested, waiting for the results, indeterminacy of results, testing errors is widely acknowledged to generate anxiety. Doctors attempt to meliorate patient anxiety or 'screeningitis' (Shickle and Chadwick, 1994) and assure compli- ance with testing protocols. Further, patients who decide not to be tested carry their own burden of anxiety of failing to act in the face of insidious disease processes, of violating medical values and of acquiring the stigma of 'willfully ignorant' or 'non-compliant'. Finally, negative results are often but momentary reprieves or are 'inconclusive', as in genetic screening where new predisposing genes are continually discovered. Screening is frequently a rite of passage into a world of disease and its management. The commencement of recommended actions (life-long behavior changes, drug therapies and medical supervision) undermines the presumption of health. Disease-as-event moves toward disease- as-emergence. The zone of danger and control is extended in time. The emergence of immunity as a medical and lay concern In a world become hazardous, the porous body penetrated, attention turns to the adequacy of defense. As Emily Martin (1994) demonstrates, immunity has achieved a pivotal position in both scientific and non-scien- tific discourse, a concern that became all the more pronounced with the advent of HIV/AIDS. With immune system consciousness, susceptibility and predisposition come to be coextensive with life itself. The body's response-ability is enhanced or undermined by living conditions, diet and health history; and, since immunity is imminently fluid, capable of fluctu- ating daily, the body is always and already compromised. Moreover, as 'psychoneuroimmunology' paves a superhighway across psyche and soma (Ignatieff, 1988), 'psychosomatic subjects' (Greco, 1993) monitor stress, life-events, coping-styles and social support for their effects on health. Emotional experience is redrawn as a map of relative peril and vulnera- bility. The field of awareness and action expands accordingly. Rapidly changing, confusing or contradictory medical information and distrust of expertise and the institutions that employ expert knowledge The production of medical knowledge of danger is matched by a produc- tion of lay knowledge about expertise. Distrust of expertise has become a constituent feature of our increasing dependence on specialized knowledge. health: 8(4) 510 Anthony Giddens (1991) underscores how much the generation of knowledge required to navigate life is increasingly remote from everyday experience and control. Wynne (1996) argues that lay people are aware of their dependency on expertise, ambivalent about it and anxious about the loss of agency such dependence entails. Controversial and confusing infor- mation deepens the ambivalence. Whom to believe? Which experts? Employed by whom? What agendas are being advanced? What profits made? Depending on the source, people may be inclined to assert the validity of expert knowledge in one instance and disavow it in another. The regulatory and litigious disputes of the last 30 years, with their conflicting expert testimony about what is safe or unsafe, leave many feeling baffled; and the continually shifting state of knowledge ('one day they tell you it's safe, the next day it may kill you!') adds to the bewilderment. The revel- ations about the harmfulness of hormone replacement therapy and continu- ing disputes about its utility or recent revisions about so-called 'good' cholesterol are but two examples. People are left wondering about the efficacy of medical advice: as the map of danger is filled in, safe passage appears all the more difficult; but as the map of safe passage becomes illeg- ible, people do not know what to believe or how to act in order to be safe. Anxiety-format advertising Preoccupation with dangers and protection is also encouraged by an abun- dance of anxiety-format advertising for drugs, medical centers, specialty clinics, insurance and a plenitude of health and fitness goods and services that exploit health or other body fears (Moynihan et al., 2002). Messages targeting health vulnerabilities, while an enduring fixture of modern adver- tising, appear to have vastly increased over the past several years. My own collection of advertisements suggests a variety of themes and approaches: accenting a disease or hazard against which one must protect; referencing the hazard by emphasizing the qualities of a product 'cholesterol-free, sodium-free, fat-free, etc; providing information about diseases, conditions, symptoms, solutions (irregular heartbeat, 'benign or life-threatening', 'diag- nostic tests', 'recent advances'; 'heart disease: the stress connection'), frequently in multi-page sections in magazine and newspapers, presented as a medical service; suggesting worrisome prevalence, frequently using relative risk numbers to heighten the attribution of susceptibility; empha- sizing the vulnerability of specific groups ('women at risk'); providing written, easy-to-take tests so that the reader can assess his/her risk ('arte- riosclerosis: are you high risk?', 'should I be adding [a protective product] to my diet?'); co-sponsoring ads by producers such as orange growers and disease-awareness organizations such as the American Cancer Society, which together 'fight cancer'; and not least, emphasizing the vulnerability of children and responsibility to family of making the right consumer choice. As Lupton summarized her brief discussion of Australian life insur- ance advertisements, they 'sell their product by emphasizing the anxiety Crawford: Risk Ritual and the Management of Control 511 caused by one's child falling ill and wanting to have medical intervention as soon as possible, in order to supposedly regain "control" over the poten- tially disruptive force of illness' (2003: 93). In the chaotic medical care insur- ance system of the USA, advertisers of all kinds can easily find and exploit the insecurity of falling ill without being 'covered'. In sum, the flood of hazard information delivers a cumulative message of danger and opens the whole of life to cross-examination, monitoring and control. Amid the ruins of safety, self-protection mandates the acquisition of more knowledge. Indeed, the dissemination of health information continues to increase in the mass media, on the Internet, via specialized magazines and newsletters and through medical centers and doctors' offices. Health consciousness has become a ceaseless but unachievable quest for security. The danger of danger The modern 'imperative of health' is to identify dangers in order to control them. Which dangers and which controls, however individual, corporate, governmental and the perceived adequacy of control are at the heart of the volatile political economy and ideology of health. There is an increas- ing gap between perception of danger and efficacy of practice political, medical or personal. The gap spells a new kind of danger: a destabilization of the precarious balance that channels anxieties into ideologically preferred or sanctioned solutions (Lupton, 1993). Individual efforts to secure health cannot be divorced from the larger context of endangerment and an accompanying sense of distrust and powerlessness about harms imposed by forces beyond individual control. In other words, there is a paradox at the center of the individualizing bias of health promotion: while the effort to increase individual protection certainly preoccupies a health- conscious public with personal lifestyle changes and medical monitoring, that very preoccupation continues to heighten awareness of dangers gener- ally. Conversely, the experience of endangerment from environmental or workplace hazards engenders both an investment in individual protections and a sense of their limits. I am suggesting that the ideologically constructed border designed to contain 'responsibility' to individual efforts is porous. The extraordinary attention given to lifestyle hazards does not solve the political problem for industry or government. The danger of danger is that no interest is immune to the destabilizing effects of anxiety and control, control and more anxiety. Moreover, the insecurities of contemporary life are prolific and cannot be contained in segmented domains of experience. Insecurity, as Bauman (1999) convincingly argues, has become a prevailing socio-cultural formation in the era of globally mobile capital and disappearing jobs. The wreckage of traditional structures of security provision has been neither repaired nor replaced, all the more so with the systematic destruction of health: 8(4) 512 the welfare state over the past 25 years. Not least, as the 'risk society' theorists emphasize, potentially catastrophic dangers, remote from personal control and apparently not controllable by anyone, shadow modern experience (Beck, 1992). The volatile mix requires continual management by political and economic interests identified or potentially identified as institutional sources for these insecurities. The danger of danger, however, is that politics motivated by insecurity continually threaten to explode the boundaries of that management. Insecurity is an experiential state prone to displacements, contagion and amplification. Ulrich Beck's prediction of a politicized 'solidarity motivated by anxiety' (1992: 49) has become a boardroom nightmare. The problem is an unstable cycle of excessive anxiety and excessive demands for control; that is, anxiety and control outside authorized parameters of concern and action. At stake is a loss of confidence in the orderliness of danger and therefore the efficacy of normative and normal- izing protections. Anxiety becomes excessive when it leads to a loss of confi- dence in individual control-ability or mistrust of expert, corporate and political authorities; and when it occasions 'disutilities' in the workplace, medical care system or 'consumer confidence'. Indeed, entire industries and even national economies can be put in jeopardy by 'runaway' fear, as demonstrated by reactions to Mad Cow disease, genetically modified food and the SARS epidemic. In post-9/11 USA, the impact of fear on the airline and travel industries and even the unintended consequences of subsequent attempts to warn and reassure the public about the safety of air travel are well known. Even prior to 9/11, commentators from various political persuasions had begun to worry that a 'culture of fear' governed by a 'precautionary principle' had come to constrain innovation and economic activity (Ferudi, 1997). 'Excess' anxiety and 'misdirected' controls, in short, destabilize the institutionalization of the risk society and the economic and political agendas that depend on the orderly management of 'safe' and 'dangerous'. The spiral of control and anxiety must be managed. The roller- coaster ride between the attempt to obtain security and the edgy, runaway character of anxiety can be harrowing for individuals and institutions alike. Both must attend to the dislocations of experience that have come to char- acterize medical culture. Risk technology/risk ritual The language and technologies of risk, risk assessment and risk manage- ment have come to dominate the professional, political and lay worlds of health and safety. Risk is a kind of knowledge about potential hazards (or, more broadly, harms and benefits), a way of ordering their magnitude. Risk technologies extend the horizon of predictability and control, a develop- ment Ian Hacking (1990) aptly designated as 'the taming of chance'. In health and safety, advocates of the risk approach seek to replace the Crawford: Risk Ritual and the Management of Control 513 experience or perception of danger as simply proximate or remote, more or less perilous, under- or over-estimated with a knowledge that more objectively assesses the potential for harm. In contrast to qualitative appraisals of potential harm, burdened by subjective and cultural meanings, risk assessment provides quantified probabilities of exposures to hazards and of the consequences or severity of such exposures. Foucaultian critics theorize risk as a 'technology of governmentality' (Lupton, 1999). To be assessed at risk is to become an object of surveil- lance and a site of intervention. Risk technology brings more of life under the net of institutional and professional control. Adopted as a practice by individuals, risk technology is a more sophisticated form of regulation, all the more effective as a form of rule to the extent that it is chosen and that self-monitoring, risk-conscious and risk-calculating subjects are con- structed. For example, 'the language of genetic risk increasingly provides a grid of perception which informs decisions on how to conduct one's life, have children, get married or pursue a career' (Novas and Rose, 2000: 502). The risk-conscious subject utilizes scientific knowledge to assess personal risk factors and exercise 'autonomy' responsibly. Thus, as Ewald has observed, risk technology entails a moral dimension: To calculate a risk is to master time, to discipline the future. To conduct one's life in the manner of an enterprise indeed begins . . . to be a definition of morality whose cardinal value is providence. To provide for the future does not just mean not living from day to day and arming oneself against ill fortune, but also math- ematizing one's commitments. (1991: 207) Foucaultian theorists are sensitive to the dependence of risk governmen- tality on a new morality consistent with the project of neo-liberal self- surveillance. The new subject of risk is an individual who has internalized the values consistent with the project of risk rationality. But what if that project cannot make significant progress against the spiral of control and anxiety? Will better risk communication strategies as heroically attempted by such prestigious centers like the Harvard Center for Risk Analysis, whose web page logo proudly asserts 'Using Decision Science to Empower Informed Choices about Risks to Health, Safety, and the Environment', be able to contain the excesses to which control and anxiety are prone? My contention is that the subject of risk is more elusive than the Foucaultians have claimed or professional risk managers have hoped. Contemporary health consciousness cannot be characterized by the triumph of a disciplined rationality about health, an assertion supported by two decades of research on public perceptions of risks and the ineffective- ness of risk communication (for recent summaries, see Kunreuther and Slovic, 1996; Slovic, 1999). How, then, to explain the persistence and growing importance of risk discourse and risk technologies in face of the abysmal failure to motivate large numbers of individuals to correctly assess and act upon comparative health: 8(4) 514 risks to health? A plausible answer would call attention to the centrality of risk analysis for institutional practices in medicine, public health, corpor- ations and governmental agencies. My argument, however, is that risk discourse can be understood as a ritualized solution for the volatile and dangerous spiral of control and anxiety. Risk signifies a symbolic order of both predictability and manageability in contrast to an unruly world of anxiety and control. In other words, the symbolic practice of risk should be understood in relation to the disarray into which health practice has fallen. Risk ritual, I am suggesting, is an attempt to restore a plausible coherence, consistent with the claimed efficacy of prevailing practices. It thereby re- authorizes structures of power through which and only through which rational coherence can be putatively achieved. Conversely, in pointing to the presumed source of disorder, risk ritual features the flawed subject of risk rationality who destabilizes the regime of individualized disease prevention and threatens risk-governed prevailing regulatory practices. Cultural anthropologists have frequently pointed to the symbolic substance of non-western healing practices. The dislocations of experience occasioned by serious affliction are ritually managed through a highly stylized manipulation of deeply resonant meanings. Healing entails a restoration of the coherence of experience, a cognitive reordering comprised of shared understandings of symbolic disorder and the reitera- tion of a prescribed and health-giving order. A meaningful and normative world is ritually rehearsed for the patient and the larger collectivity alike. Western medicine is no exception. Western medical ritual, in Jean Comaroff's words, expresses and reinforces core notions about self and world: The apparently 'instrumental' acts of modern medical practice have thus become important symbolic foci of secular ritual for us, and its techniques and concepts serve as metaphors of our state of being as bio-physical individuals, seeking to enlist 'natural' science in our secular opposition to the forces of disease, decay and death. It is this metaphoric role, then, that accounts for the perpetuation and effectiveness of a host of medical beliefs and practices whose specific efficacy is almost impossible to establish. Thus, while scientific knowledge has clearly provided us with important means for the specific control of affliction, it has also come to fulfill a more embracing cultural role. Indeed, 'science' has become our primary symbolic order, in which 'instrumental efficacy' serves as our ritual mode, and 'rational practice' our dominant ideology. (1981: 36, emphasis added. For the published version of this paper, see Comaroff, 1982) Western medical ritual affirms participants' place as rational subjects in a world that is also apprehended as rational and, because rational, control- lable. The self-proclaimed truth of modernity the locus of power and auth- ority of its institutions, the right to rule claimed by its elites is the domination of all contingency. Technological control is an ideology for which every discovery of the contingent, the indeterminate, the unex- plainable, becomes a call to arms and every advance a celebration of 'the Crawford: Risk Ritual and the Management of Control 515 beauty of our weapons'. In secular rituals of technical control, the contingent can only temporarily elude conquest not yet controllable, about to be controlled. The phantom adversary of control is thereby ritually magnified as well. Practices of control give birth to new horizons of contin- gency. The horizon, however, is a line of ambiguity both opportunity and chimera of that which not only eludes control but which may be, in the end, uncontrollable. This uncontrollable looms as an ever-present shadow, the deep disorder of modern life, its heart of darkness and its repressed Other. Medical ritual attends to the disorder, employing an ideology that gives no quarter to its opponent, no free-standing existence. Risk ritual, as I will argue, locates that disorder in the person of the flawed subject of health consciousness and action. I have argued that the imperative of health, and the conviction of efficacy that authorizes its mobilizations of individual commitment, founder on the contradictions of social practice. As the orderly world of danger and safety, problem and solution, knowledge and practice is increasingly disrupted, the restoration of cognitive-symbolic order becomes a priority for those insti- tutions, professionals and individuals most affected. My contention is that risk discourse can be understood as a ritual that promises a symbolic reso- lution of the disordered and disorderly swings of control and anxiety in our health-conscious era. Risk ritual: three dichotomies Risk discourse depicts a stark contrast between ways of apprehending and acting upon potential harm. In essence, the contrast is between reason and unreason. I argue that the repeated juxtaposition of 'rational' risk assess- ment with 'irrational' lay experience of danger takes on the character of a ritual with ideological effects. Risk ritual features three dichotomies. I will briefly illustrate each dichotomy by referring to recent statements by David Ropeik, the director of risk communications at the corporate-funded and politically influential Harvard Center for Risk Analysis. First, risk stands in opposition to danger. The problem in need of solution is the volatile experience of endangerment, described in risk discourse as the 'misperception of risk'. In part, the problem of danger is located within the perceiving subject, the result of cognitive or emotional deficiencies. In part, however, the fault lies with the object of misperception, the potential harm; or more precisely, how that harm is characterized. I use the word 'danger' to encompass both the experience of endangerment and object perceived. In comparison with risk, danger is similar to Hacking's (1990) description of chance as 'untamed' the detritus of a pre-scientific form of thought that none the less stubbornly persists in lay consciousness. Unlike risk, danger is wild, amorphous and erratic, readily available for psychic, cultural and political purposes. Since the properties of danger are incom- patible with quantification, the more troublesome aspects of potential harm health: 8(4) 516 take center stage: imagined pain, dread, the social meanings (or metaphors) of associated illnesses, just or unjust etiologies, spectacular images, trau- matic memories, etc. In short, danger is a flawed, polysemic object of perception flawed because polysemic which lends itself to the immedi- acy of experience with its inherent volatility and tendencies toward distortion. Stated differently, experiencing subjects find in danger a polyphony of meanings that confound a disinterested perception of risk. Risk stands against this dangerous affinity between object and person. Simply put, danger is false consciousness. Ropeik and Holmes (2003: A11) describes it in this way: 'We fear the unlikely and are relatively uncon- cerned about the truly dangerous'. Rough divisions like voluntary/imposed or familiar/new are emotively compatible with equally rough distortions like fearful/unconcerned or exaggerated/minimized. Other rough divisions also come into play: Risks that are man-made, like radiation from a nuclear plant, generally scare us more than natural things that are far more likely to harm us, like radiation from the sun. And something that is extremely rare that kills in a particularly dreadful way, like a shark attack evokes more fear than something far more common that kills in a less gruesome manner, like a heart attack. (Ropeik and Holmes, 2003: A11) Danger, with its many different faces, 'evokes' inappropriate responses. In other words, suggestible perceiving subjects, rather than becoming masters of danger, are ruled by emotions or cognitive distortions evoked by poten- tial harms, each with its own compelling, affective properties. As Ropeik and Holmes (2003: A11) concisely state, 'When [lay people] are faced with specific threats, emotion overrules logic pretty quickly'. In short, endan- germent is experience unmediated by risk rationality. In a similar fashion, risk ritual features how the same distortions toward over-alarm or unwarranted apathy infect the way the media report risks: Between Memorial Day and Labor Day last year, major American newspapers and wire services ran 2,240 articles on West Nile virus, which kills fewer than 300 Americans a year, while there were 257 articles on food poisoning, which will kill more than 5,000 of us . . . (Ropeik and Holmes, 2003: A11) Reporters, unsurprisingly, are as susceptible as consumers of news to untamed danger: 'The danger [of danger] is that journalists can be so seduced by these subconscious risk perception fear factors that they play them up while failing to qualify how big or small, certain or not, the actual risk is' (Ropeik, 2002: 2). Unsurprisingly, the media are also faulted for selling fear and for reporters' drive for professional advancement. In reconstructing danger as risk, professional risk analysts see themselves as involved in a rescue mission. Phantoms of danger can be replaced by factors of risk precise, discrete and calculable. Knowledge of potential harm is thereby rendered 'objective'. Armed with risk knowledge, reporters 'can gather facts with greater perspective' and 'write their stories with more Crawford: Risk Ritual and the Management of Control 517 balance' (Ropeik, 2002: 2). For individuals who must make sense of a dangerous world, risk allows for a more judicious selection from the menu of hazards, a way to screen the overabundance of health hazard information and identify and act upon the most significant hazards. In converting the wildness of danger to the discipline of risk, the spiral of control and anxiety can hopefully be contained. Second, the endangered person stands in opposition to the at-risk person. The contrast of danger and risk is linked to a contrast between kinds of person said to be associated with each approach to apprehending harm. The accomplished subject of risk ritual is a person who is capable of abstracting or distancing from the experience of danger. The experiential body is abandoned so that the body of distance, a body known in relation to an analyzed totality of bodies can come into view (Romanyshyn, 1989). The endangered self, however, is entrapped by a proximate relation to danger; unable to detach herself from feelings, she is unable to assess poten- tial harms proportionately. At best, she is 'biologically programmed': 'when you don't have all the facts, you will over- or under-react to a risk, based on your instincts' (Ropeik in the New York Times, 2002). More insidiously, the endangered self is sometimes feminized and pathologized. Living in the terror of dread consequences and in making irrational demands for safety, she is the classic Chicken Little or 'cancerphobe' excoriated by industry's paid intellectuals. She is also medicine's somaticizer, its contemporary hysteric, one of the 'worried well' who burdens the medical system with unfounded anxieties. The ritualized subject of risk is concerned rather than anxious, able to distance without deserting the field. In this way, she is also contrasted to the other classic deviant of health promotion, the masculinized denier of danger who adopts the defense of invulnerability, 'unrealistic optimism' or the resig- nation of a fatalist. In contrast, the 'at-risk' person assesses herself as a composite of risk factors. She acquires a 'risk portfolio' a map of the self as a lifespan with signposts of risk factors to keep one from harm's way. Map in hand, she sets out to change the unfavorable numbers and maintain or improve favorable ones. The task is consuming, for the map is detailed and provisional; all variables are in flux exposures, life circumstances, age and, most importantly, medical knowledge itself. The at-risk self is a draft that will be continually rewritten. Yet, she must not read the map too closely, lest she be overwhelmed: proportionality is the rule; an overly 'risk adverse' person is part of the problem that needs fixing. The risk-aware person recog- nizes the difference between the unreasonable goal of absolute safety and the realistic goal of harm reduction and thus screens the overabundance of health hazard information and carefully selects among the possibilities for action. Finally, since she is always already at-risk, she willingly submits to medical supervision and recommended screening for early detection. In this way, the subject of risk becomes the master of danger and the practitioner of a self-mastery necessary for a 'mature' relation to potential health: 8(4) 518 harm. In occupying the stable center between excess control and excess anxiety, she is able to stay the course. She is positive about the future. Indeed, risk ritual aims at restoring confidence. In taking measure of life, the ritualized subject of risk acts to control the future. Knowing her risks, she avoids the unstable polarities of flight or fight. She is a person who engages in a consistent, self-monitoring practice over time, unpunctuated by excesses of control and anxiety. Third, the lay public stands in opposition to expertise. Here, risk ritual moves to its ideological finale: the distinction between legitimate and illegitimate knowledge and thus legitimate and illegitimate participation in institutional decision making and public policy. Risk professionals see themselves as uniquely qualified for the task. In a New York Times (2002: F2) interview, titled 'The fear factor meets its match', Ropeik comments: When people are over- or under-afraid, based on what the statistics suggest they ought to be of any given risk, they make bad choices . . . At the Harvard Center for Risk Analysis, we analyze how big or small a risk might be, how one risk compares to another, and the effectiveness and costs of various risk manage- ment strategies, to identify how to maximize risk reduction with the most efficient use of limited resources. If lay people are 'hard wired' into emotional responses, efforts to convince people to act differently are not likely to succeed. Risk communication experts are unwilling to abandon the heroic task. Yet, while promoting a 'more realistic' risk communication to the public, 'so they are empowered to put the risk in perspective and make more informed choices' (Gray and Ropeik, 2002: 112), Gray and Ropeik none the less 'support a good measure of [the] argument' that 'risk science, economics, and policy are so complex that experts and technocrats ought to be left to figure out what's best, and risk communication can just explain it all, ex post facto, to the public' (2002: 114). Their only problem with this approach seems to be that it 'fails to include' the recognition that fear may induce people to adopt greater risks or make demands on government to take actions that would also increase risks. 'Fear itself', they proclaim, 'is a risk and must be included in risk- management policy making' (2002: 114). Or, as Ropeik and Holmes (NYT, 2002: F2) put it, 'On a larger scale, we often look for government protec- tion from risks that hit our "fear buttons," and that can take money and attention from greater threats.' Thus, the experience of danger is identified as the disorder at the heart of health policy, and its unruly rule has predictable results. If regulatory health policy could be left to risk experts, a more orderly management of risk society could be achieved. Risk communication experts can attempt to manage public fear; but given the inevitable failure to achieve the desired risk rationality, unfounded public fears and unreasonable demands from interest groups could be kept in check by risk professionals who would work with other elites, also able to grasp the complexity of riskbenefit or costbenefit equations, to Crawford: Risk Ritual and the Management of Control 519 formulate rational public health policy. Responding to concerns about the impartiality of risk experts, specifically about the Harvard Center's reliance on corporate funding, Ropeik remarked: Is that kind of rational costbenefit thinking going to attract Greenpeace, or the Sierra Club, or National Audubon, or whatever? Less likely than it's going to attract corporations who find comfort in that careful, non-emotional, non-value- based, but 'just the facts, please' sort of approach. (NYT, 2002: F2) In policing the border between endangerment, with its excess of anxiety and control, and a putatively 'non-value-based . . . approach', risk manage- ment conceals the political motives of risk technology as the basis for health policy (Tesh, 1988). In sum, risk ritual depicts both danger and the danger of danger as the problems for which risk expertise is the solution. Through a drama of contrasts, it legitimizes a political strategy aimed at restoring order to the disorder of health consciousness and action. Rehearsal of both problem and solution is crucial for its ideological task. In a sequence of moralizing distinctions between danger and risk, between endangered and at-risk persons, and, in the end, between lay people and experts the ritual desecrates as well as sanctifies, displays the polluting danger and then offers a purifying answer. Risk experts take on and assign themselves the role of ritual specialists who manage the contradiction of control and anxiety through promoting a 'trust in numbers' along with a trust in those who 'neutrally' command the numbers. In carrying out this task, they glean the symbolic capital of healers of the body politic masters not only of danger- ous contingency, now safely contained within the bounds of scientific and technical control, but of the more pressing problem of a dangerously aroused public. Never mind that the experience of endangerment and the social relations that structure that experience (the unjustness of imposed hazards; the corporate and political complicity in promoting 'at-risk' behav- iors; the social inequalities that give shape to endangerment; the flood of contemporary insecurities that spills into anxieties about health) are converted through risk ritual into the 'phantom objectivity' of risk manage- ment. Taussig's comment about medical reification applies to the essential message of risk ritual as well: Don't trust your senses. Don't trust the feeling of uncertainty and ambiguity inevitably occurring as the socially conditioned senses try to orchestrate the multitude of meanings given to otherwise mute things. Don't contemplate rebellion against the facts of life for these are not in some important manner partially man-made . . . . To the degree that matter can be manipulated, leave that to 'science' and your doctor. (1980: 5) The inefficacy of risk ritual Risk ritual contains a recognition that the volatility of health conscious- ness ('distorted risk perception') cannot be eliminated by better risk health: 8(4) 520 communication. This is why the third opposition between the lay public and expertise is so crucial: only a risk-management state will suffice. I have also argued that given the contradictions underlying the spiral of control and anxiety, risk discourse cannot achieve its aim. Lay people may employ risk language and expert knowledge, but this does not mean that the ritualized subject of risk rationality is replacing its troubled and trouble- some nemesis. More importantly, neither are health-conscious people likely to forgo their own sense of endangerment and accompanying demands for safety in favor of the assessments and policy priorities of risk experts. Consider the following: First, risk does nothing to erase the already frayed boundary between safety and danger. With risk, we find ourselves, in Sandra Gifford's (1986: 224) apropos term, in the 'grey zone', betwixt and between health and disease (also, see Armstrong's (1993) analogy with a 'no man's land'). As the boundary between health and disease dissolves, so does the 'bill of health', that comforting pronouncement whereby one could put worry aside until sometime later. Neither will feeling healthy do. 'Risk factors' such as genetic predisposition, cellular changes, hypertension or cholesterol extend the idea that disease develops 'silently', long before symptoms are perceived. As risk factors are elaborated for populations, groups and indi- viduals, the zone of safety shrinks and, for many, disappears. The individual becomes a balance sheet of health-promoting and health-endangering vari- ables. Second, risk cannot predict the unwanted event for any particular indi- vidual. Epidemiological knowledge is a science of probabilities based on populations. The proportionality of numbers does not help eliminate the question 'What will happen to me?'. Individuals who fall into elevated risk categories must still try to imagine what will account for their personal fortune or misfortune. Davison et al. (1991) describe what they call 'the prevention paradox'. Lay people are aware of risk factors but are equally aware of 'anomalies' that contravene predictions based on risk. These anomalies become marked events, occasions for explanation and commen- tary about the limits of medical knowledge stories about people who followed all the rules and still became sick and, conversely, about those who continually violate the rules and live a long, healthy life. (Also, see Balshem, 1993.) Third, lay people make the distinction between what is within the realm of personal control, even if not fully acted upon, and what is not control- lable. If significant risks are regarded as uncontrollable, an assessment of controllable risk factors provides little assurance. Both Gifford (1986) and Robertson (2001), for example, report that women diagnosed at high-risk for breast cancer feel that most of their risks are located outside their personal control. The only perceived control may be more medical surveil- lance ('catch it early'). Not much to lean upon. Further, Gifford argues that some women diagnosed at high-risk choose to resolve the agonizing Crawford: Risk Ritual and the Management of Control 521 ambiguity by converting risk into a 'state of being', more like a 'physical state of ill health'. Gifford's point is that risk is experienced, and experi- ence cannot be neatly contained by the boundaries of ordered proportion. To be classified high-risk may feel something like being sick, no longer in a state of health. Indeed, I have argued that contemporary medical culture exhibits precisely such characteristics. Fourth, risk rationality cannot change the institutionalized momentum toward identifying, communicating, amplifying and revising risk factors or their control. Skolbekken (1995) found over 300 risk factors for coronary heart disease alone. Risk factors associated with pregnancy also number in the hundreds. Health-conscious people will continue to be aware of the growing discrepancy between their health-protective acts and professional recommendations for the control of risk. They will also continue to be confused about the inevitable conflicts over the significance of epidemio- logical research, especially studies that contravene previously accepted medical truths. The utility of communicating exaggerated danger, whether for advertisers or health educators, or the value of the scary headline, will not be easily subordinated to the logic of restraint suggested by risk propor- tionality. Finally, given that dependence on expert knowledge and a distrust of expertise are already major sources of anxiety, the attempt to engender a 'trust us, we're experts' mentality is unavoidably compromised. Moreover, distrust of the institutional commitments of experts further complicates the task, especially in an era of growing corporate power and regulatory retreat. The most likely effect of risk ritual is to reinforce existing enthusiasm for a risk-management state among economic, political and professional elites itself, a significant achievement. Health-conscious people, however, will not be seamlessly recruited to risk subjectivity, are not likely to trust expert decision making, and will certainly be unwilling to refrain from making their own demands for safety. Risk and the symbolic power of control In spite of these difficulties, the utility of risk discourse for lay people should not be underestimated. In a culture premised on individual autonomy and control, risk consciousness aligns the self with a confident rationality and the cultural capital of biomedicine. After all, I have argued that the current state of health consciousness is profoundly unsettling; and if Barsky (1988) is correct, sickening. If risk rationality cannot answer anxious questions about personal fate, it none the less provides an account of the future consistent with a rational worldview a map and moral compass for living in the present that claims to optimize life-chances. In addition to the practical uses of risk for guiding personal choices, never denied here, the power of risk can be found in the compelling illusion of control it offers. Destiny can be read in the symbolism of numbers, and if the numbers can health: 8(4) 522 be improved, mortality kept at bay. The deluge of information and conflict- ing truth claims, the cacophony of dangers and the sense that dangers continually exceed personal attempts to control them might be managed by participating in a symbolic practice that represents danger as calculable and the endangered self as capable of mastery. The lived insecurity of contemporary life may be more tolerable to the extent that insecurity itself becomes the object of a problem-solving technique. Never mind that a trust in numbers entails an extraordinary leap of faith, a suspension of the rule of contingency and its harrowing shadows of helplessness. That is precisely the point. The symbolic substance of risk discourse can be illustrated by an example discussed by Robertson (2001: 299; also see 2000) in her study of Canadian women's accounts of being diagnosed at high-risk for breast cancer. A woman given the name of Donna converts her overwhelming sense of danger into a more manageable risk paradigm. She assesses her odds of getting cancer at 85 percent, a figure ascribed to genetic predisposition that is out of her control. None the less, 15 percent remains within her control. At first, she speculates that if she adopts medically recommended lifestyle changes, her fate is still uncertain. After all, the 85 percent remains untouched. If she does not comply, however, she says her chances of getting cancer are certain 100 percent. The unattended 15 percent is added to the column of the 85 percent. But then Donna makes a significant move, asserting that if she attempts to control what is in her power to control she will then have a '100 percent chance of living', even if she gets cancer. Why this shift? Robertson is not explicit here, but I would suggest the reason is symbolic. Donna talks of the 'emotional advantage' of acting on her own behalf, which, she says, will include monitoring the early stages. I suspect that Donna manages her anxiety by imagining herself 'in control' and there- fore safe. In 'playing the odds' (Robertson's term), Donna asserts her unwillingness to submit to the odds, indeed, that she will beat the odds. In the symbolic practice of risk, hope is harnessed to the conviction carrying all the symbolic power of instrumental control that vulnerability can be eradicated. 'Even if we say we can accept death', writes Callahan, 'we believe in our hearts that the sting of death can be medically delayed, that fatalism is itself a source of fatality, that death is a kind of human artifact' (1993: 51; emphasis in original). Risk is compelling because of the symbols it mobilizes our boundless faith in instrumental action and its death- defying powers. One must act as if one is in control individually, autonomously and yet in alliance with medicine's unending war on death. The politics of insecurity If instrumental control is the cardinal symbolic practice of modern culture, insecurity is its lengthening shadow. The paradox of control is the accompanying fear of its loss. Experience provides ample substantiation for Crawford: Risk Ritual and the Management of Control 523 such fears. World-changing events, like the terrorist attacks of 9/11, cannot be predicted or prevented. Safe investments prove not to be safe after all; secure jobs are outsourced; retirement plans are thrown into disarray; Social Security and Medicare are threatened with bankruptcy; relationships fail; and disease 'strikes'. Notwithstanding instrumental logic, control is elusive and feelings of being 'out of control' common; and feelings of little or no control in one aspect of the life-world are often replicated in others, inviting cascades of displacement. Bodily fears, argues Bauman (1999), following a long tradition, are often an expression of larger insecurities and their uncontrollability. As the social forces that actually determine individual life-chances recede from the horizon of efficacious personal control and political control appears increasingly remote, an adaptive or therapeutic strategy of uncon- trollability becomes more attractive. God's will, fate, chance and luck are alternative categories for interpreting events. The situated complexity of lay knowledge in relation to health, including the place of uncontrollabil- ity, deserve more attention than space will allow. For important discussions, see Davison et al. (1992), Balshem (1993), Wynne (1996), Lupton (1999) and Tulloch and Lupton (2003). Plausibly, for most people, however, life strategies are characterized by attempts to replace experiences of uncon- trollability in one domain for a sense of control in another notably health or other bodily concerns. Yet, I have argued here that the structural contra- dictions of health consciousness and action make health an unlikely location for regenerating a sense of safety and thus cannot provide safe harbor for other insecurities. Unable to escape medical knowledge and mandates, health-conscious people are caught on the horns of a dilemma. On the one hand, health knowledge cannot sustain nor regenerate trust in government or corpor- ations. Even medical authority suffers. When the life-world is colonized by medicalized insecurity, medicalized subjects come to suspect the messen- gers and the knowledge they bear, including risk experts. On the other hand, the dream or 'mirage' of health as an achieved state, the (iatrogenic) promise of long life without debilitating disease, decline or pain (Illich, 1976), propel the embrace of medical authority. Disobedience of the laws of life as determined by the biomedical sciences engenders anxiety. Of course, more than the fear of bodily retribution keeps us in. The trans- gression of obligatory rites carries its own burden. In medical culture, 'fatalism' is a ritualized profanation, a disregard for biological life. After all, if health has become modernity's secular salvation, its hedge against the irreversibility of death, uncontrollability becomes the scandal a kind of suicide. The cultural commitment to control, the class and identity strategies invested in it and the institutional practices that direct and coerce behavioral conformity will permit but momentary breaks with our Promethean tether. Control and anxiety, a tangle of mutual escalation, have become our collective fate. health: 8(4) 524 Thus, the management of control and anxiety will continue to be a pressing problem in risk society. The excess of 'misplaced' fears and 'mis- directed' demands destabilize the neo-liberal objectives of individual self- regulation and political quiescence. The border between dangers for which individuals are said to be responsible and dangers for which corporations or governments are held accountable cannot be secured. The danger of danger is that 'communities of anxiety' will periodically disrupt and constrain dominant political and economic agendas and subvert the prevail- ing myths of risk acceptability for health and safety. The larger danger is that institutional and individual strategies of displacing the lived insecurity of our times onto the body will reverse direction, coalescing into political movements aimed at the social production of insecurity in the body politic. For these reasons, risk ritual, in troubled relation to a non-containable spiral of control and anxiety, will occupy a central place among the symbolic practices of health for some time to come. Note 1. I have decided to employ the word 'anxiety', even though my meaning is closer to the idiomatic meaning of 'insecurity'. My argument does not rest on a demonstration of a high prevalence of anxious symptoms. Rather, my use of the term is closer to its original existential meaning a state of being or angst. Death anxiety, after all, is hardly unrelated to matters explored in this essay. I do emphasize, however, the amplification of a sense of insecurity in relation to health and, thus, one must suppose an increase in symptoms among vulnerable individuals. Neither do I presume health to be the primary source of contemporary anxiety. See Wilkinson (2001) for a trenchant critique of such an assumption, a critique that also implores that such claims require empirical verification. Wilkinson cites evidence that the experiential instabilities of work and relationships, particularly unemployment and divorce, are primary sources of contemporary anxiety, a relevant finding for my argument that the nexus of control and anxiety in health forms a homology with other contemporary anxieties. Some omissions deserve brief comment. Except for a few examples, I will not discuss differences in control and anxiety that form around the prevention of particular diseases, such as AIDS, and particular subject positions having to do with class, gender, age, ethnicity and sexual orientation. All are crucial to a critical theory of health and their exclusion from this essay can only be defended on grounds that I am attempting to describe experiences that cut across many of these categories that is, characteristic of people who have become health conscious and are engaged in various practices to protect or improve health. This essay is perhaps most amiss in not taking account of the extraordinary differences among people due to health status. People who are living with illness cardiovascular disease, cancer, asthma, diabetes, HIV/AIDS, immune system disorders live with experiences of anxiety and control that are distinctive of their condition, symptoms, prognosis and much more. Protecting and promoting health is not a concern that disappears with illness; to the contrary, the stakes become all the greater. Crawford: Risk Ritual and the Management of Control 525 References Armstrong, D. (1993). Public health spaces and the fabrication of identity. Sociology, 27(3), 393410. Balshem, M. (1993). Cancer in the community: Class and medical authority. Washington, DC: Smithsonian Institution Press. Barsky, A. (1988). Worried sick: Our troubled quest for wellness. Boston, MA: Little Brown. Bauman, Z. (1992). Mortality, immortality and other life strategies. Cambridge: Polity. Bauman, Z. (1999). In search of politics. Stanford, CA: Stanford University Press. Beck, U. (1992). Risk society: Towards a new modernity. Trans. R. Ritter. London: Sage Publications. Callahan, D. (1993). The troubled dream of life. New York: Simon & Schuster. Comaroff, J. (1981). Symbolic healing: Medicine as a socio-cultural system. Unpublished. Comaroff, J. (1982). Medicine: Symbol and ideology. In P. Wright and A. Treacher (Eds.), The problem of medical knowledge, pp. 4968. Edinburgh: Edinburgh University Press. Crawford, R. (2000). The ritual of health promotion. In S. Williams, J. Gabe and M. Calnan (Eds.), Health, medicine and society: Key theories, future agendas, pp. 21935. London: Routledge. Davison, C., Davey-Smith, G. and Frankel, S. (1991). Lay epidemiology and the prevention paradox. Sociology of Health and Illness, 13, 119. Davison, C., Frankel, S. and Davey-Smith, G. (1992). 'To hell with tomorrow': Coronary heart disease risk and the ethnography of fatalism. In S. Scott, G. Willliams, S. Platt and H. Thomas (Eds.), Private risks and public dangers, pp. 95111. Avebury: Adlershot. Douglas, M. and Wildavsky, A. (1983). Risk and culture. Berkeley, CA: University of California Press. Ewald, F. (1991). Insurance and risk. In G. Burchell, C. Gordon and P. Miller (Eds.), The Foucault effect: Studies in governmentality, pp. 197210. Chicago, IL: University of Chicago Press. Ferudi, F. (1997). The culture of fear. London: Cassell. Forde, O.H. (1998). Is imposing risk awareness cultural imperialism? Social Science and Medicine, 47, 11559. Fox, R. (1980). The evolution of medical uncertainty. Health and Society, 58(1), 149. Giddens, A. (1991). Modernity and self-identity. Cambridge: Polity Press. Gifford, S. (1986). The meaning of lumps: A case study of the ambiguities of risk. In C. Janes, R. Stall and S. Gifford (Eds.), Anthropology and epidemiology, pp. 21346. Dordrecht: Reidel. Glassner, B. (1999). The culture of fear. New York: Basic. Gray, G. and Ropeik, D. (2002). Dealing with the dangers of fear: The role of risk communication. Health Affairs, 21(6), 10616. Greco, M. (1993). Psychosomatic subjects and the 'duty to be well': Personal agency within medical rationality. Economy and Society, 22(3), 35772. Hacking, I. (1990). The taming of chance. Cambridge: Cambridge University Press. Ignatieff, M. (1988). Modern dying. The New Republic, 26 December: 2833. health: 8(4) 526 Illich, I. (1976). Medical nemesis: The expropriation of health. New York: Pantheon. Kolata, G. (1999). Experts unsure of effects of a type of contaminant. New York Times, 4 August , A16. Kunreuther, H. and Slovic, P., Eds. (1996). Challenges in risk assessment and risk management: Annals of the American academy of political and social science, 545 (May). Lupton, D. (1993). Risk as moral danger. International Journal of Health Services, 23, 42535. Lupton, D. (1999). Risk. London: Routledge. Lupton, D. (2003). Medicine as culture, 2nd edn. London: Sage Publications. Martin, E. (1994). Flexible bodies. Boston, MA: Beacon Press. Moynihan, R., Heath, I. and Henry, D. (2002). Selling sickness: The pharmaceutical industry and disease mongering. British Medical Journal, 324, 88692. New York Times. (2002). 3 December. Claudia Dreyfus. The fear factor meets its match: A conversation with David Ropeik. Novas, C. and Rose, N. (2000). Genetic risk and the birth of the somatic individual. Economy and Society, 29(4), 485513. Robertson, A. (2000). Embodying risk, embodying political rationality: Women's accounts of risks for breast cancer. Health, Risk and Society, 2(2), 21935. Robertson, A. (2001). Biotechnology, political rationality and discourses on health risk. Health, 5(3), 293309. Romanyshyn, R. (1989). Technology as symptom and dream. London: Routledge. Ropeik, D. (2002). Journalists can be seduced by aspects of risk: By understanding how and why people perceive risks, reporters and editors can cover risk-related issues with more caution and balance. Nieman Reports, 56(4), on-line, 15. Ropeik, D. and Holmes, N. (2003). 'Never bitten, twice shy': The real dangers of summer. New York Times, Op. Ed., 9 August, A11. Shickle, D. and Chadwick, R. (1994). The ethics of screening: Is 'screeningitis' an incurable disease? Journal of Medical Ethics, 20, 1218. Skolbekken, J.-A. (1995). The risk epidemic in medical journals. Social Science and Medicine, 40(3), 291305. Slovic, P. (1999). Trust, emotion, sex, politics, and science: Surveying the risk-assessment battlefield. Risk Analysis, 19(4), 689701. Sontag, S. (1978). Illness as metaphor. New York: Farrar, Straus & Giroux. Taussig, M. (1980). Reification and the consciousness of the patient. Social Science and Medicine, 14B, 313. Tesh, S. (1988). Hidden arguments: Political ideology and disease prevention policy. New Brunswick: Rutgers University Press. Tulloch, J. and Lupton, D. (2003). Risk and everyday life. London: Sage Publications. Wilkinson, I. (2001). Anxiety in a risk society. London: Routledge. Wynne, B. (1996). May the sheep safely graze? A reflexive view of the expertlay knowledge divide. In S. Lash, B. Szerszinski and B. Wynne (Eds.), Risk, environment and modernity: Towards a new ecology, pp. 4483. London: Sage Publications. Crawford: Risk Ritual and the Management of Control 527 Author biography ROBERT CRAWFORD has contributed to the discussion of health, culture and ideology since the late 1970s. He teaches in an interdisciplinary liberal arts program at the University of Washington, Tacoma, and lives with his wife, Merna, on Vashon Island, where they cultivate blueberries. health: 8(4) 528</meta-value></custom-meta></custom-meta-wrap></article-meta></front><back><notes>
<p>1. I have decided to employ the word ‘anxiety’, even though my meaning is closer to the idiomatic meaning of ‘insecurity’. My argument does not rest on a demonstration of a high prevalence of anxious symptoms. Rather, my use of the term is closer to its original existential meaning - a state of being or angst. Death anxiety, after all, is hardly unrelated to matters explored in this essay. I do emphasize, however, the amplification of a sense of insecurity in relation to health and, thus, one must suppose an increase in symptoms among vulnerable individuals. Neither do I presume health to be the primary source of contemporary anxiety. See Wilkinson (2001) for a trenchant critique of such an assumption, a critique that also implores that such claims require empirical verification. Wilkinson cites evidence that the experiential instabilities of work and relationships, particularly unemployment and divorce, are primary sources of contemporary anxiety, a relevant finding for my argument that the nexus of control and anxiety in health forms a homology with other contemporary anxieties.</p>
<p>Some omissions deserve brief comment. Except for a few examples, I will not discuss differences in control and anxiety that form around the prevention of particular diseases, such as AIDS, and particular subject positions having to do with class, gender, age, ethnicity and sexual orientation. All are crucial to a critical theory of health and their exclusion from this essay can only be defended on grounds that I am attempting to describe experiences that cut across many of these categories - that is, characteristic of people who have become health conscious and are engaged in various practices to protect or improve health. This essay is perhaps most amiss in not taking account of the extraordinary differences among people due to health status. People who are living with illness - cardiovascular disease, cancer, asthma, diabetes, HIV/AIDS, immune system disorders - live with experiences of anxiety and control that are distinctive of their condition, symptoms, prognosis and much more. Protecting and promoting health is not a concern that disappears with illness; to the contrary, the stakes become all the greater.</p>
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</ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Risk Ritual and the Management of Control and Anxiety in Medical Culture</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Risk Ritual and the Management of Control and Anxiety in Medical Culture</title></titleInfo><name type="personal"><namePart type="given">Robert</namePart><namePart type="family">Crawford</namePart><affiliation>University of Washington, Tacoma, USA</affiliation></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article" authority="ISTEX" authorityURI="https://content-type.data.istex.fr" valueURI="https://content-type.data.istex.fr/ark:/67375/XTP-1JC4F85T-7">research-article</genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">2004-10</dateIssued><copyrightDate encoding="w3cdtf">2004</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><abstract lang="en">Medical culture in advanced technological societies is characterized by an abundance of warnings about health hazards, along with an equally abundant flow of prescriptive advice for protecting individuals against them. Knowledge of health hazards also defines living and working environments and has spawned a politics of regulatory control. These features of contemporary health consciousness and action, along with deepening insecurities in the larger body politic, precipitate a spiral of anxiety and control. The spiral disrupts the presumed security derived from medical knowledge and medically informed behaviors and threatens to erode the boundaries of sanctioned action for health protection. In the context of the volatile political economy of health, the spiral, with its excesses of anxiety and demands for unauthorized controls, elicits efforts to contain it. I explore the symbolic dimensions of risk, what I call ‘risk ritual’ - the prevailing form of managing this troublesome contradiction.</abstract><subject><genre>keywords</genre><topic>anxiety</topic><topic>control</topic><topic>culture</topic><topic>health</topic><topic>risk</topic></subject><relatedItem type="host"><titleInfo><title>Health</title></titleInfo><genre type="journal" authority="ISTEX" authorityURI="https://publication-type.data.istex.fr" valueURI="https://publication-type.data.istex.fr/ark:/67375/JMC-0GLKJH51-B">journal</genre><identifier type="ISSN">1363-4593</identifier><identifier type="eISSN">1461-7196</identifier><identifier type="PublisherID">HEA</identifier><identifier type="PublisherID-hwp">sphea</identifier><part><date>2004</date><detail type="volume"><caption>vol.</caption><number>8</number></detail><detail type="issue"><caption>no.</caption><number>4</number></detail><extent unit="pages"><start>505</start><end>528</end></extent></part></relatedItem><identifier type="istex">201156BA33654076CAC6B9D6DEB98C19F5B36D8D</identifier><identifier type="ark">ark:/67375/M70-WF8KB9V8-4</identifier><identifier type="DOI">10.1177/1363459304045701</identifier><identifier type="ArticleID">10.1177_1363459304045701</identifier><recordInfo><recordContentSource authority="ISTEX" authorityURI="https://loaded-corpus.data.istex.fr" valueURI="https://loaded-corpus.data.istex.fr/ark:/67375/XBH-0J1N7DQT-B">sage</recordContentSource></recordInfo></mods><json:item><extension>json</extension><original>false</original><mimetype>application/json</mimetype><uri>https://api.istex.fr/ark:/67375/M70-WF8KB9V8-4/record.json</uri></json:item></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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