# Session Overview By the end of this session you will be able to: · Analyse the concept of identity in relation to global health and global health governance. · Assess the way power dynamics shape identities. · Critically discuss the way gendered and racialised identities emerge through practices of health governance and assess what their consequences are. · Critically engage with the COVID-19 pandemic through the lenses of identity, health, and health governance. # 1. Identity ## 1.1 What is Identity? Identity, as it is commonly understood, is a concept that describes how people perceive themselves and/or others to be. It is associated with specific individual characteristics (e.g. ethnicity, gender, and/ or sexual orientation) and/or with the groups, ideas, ideologies, and institutions with which people associate (e.g. nationality and/or religion). These characteristics and associations provide a series of lenses through which individuals view themselves and, crucially, through which others may view them in specific contexts. Identities are often linked to social practices and behaviours through which identities are defined and consolidated. Gendered identities and identities of sexual orientation are fundamental to the way our societies are structured. These may be consolidated through narratives of ‘gender-specific’ roles at the societal level and through personal preferences in the selection of a sexual partner on a personal level. These identities may be consolidated through day-to-day activities, campaigns for equality, emancipation, and civil rights. Thinking about these diverse phenomena, social scientists have wrestled with how best to understand the concept of identity. According to Jenkins (2014), it is the verb ‘to identify’ more than the noun ‘identity’ that opens the richest analytical perspectives for understanding these processes. From this perspective, identity is the result of an active process of ‘identification’ and thus the most important aspect of ‘identifying’ is recognizing and affiliating yourself (or another person) with specific ‘identity positions’ defined in terms of ideas, ideologies, institutions and groups. The process of identification is at once about finding similarities and differences with these social objects and other individuals. A sense of belonging or identification with one group may lead to a dissociation from another group. Identity is shaped, therefore, by what we are and are not; by the identity positions we associate with and those we do not. ## 1.2 Identity as a process of simplification The way identities have been introduced so far presents them as largely unambiguous, self-determined and neutral. In reality, however, identities are complex, contested and highly political. In order to see this side of identity we must take a reflexive approach. In doing so, ==we see that there is no one way to ‘be’ religious or political, to ‘be’ female, male (or to identify along a more fluid gender spectrum), to ‘be’ a nurse, doctor, or any other professional with a working identity.== The way identities come to be simplified and reified can allow individuals and groups to self-identify as the same thing. This can be a process of choice and empowerment, allowing individuals to overcome differences by identifying through shared interests, beliefs, or shared struggles. For example, self-identifying as an alcoholic and interacting with other self-identified alcoholics may be a powerful way for individuals to take ownership of, and to manage, their condition. It is not that their alcoholism is the same, but utilising this overarching identity can be a source of help and comfort. Simplification, however, is also a way in which individuals and groups may be identified by others, and this can be a process of subjugation. Being identified by the state or an employer as an alcoholic might not be an empowering experience. In fact it might lead to poorer treatment and affect job opportunities as alcoholics are often viewed as a homogenous group; identified as ‘addicts’ rather than as individuals with diverse alcohol dependency problems. This example reminds us that identities are imbued with power dynamics and can be laden with assumptions about the ‘kind of person’ someone is. As we will come to explore, ‘self-identifying’ and ‘being identified’ (by others) are central to personal health practices, as well as national and global health governance, and have both positive and negative consequences for health outcomes. ## 1.3 Multiple identities Taking a reflexive approach to the concept of identity forces us to appreciate identities not as stable or neutral objects but as complex, temporally fluid, multiple phenomena. The multiple identities that individuals occupy are not mutually exclusive but exist concurrently. For example, you might consider yourself as a citizen of a particular country with a shared national identity and common symbols of the nation (e.g. a flag; national anthem; national histories, myths and rituals; literature; dress code; cuisine, etc) and the same rights and obligations within a shared economic and political system. At the same time, you may be a member of a wider community with which you share a similar culture or characteristic (i.e. language, religion, gender, sexual orientation, etc.), which transcend national boundaries. These identities are not fixed temporally but may evolve and change over time. Someone may be born into and brought up as a member of a religious community but may decide they no longer wish to affiliate with that faith later in life. Others, meanwhile, may discover religion only in later life or covert to another denomination. Similarly, different aspects of identity may come to the fore in different context. It may only be when you move to, or travel around, another country that you become aware of your nationality or ethnicity, and this becomes an important component of your self-perception and of how others perceive you. [[Identities are also emergent, reflecting social and political periods in time]]. The philosopher of science Ian Hacking has explored the emergence of the category of ‘child abuse’ which was first defined by paediatricians in Baltimore USA in the 1970’s. He explains that before this period while behaviour synonymous with child abuse occurred, you could not have identified an individual as a ‘child abuser’ as this category, and thus this identity, did not exist (Hacking 1999). This example reminds us of the temporally contingent and emergent nature of identities. Social scientist [[Amartya Sen]], (2005), has advocated an approach to identity that recognises its multifaceted nature. Sen explains that a person may have multiple, overlapping identities which co-exist. He also differentiates between self-identity and identities conferred onto individuals or groups by others, the phenomenon we explored through the example of alcoholism. Part of what makes identities multiple is their inherently relational nature, and the way they emerge over time. As we age, travel, learn and grow, our identities morph alongside us. Thus, we see that identities are multiple, existing both as a possibility within each individual or group, and as the possibility for identification by external entities. We will continue to return to this idea of identities as multiple throughout this topic. ## 1.4 Governing identities As we explored in Section 1.2, ‘being identified’ is one way in which power and judgement can be exercised over individuals or groups. This process of identification and power in society has been a crucial part of governance efforts by states, a phenomenon explored in depth by the French philosopher and social theorist Michel [[Foucault]]. Exploring the changing ways in which the state has exercised power and discipline over its citizens in Western Europe since the 18th century, Foucault developed the notion of governmentality to describe the organised practices through which society is made governable and through which subjects and particular subjectivities are brought into being. Foucault explains that institutions such as the family, schooling, medicine and the penal system all function as powerful vehicles for creating and ensuring particular subjects (Foucault 1979). To Foucault, the subject (le sujet) is not simply a synonym for “person”; instead the term captures the possibility of being a certain kind of person within a given socio-political and historical context. If we return to the example of Ian Hacking’s work on the emergence of the category and identity of ‘child abuser’ we can see that this fits with Foucault’s notion of subjects as being emergent and reflecting particular socio-political and temporal contexts. Two emerging and intimately related aspects of governmentality explored by Foucault are what he calls ==biopolitics and biopower==. [[biopolitics]] is a particular political rationality, one that takes ‘life itself’ and citizens, imagined as ‘populations’, as its subject. This means that people are governed in relation to aspects of their biological being, and that governance is aimed at maximizing and/or controlling aspects of health at the population level. [[biopower]] is the way biopolitics is exercised and is intimately related to the emergence of disciplinary institutions that produce particular subjects. According to Foucault, through knowledge production, the rising status of the medical profession and public health regulations, states in Western Europe in the late 18th and early 19th centuries increasingly identified citizens as biological entities as a way to exercise power over populations (Foucault 1998). This disciplining worked on citizens as ‘individual bodies’ and the population as a ‘collective body’. From this perspective, the identity of citizens was increasingly linked to their biology, to their sex, and to disease. This form of governing and disciplining citizens as a biological collective worked not only via coercion from state institutions, but was premised on individuals understanding and regulating themselves in a more biologically focused way; i.e. understanding their own identities as inherently biological. This means, for example, people linking their behaviour, eating habits, and exercising regimes to the physical state of their bodies and taking ownership of these linkages. ^f388af ## 1.5 Governing identities, governing health While the governance of health identity originally stemmed from debates around stigma, humiliation and injustice (Whyte, 2009), this discourse has extended to interrogate a broad array of questions and debates around governance, human beings and their identities (Carpenter, 2012). As we have seen through Foucault’s theory of biopolitics, governance has increasingly occurred at the level of life itself, both for the state which is ‘identifying’ its citizens and populations, and for individuals who are ‘identifying’ themselves and those around them. If the governance of populations and the self increasingly focuses on the biological, then this implies a connection between governing, identity, and health. ==Two identities that have been central to global health governance, and associated discourses, are those of the patient and of the research subject==. An increasing number of sociologists and anthropologists over the last fifteen to twenty years have coined terms and concepts to depict and make sense of a shift in the way patient and research subjects have been seen in relation to biomedicine and biomedical science. These include Rabinow’s concept of [[biosociality]] (2010), Epstein’s notion of lay expertise and AIDS or patient activism (1998), Rose and Novas’ concept of biological citizenship (2001-2005) and Nguyen’s notion of therapeutic citizenship (2005). While there are some differences between these concepts, and they have been crafted in relation to geographically specific regions, they all suggest that there has been a radical transformation of political and biomedical identities in the last thirty years. They argue that before the 1970’s the dominant politico-medical subject was the passive citizen with social rights and duties who was cared for by the welfare state and who submitted to the authority of medical experts. This figure they argue, has been replaced by the active, autonomous individual who is responsible for his/her own health. This transformation is related to the development of new biomedical knowledge, in particular genetics and neuroscience, emerging public health issues such as HIV/AIDS and corresponding forms of patienthood. It is also linked to neoliberal forms of governance which have focused on the individual and the role the individual should play in maximising aspects of their own life and health. Thus, while the welfare state has been rolled back, leaving individuals to fend for their own health more and more, the rise of new forms of biologically attuned citizenship have also made individuals more active participants in the coproduction of health alongside medical and state apparatuses. The authors introduced above, and other contemporary scholars across the globe have taken forth Foucault’s notion of biopolitics, exploring its various manifestations in different contexts and the way governing at the level of ‘life itself’ creates and entrenches identities. They have also explored the way biopolitics suffuses practices of health governance and the implications of this for the health of diverse populations. We will now briefly explore some examples. Anthropologist Joao Biehl has dedicated much of his career to exploring the way biopolitics works in the case of AIDS treatment in Brazil (Biehl et al. 2001). Biehl highlights the way the identities of the marginal, poor, and those ‘living on the street’ are governed and entrenched through the state’s AIDS response. ==Biehl describes the ways in which social exclusion extends to those ‘identified as’ poor and marginal== meaning these individuals are left to ‘die in abandonment’. He argues that ‘the invisibilization of death among the poorest with AIDS is concomitant with the successful control of mortality as articulated by Brazil’s new biopolitical paradigm’ (Biehl 2005:255). His work demonstrates the intimate relationship between identities, governance and health and how those identified by the state and others as being of lower socio-economic standing in society or ‘living on the street’, often find their health compromised as a result. ==While Biehl works to expose the darker side of biopolitics, the kinds of identities it creates and entrenches, and the citizens whose health it allows the state to neglect, other contemporary scholars have focused on more positive emergent relationships between health, health governance and identity.== Social theorists Rose and Novas argue that the rise of biopolitics has led to forms of biological citizenship, a phenomenon whereby communities of individuals are formed around shared biological profiles and disease categories. These groups of individuals ‘identify’ with a particular illness, and in turn with each other, their identity intimately linked to the process of medical knowledge and power that originally identified them as having a disease (Rose and Novas 2010). They explore how individuals that identify as having Huntingdon’s disease build and utilise online communities sharing knowledge, experience and comfort. In this case, by understanding their identity through this biological lens of disease, individuals take their diagnosis into their own hands and craft new modes of thinking, being with, and governing their illness – a new form of [[genetic responsibility]]. Anthropologist Susan Whyte (Whyte, 2009) has also explored the way emerging medical diagnoses have introduced and forged new forms of identities, and so subjectivities which govern the choices and attitudes of patients in certain ways. This includes dietary and working habits, as well as the rights and benefits individual citizens are entitled to. At the same time, however, she argues that these new identities risk reducing the agency of individuals by empowering institutions such as hospitals and insurance companies to exercise their power to decide whether to include or exclude these social groups. An example of this would be an insurance company refusing to insure an individual who has existing health conditions or charging an older individual a higher premium. Thus, we see the way health institutions and forms of governance that take health as an indicator, construct particular identities for individuals and interact with them on the basis of these constructed identities. #health-technology An important way in which identities are created and expressed in relation to health and health governance is through the use of medical technologies. According to Guery and Deleule (2014), in the 21st century [[technology has proved to be the best tool for capitalist structures to acquire hegemony over the total productive process by means of appropriating human identities, their preferences, and their perceptions of themselves]]. An example of this is the way employers have integrated personal wellness activities into the daily routine of their employees. From personal medical devices to fitness apps and calories counters, these tools are intended to promote employee’s health and wellbeing, but also enable employers to increase work efficiency and productivity. Social scientist Deborah Lupton has argued that emerging forms of mobile health technology produce subjects as [[objects of surveillance]], while also tasking individuals with responsibility for their own health outcomes. She argues that this has led to a new kind of subject: the digital cyborg body (Lupton 2012). Looking at the way medical technologies produces and reify particular subject positions and identities in prison settings, Nikolas Rose continues to explore biopolitical processes. Rose traces the powerful dual forces of medical imaging (in this case brain scans such as MRIs) and the penal system, arguing that they create a particular kind of prison subject and a particular biological profile; that of the ‘risky brain’ (Rose 2010). Here, through the institutions of medicine and prison, individuals are created and governed as particular biological subjects – ‘risky’ subjects. Anthropologist Ann-Marie Mol has further added that medical technological devices can exert power over individuals, conditioning particular identities. She looks at glucose monitoring devices, which have been developed as instruments of healthcare meant to both improve health outcomes and grant more freedom to individuals suffering from diabetes. However, rather than liberating diabetic patients, Mol explains that ==these devices can act as instruments of governmentality, exerting power over decisions of diet and lifestyle, and guilting patients whose daily lives do not fit into this rigid regime of blood taking==. Mol concludes that these devices offer illusions of control for individuals, while exerting increasing control over their daily lives (Mol 2009). As this collection of scholarly insights show, the relationships that emerge at the interface of governance, health and identity, are complicated, contingent, and highly political. ## #to-write Activity 1 In section one we have discussed the concept of identity and how more biologically focused forms of governance have led to the emergence of new health-related identities. Summarise what you have learned in section 1 and explain how this relates to/complements/challenges existing ideas you hold about identity. Post your reflections to the Activity 1 message board. Compare and contrast your summary to those of your peers and comment on at least one of these your find interesting. # 2. Identity, race and gender ## 2.1 Defining racial and gendered identities Gender and race are two central ways in which individuals have been identified, and through which individuals and groups have come to identify themselves and others. When we initially think about these identity labels, we are likely to draw upon learned discourses, ingrained assumptions, and simplifications. The Oxford Dictionary defines race as ‘each of the major groupings into which humankind is considered (in various theories or contexts) to be divided on the basis of physical characteristics or shared ancestry’. Thus, ==we might say that someone’s racial identity is dependent on their physical characteristics and ancestry. When it comes to gendered identities, the Oxford Dictionary defines gender as ‘either of the two sexes (male and female), especially when considered with reference to social and cultural differences rather than biological ones.’ We might say then that a person’s gender identity reflects the extent to which they align themselves with either ‘male’ or ‘female’ social and cultural norms.== ## 2.2 A reflexive approach to racial and gendered identities The definitions of racial and gendered identities introduced above seem simple enough. However, through the reflexive approach we introduced in Section 1, we acknowledged that all identities are multiple and temporally fluid. In addition, they are inherently political, contested and imbued with power structures. No identities exemplify this more than race and gender. It has been argued by social scientists, activists and human rights lobbyists, that race is a social construct with insidious effects and no biological basis (Lieberman 1997). That is not to say that racial identities do not exist, rather that these identities have been created through mechanisms of power and domination to subordinate particular groups to others. In its statement on race, the American Association of Physical Anthropologists (2020) says that: > the 'racial' worldview was invented to assign some groups to perpetual low status, while others were permitted access to privilege, power, and wealth. The tragedy in the United States has been that the policies and practices stemming from this worldview succeeded all too well in constructing unequal populations among Europeans, Native Americans, and peoples of African descent. This statement highlights the way structures of power and governance, particularly in the United States, have created and perpetuated racial identities in order to preserve systems of inequality. Issues such as racial profiling and police violence towards black individuals highlight the way power and governance figure in identifying, and brutalising, people with particularly defined racial identities. Gendered identities have also been fraught with politics and forms of violent governance, and as with racialised identities, this violence has been both physical and structural (Farmer et al. 2006). ==The male, female binary has been a prominent part of an enduring patriarchal societal worldview, in which the gender identity of women has been subordinate to that of men. This subordination has been tied to ideas of gender-normative practice such as maternal roles of child-care and domestic duties, as well as to biologised ideas about physical and mental ability.== Social scientist and gender theorist Judith Butler has explored the way that constructed sexual differences are materialised ‘as the effect of power’ (Butler 1993: 2) and scholars have built on her work to explore the way medical biotechnologies have been used to continue this materialisation of bodily differences (that is, how differences are made visible for example through visual imaging technologies) between the sexes and to exert power over gender-defined bodies (Burfoot 2003). An example of this is the way assisted reproductive technologies make visible the biological differences between those classified as male or female, and how egg and sperm donors are expected to personify gendered norms, as altruistic givers of life in the case of women, and as self-maximizing and financially driven in the case of men (Almeling 2011). Across history, time and space, these gendered identities have prevented women exercising the democratic right to vote, from achieving equal pay in the workplace, and in certain places, continues to limit their movement and ability to associate with individuals outside the home. Where women have been able to work, this has often been in roles that meet and reinforce these gendered norms, such as nannying and overseas domestic work (ODW). As anthropologist Nicole Constable explains, ODW is built on unequal global power relations and entrenches racialised assumptions and prejudices, with women from selected geographic locations being prized for their domestic services more highly than others. Scholars focusing on Philippine ODWs have also documented the way the identities of these female workers are shaped by government branding efforts, who designate women as ‘supermaids’ to attract more money for their services (Guevarra 2014). Gendered identities as they have been traditionally understood have also entrenched a binary of male and female, ostracizing individuals across the globe whose identities do not fit into this rigid dualism. The policing of individual bodies for not meeting the norms of a ‘female’ or ‘male’ gender identity has been rife, often resulting in violence and limiting the opportunities, rights and freedoms of individuals who identify outside this binary, or in a more fluid way across the gender spectrum. ## 2.3 Reclaiming identities While the construction of racial and gendered identities in society has subordinated some citizens unfairly and with negative implications for wellbeing, those self-identifying under these labels have worked to reclaim these identities, lobbying for change, respect, and equality. These identities have been the site of enduring struggles throughout history. From the fight against slavery, which could be the pinnacle of governmentality and brutality against particular racial identities, to the suffragette movement, to ==LGBTQ activism for fair access to HIV/AIDS treatment==. The changing faces and emergent movements that make up these identities remind us that while racial and gendered identities can make individuals the targets of forms of governance with negative impacts on wellbeing and health, they also remain powerful sites for potential change. In these instances, identities may be reclaimed and remade by those lobbying for a brighter, fairer future for those identifying through these racial or gendered categories. The emergence of the LGBTQ community, and wider societal acknowledgement of these identity positions demonstrates the way gendered identities have been challenged and remade to encompass a wider reality of gendered identities. The rising voice of feminism, exemplified through the MeToo movement, demonstrates the way women are fighting for equality, fair treatment, and protection from sexual harassment in a gendered society that has put the identity of men first. The strength of the growing Black Lives Matter movement, celebrating black identity, highlighting the deliberately marginalised and airbrushed achievements of black individuals throughout history, and the taking of one knee as a powerful symbol in response to the brutal killing of George Floyd at the hands of law enforcement officers in the USA in May 2020, all demonstrate the way particular racialised identity of ‘being black’, are being contested, remade, and redeployed to achieve a fairer and safer future for those being identified, and identifying themselves in this way. ## 2.4 Case study: race, gender and health governance Having introduced and explored some of the complexities and politics that underlie racial and gendered identities, in this section we will take an in-depth look at a particular case study to explore how the governance of racial and gendered identities and the governance of health relate, and how this relationship affects the health outcomes of individuals. [[Anne Pollock]], Professor of Global Health and Social Medicine at Kings College London, has written extensively about biomedicine and theories of race and gender, as well as the way science and medicine are mobilised in social justice projects. Her work is demonstrative of the reflexive approach to identity that we have highlighted. In her article ‘On the Suspended Sentences of the Scott Sisters: Mass Incarceration, Kidney Donation, and the Biopolitics of Race in the United States’, Pollock traces ‘the racialised contours of biopolitics in the United States’ (2014:250). In the article Pollock discusses the case of the Scott Sisters. The Scott sisters, a pair of black sisters from a low socio-economic background living in Mississippi, were both handed double life sentences for orchestrating an armed robbery in 1993. No one was hurt, and the men who were supposedly their accomplices were handed reduced three-year sentences for testifying against the two sisters, who incidentally have always maintained their innocence. This first part of this story speaks to our earlier discussion of Foucault and the governance of identities through institutions of power and control. It also speaks to our discussion of racialised identities and the way their social construction, premised on power and the subordination of non-white groups has led to their unjust treatment. Finally, it speaks to what we discussed in relation to the structural violence built into gendered identities, that the men involved in this crime served so little time in prison compared to their female counterparts. Pollock goes on to explain the relationship between the forms of governance and oppression that put the Scott Sister’s into this situation of elongated incarceration, the negative effect this had on their health, and the solution proposed by the state judiciary to resolve this issue, which was, ironically, a form of neo-liberal health governance. Years of incarceration and absence of adequate medical care while in prison led to a situation in 2010 where Jamie Scott, one of the sisters, required an urgent kidney transplant. Her sister Gladys offered. Activists pushed for their sentences to be pardoned, allowing for their release and for Jamie to receive the medical care she needed. However, the sisters were only granted only a ‘suspension’ of their sentences, and this was on the condition that Gladys donate her kidney to her sister. This solution released the state of obligation to care for the health of Jamie, putting this into the hands of her own sister. Despite this condition of their release, the poor physical health of both sisters has meant that the transplant has not happened, and the sisters have not been returned to prison. But as Pollock states ‘this narrative of prison release conditional upon organ donation is a revealing site for considering how incarceration plays a role in the constitution of racialized biological citizenship in the United States’ (ibid: 256). While this case mainly focuses on the way external forces have identified the Scott sisters in various ways: through their race, their gender, as guilty or innocent, as biological matches for kidney donation and as obese – and what this has meant for the health outcomes of the pair. The Scott sisters themselves focused on their identities as Christians throughout their incarceration. It was this form of self-identification that gave the sisters strength and resolve and was an identity no external force could ascribe for them, onto them, or take away from them. Through Pollock’s examination of this case, we see a multiplicity of identities, forms of governance, and issues of health as they emerge and interrelate. ## #to-write Activity 2: Read [[@SuspendedSentencesScott]] As you are reading, consider the following questions: What identities do the Scott sisters embody? How have these multiple identities affected the way the Scott sisters have been ‘identified’ by structures of power? How has the Scott sister’s health been governed as a result of the way they have been identified and incarcerated? How does the donation of an organ as a condition of their release demonstrate neoliberal approaches to health governance? How does this case help us to understand/critique biopolitical regimes in the USA today? Post your reflections on these questions on to the Activity 2 message board on Moodle. Compare your ideas with other students’ posts and comment on at least one of these. # 3. The COVID-19 pandemic ## 3.1 Biosecurity, risk, and identity Issues of biosecurity and the creation of identities of risk or ‘risky subjects’ were exemplified in the case of cruise ships stranded around the world where coronavirus had been identified onboard. Ships were prevented from docking and thus individuals were quite literally ‘left at sea’, their biological status as ‘risky’ identifying them as unwelcome. Individuals on these cruise ships reported concerns about not receiving medical attention and the impacts on their health of having to quarantine onboard the cruise ships for 14 days before being allowed to disembark. This was particularly concerning for individuals suffering from chronic or terminal illness (Guardian 2020). The notion of the risky subject and identity was also apparent in the discourse that surrounded the virus. Early media reporting of the virus, and many global leaders such the as the ==American president Donald Trump have referred to the virus as the ‘Chinese’, or ‘Wuhan virus’ (Jensen 2020). Identifying the virus as synonymous with a location quickly extended to the body politic of China and its population (Henry 2020)==. Chinese individuals across the globe were targeted as ‘carriers’ or ‘embodiments’ of the virus. This form of abuse was centred on the construction of a racially risky identity and has led to forms of racist abuse (Davey 2020). Despite the global spread of the virus, and cases across Europe, Brazil, India and the USA far exceeding recorded cases in China, the stigma of this identity has continued. One common governance strategy employed by states across the globe seeks to slow the spread of coronavirus through populations by implementing social distancing rules. While encouraging individuals not to be in physical proximity with individuals outside their households may be an important public health strategy, anthropologist Thurka Sangaramoorthy has argued that a nuanced and careful approach to social distancing must be taken. Working with black HIV positive women in the USA, Sangaramoorthy argues that forms of social distancing have been practiced against HIV positive individuals throughout history, and that for these individuals being asked not to embrace, touch or be close to others brings back feelings of stigma and pollution. She thus argues that the multiplicity of existing health identities be considered when introducing public health measures on social distancing (Sangaramoorthy 2020). ## 3.2 COVID-19 and identity in the UK In this section we will look at a couple of examples of the ways in which the UK Government’s strategies of governance in the face of the COVID-19 pandemic intersect with issues of identity and health. The pandemic raises a plethora of examples and questions about health governance, identity, and individual health outcomes. There are many other examples that could be made from the UK case, and examples continue to emerge as the pandemic wages on. ==We will be focusing on the emergent identity of the ‘vulnerable’ and how this relates to governance and health==. ## 3.3 Constructing and governing the 'vulnerable' In late March 2020, under the guidance of Public Health England, the UK Government announced that the risks of the coronavirus were higher for those with underlying health conditions and those over the age of 70. These populations were highlighted as particularly vulnerable. The National Health Service (NHS) was put to work, acting as a governance structure through which to identify vulnerable individuals. General practice and hospital medical records were used to identify these individuals, and they were contacted through the postal service and advised to stay isolated inside their homes until the end of June at the earliest. A new discourse and identity had emerged; that of the ‘vulnerable’, and people began to identify themselves and others around them through this language. This new language was also accompanied by new practices. Vulnerable people could not be expected by their employers to go to their place of work for example. They were exempt, or must be allowed where feasible, to work from home until the end of June. The practices of those living with, or with relatives classified as vulnerable changed to. If you lived with someone vulnerable you were expected to take extra precautions to protect them. As some lock-down measures eased in June, many people classified as vulnerable were left isolated at home while the rest of their family and friends were able to be reunited. Identifying individuals as vulnerable was, and continues to be, a concerted effort to govern the public health of a medically defined section of the UK population1. This was a neoliberal approach to health governance, as while individuals were advised to stay at home, the decision ultimately lay in their own hands. The government were not taking responsibility for the individual welfare of the vulnerable, but through identifying individuals as vulnerable, were asking individuals to take care of themselves. ## 3.4 Vulnerable identities: conflicts, multiplicity, and health While identifying individuals as vulnerable to the coronavirus was orchestrated as a public health governance technique, it had far-reaching consequences beyond that of keeping individuals healthy, and safe from the virus. Many of these consequences stemmed from the fact that these newly identified ‘vulnerable individuals’ already had a multiplicity of identities, and this new identity did not necessarily gel with existing identities, in fact it often clashed. An example of this can be seen in the case of individuals whose working identities did not sit comfortably with an emerging identity that confined them to their homes. ==Doctors, nurses and hospital workers in all their guises had been designated as ‘key workers’, some of the only individuals exempt from the rules of lockdown scenarios, as they were desperately needed to deal with the influx of coronavirus patients.== The problem was that some of these same key workers also received letters identifying them as vulnerable and advising them to shield. These two identities sat in direct conflict and individuals had to make difficult decisions which had the potential to negatively affect both mental and physical health. To sit at home and feel like they were doing nothing, not living up to the identity of caregiver, lifesaver, or to go to work and risk being ventilated (or worse) themselves because of the virus? Another problem that emerged from this public health message were the logistical challenges of ensuring those shielding at home had food and medical supplies. As part of their efforts to keep vulnerable people at home, the government organised a scheme to deliver food to vulnerable individuals. However, the scheme was reported to be flawed. The government stated that food parcels would have to be a ‘one size fits all’, and thus included items that did not account for the dietary requirements or religious and ethical observations of individuals receiving them (Asian Standard 2020). Moreover, this scheme was only accessible for a fragment of the individuals who had been advised to stay at home and isolate. Reports emerged of vulnerable individuals left homebound, unable to access supermarket food delivery slots and contacting local food banks due to a lack of food (Guardian 2020). This set of examples shows the darker side of this neoliberal public health message which encouraged individuals to stay at home for the good of their health, yet provided foods that were unacceptable to many individuals, or left vulnerable individuals responsible for obtaining their own food from home, a difficult feat in the face of the pandemic. While the government identified more than 2.2 million individuals as vulnerable, individuals exercised autonomy in accepting or rejecting this newly received identity. Some very elderly individuals and some individuals of varying ages with terminal illnesses argued that with potentially not long left to live regardless of the coronavirus, why would they spend their last few months inside their homes alone. These individuals already identified with a recognition of their own mortality and thus being identified as ‘vulnerable’ would not lead them to accept the behaviour change the government wished those as vulnerable to embody. Ironically, the sense of vulnerability to death they already identified with made them less willing to stay at home. Conversely some individuals newly identified as vulnerable did accept this identity and embodied it to an extent that once the end of June arrived, they still did not feel comfortable leaving their homes. Having spent the best part of 4 months isolated and controlling their surroundings for the sake of their health, many of these vulnerable individuals reported feelings of severe anxiety and fear about re-entering society. They had become fearful of ‘non-vulnerable’ people outside of their home who might put them at risk of contracting the virus. These sets of examples show the multifaceted nature of the identity of vulnerability. They demonstrate the way health governance and identity intersect. While the aim of this neoliberal public health message was to preserve the vitality of high-risk individuals, this identity label did far more than this, it interacted with individuals existing forms of identification, it posed challenges to individuals sense of self, morals and daily life and in some cases affected individuals mental health by conditioning a lasting ‘fear of others’ (Roy 2020). ## #to-write Integrating Activity: Prepare your own COVID-19 Case Study In section 3 we have explored ideas of governance, health, and identity in relation to the COVID-19 pandemic. This section has relied on the example of identities of vulnerability within the UK context. For this activity, select any country of your choice and write a short case study, presenting and analysing some of the relationships between governance, identity and health in this setting during the COVID-19 pandemic. If you wish to write about the UK please use different examples to the ones presented in this document. Post your discussion on the Integrating Activity page on Moodle. Compare this to other students’ responses and comment on at least one of these that interests you. # 4. Summary In this session we looked at the concept of identity and the relationship between governance, identity, and health. In so doing, we: · Introduced the concept of identity and demonstrated the importance of a reflexive approach that acknowledges the complex, political, multiple nature of identities. · Discussed the way scholars, such as Foucault, have understood changing modes of governance that take life itself as their object. We explored the kinds of subjects these modes of governance bring into being and exert power over, as well as the possibilities they offer for autonomy and self-discovery. · Used the examples of gender and race to explore inequalities in society that result from the construction of identities and the subordination of certain groups. Through the case study of the Scott sisters we analysed the intimate relationship between forms of governance, power, identity, and health. · Explored the concept of identity and health governance during the COVID-19 pandemic, focusing on the creating of subjectivities, the entrenching of national identities, and the conflicts that emerge where multiple identities intersect. # 5. References ## 8.1 [[Essential readings]] [[@GovernmentLivingBeings]] Lemke, T., Casper, M., Moore, L. (2011) Biopolitics An Advanced Introduction. Chapter 3: The Government of Living Beings: Michel Foucault. New York, NYU Press. pp. 33-52 [[@HealthIdentitiesSubjectivities]] Whyte, S. R. (2009). Health identities and subjectivities: The ethnographic challenge. Medical Anthropology Quarterly, 23(1), 6–15 [[@pollockSuspendedSentencesScott2015]] Pollock, A. (2015) On the Suspended Sentences of the Scott Sisters: Mass Incarceration, Kidney Donation, and the Biopolitics of Race in the United States. Science, Technology, & Human Values Vol. 40(2) 250-271 ## 8.2 [[Recommended reading]] [[@henryReconstitutingChinaTime2020]] Henry, E. S (2020) Reconstituting China in a Time of Pandemic. Anthropology Now. Volume 12, Issue 1: An anthropology of the COVID-19 Pandemic. pp. 50-54 [[@novasGeneticRiskBirth]] Rose. N., and Novas, C. (2010) Genetic risk and the birth of the somatic individual. Economy and Society Vol. 29, Issue 4, pp. 485-513 [[@braunBiopoliticsMolecularizationLife]] Braun B. (2007) Biopolitics and the molecularization of life. cultural geographies.14(1):6-28. doi:10.1177/1474474007072817 [[@luptonMhealthHealthPromotion2012]] Lupton, D. (2012) ‘M-health and health promotion: The digital cyborg and surveillance society’, Social Theory and Health, 10(3), pp. 229–244. doi: 10.1057/sth.2012.6.