Citizenship by vitality: rethinking the concept of health citizenship

ABSTRACT

In this article, we develop a concept of health citizenship that is specific, historically informed, and flexible to use in the analysis of different domains of medicine and healthcare. Our starting point is that health citizenship is rooted in notions about the vitality and biological existence of populations and individuals. Key tensions in citizenship vis-à-vis health and illness emerge when ideas of membership of a nation, rights and responsibilities, and the related ethical principles of access, equality, and participation encounter ‘truths’ regarding the vital capacities and characteristics of individuals and populations. Drawing from historical and contemporary examples from Finland, we analyse how biological and medical facts and related expert knowledge enter into and influence the domains in which citizenship is defined and contested. Our concept shares the Foucauldian tenet of biological citizenship, but we expand its scope beyond the focus on recent developments in life sciences and biotechnology, situating it in a broader historical trajectory. Our approach also stresses the specificity of health within the field of social citizenship and offers a more balanced account of the historical development of health citizenship, as compared to the liberal reading focused on the right to health.

KEYWORDS:

• Citizenship
• health
• biopolitics
• history
• Finland

Introduction

Citizenship is a key concept in political thought that designates the relationship between the state and the individual. Regarding the discussion in this paper, citizenship has three essential characteristics: First, it implies membership in a political community, or polity, which in turn opens up questions of inclusion and exclusion. Second, citizenship has to do with rights and entitlements granted and guaranteed by the polity and with individuals’ responsibilities and obligations towards the political community. Third, citizenship is about the capabilities of the members of a polity to participate in its affairs as more or less autonomous and competent individuals.

In recent decades, citizenship has been a fashionable concept to capture changes in the relationship between nation-state institutions and individuals induced by a number of developments such as economic and cultural globalisation, transnational migration, dismantling of the welfare state, and technological development (Turner 1993; 2001; Novas 2006). The current interest in the topic has resulted in a proliferation of conceptual innovations, such as sexual, biological, ecological, multicultural, cosmopolitan, and consumer citizenship (Isin and Turner 2002). In this topical gallery, health citizenship – and its close relatives biological, therapeutic, and pharmaceutical citizenship – represents one further type.

However, the concept of health citizenship currently exists in several iterations across various academic domains, in both social sciences and historical research. These versions are only loosely connected, and each presents only a partial view of the amalgamation of health and citizenship. First, in the sociology of health and illness and in medical anthropology, the concept has referred to the roles and responsibilities public authorities assign to subjects of illness, risk, or healthcare in different biomedical contexts, but with a focus that has been restricted to current neoliberal policies (e.g. Petersen et al. 2010). Second, in studies focusing on the context of the welfare state, health citizenship has typically been subsumed into social citizenship and discussed narrowly as a matter of access to healthcare, thus missing the specificity of health vis-à-vis citizenship (e.g. Johnson Redden 2002; Harjula 2015, 2016). Furthermore, authoritative historical treatments of health citizenship (Huisman and Oosterhuis 2014; Porter 1999, 2011) tend to highlight rights-based principles, thus implicitly subscribing to a liberal (that is, a historically specific and partial) reading of health citizenship.

Our aim is to rethink health citizenship and redefine its conceptual domain to make it operable across all these academic discussions. We suggest that the distinctive feature of health citizenship is its relationship to vitality; in our definition, health citizenship is citizenship by vitality. Vitality refers to characteristics and capabilities of individuals and groups of people, which are biologically elementary, crucial for their viability, and often seen as congenital. Examples include physical health, mental abilities, hereditary characteristics, reproductive capacities, fitness for work, etc. Vitality is historically and socially contingent: what are considered basic vital features and forces in humans, how they are understood to be effective, and how their political significance and moral value are conceived of differ between historical periods or social settings. Science and expert knowledge – especially in life sciences and medicine – have held a key position in defining vitality and in determining ways to measure and modify it. Therefore, experts and their knowledge of vitality are directly or indirectly involved in social contestations and politics of vitality, that is, biopolitics.

When citizenship is about membership in a polity, recognition and rights, and citizens’ capabilities, health citizenship covers definitions of membership, struggles about recognition and rights, and characterisations of capabilities that refer to the vital traits of individuals and groups. Thus, we suggest that key tensions in citizenship vis-à-vis health and illness result from the multiple intersections at which ideas of membership and belonging, rights and entitlement, and the related ethical principles of access, equality, and participation in a society encounter ‘truths’ regarding the biological capacities and characteristics of individuals and groups of people – that is, vitality. We underline that our intention is not to ground citizenship in biology. Rather, we attempt to provide a perspective on how biological and medical facts and related expert knowledge enter in and influence the domains in which citizenship is defined and struggled over.

Our concept of health citizenship is obviously related to the notion of ‘biological citizenship’, which has been very influential in recent discussions on health and citizenship. We (Helén and Jauho 2003) first introduced our concept around the same time as the key formulations of biological citizenship were published (Rose and Novas 2005; cf. Petryna 2002). Both concepts draw from Foucauldian notions of biopolitics and governmentality and subsequent studies that focus on the government of the life of populations and individuals (Helén 2016; Burchell, Gordon, and Miller 1991; Foucault 2008, 2009; Lemke 2011) and thus share a common premise: namely, the emphasis on the importance of vitality and ‘biological facts’ in citizenship projects. However, the scopes of the concepts differ in crucial ways. Rose and Novas (2005) and many of their interlocutors have used biological citizenship primarily to address recent changes in the government of life induced by genomic research and advanced biotechnologies and to describe an emerging mode of ‘molecular biopolitics’. Biological citizenship foregrounds the role of biomedical knowledge and advanced biotechnologies in the shaping of subjectivities (somatic individuality), the emergence of advocacy groups based on biological characteristics (biosociality), and the conception of biological materials as valuable resources and sources of economic profit (biovalue) (Rose and Novas 2005). Health citizenship, by contrast, is rooted in ‘the government of the social’ (Donzelot 1993; Rose 1999). The phrase refers to a rationale and set of practices of modern government that attempt to juggle the tensions between the freedom of the economic market and the need to solve social problems and provide social security (Brodie 2008). Health citizenship addresses the ways modern states have embraced ensuring the vitality and well-being of the population as their central task and transformed into welfare states. We thus place the alignment of biology and citizenship in a broader context and into a longer historical trajectory compared to biological citizenship. In this sense, biological citizenship as discussed above can be seen as one iteration of a more comprehensive concept of health citizenship, and our approach as corrective to the original biotechnological framing of biological citizenship (cf. Raman and Tutton 2010). The choice of wording also reflects our aim to explicitly connect the previous literature on health citizenship with the analytics of government-inspired approaches (e.g. Rose 2007) behind the notion of biological citizenship.

We offer a novel perspective to health citizenship that expands the concept of biological citizenship and addresses key lacunae in other notions of health citizenship. Using Finland as our case, we illustrate our perspective with empirical examples from different time periods and representing different types of ‘citizenship technologies’ (see Cruikshank 1999). The examples provide an outline of the historical trajectory of health citizenship starting from i) the protection of society from groups not deemed to fulfil the membership criteria for proper citizens through ii) the safeguarding of individual rights by the state offering universal health services to iii) the challenging and reconfiguring of these established modes of health citizenship by the current focus on self-responsibility, choice, and consumerism (active citizenship) on the one hand and the fiscal crisis of the state on the other. Rather than successive historical phases, these should be understood as three different political configurations that enact the relationship between a polity and its members in distinct ways. Elements of these configurations coexist in current citizenship projects and struggles.

The next two sections critically discuss the literature on health and citizenship, carving out a place for our concept of health citizenship. In the following two sections, we sketch the historical trajectory of health citizenship from the French Revolution in 1789 to current neoliberal policies. The concluding section draws together our argument and calls for situated, historically informed, and comparative studies of citizenship by vitality.

Citizenship, welfare, and health

Compared to other domains, health has not been a major focus in studies on welfare and citizenship within social and political sciences or in historical research. Existing accounts occasion three general observations regarding the alignment of health and citizenship.

First, studies on the development of the welfare state and citizenship rights do include health, but it is typically discussed within a larger framework of social welfare (e.g. Moran 1991; Turner 2001; Kotkas 2010; Leppälä 2014a). In T. H. Marshall’s (1950) influential formulation of social rights, health was only one aspect pertaining to social citizenship. Marshall connected social rights to the rise of the welfare state, which granted citizens an adequate standard of living, social protection, education, and health to shield them from the negative consequences of market society and enable them to fully participate in social and civic activities. In this constellation, ‘the social’ refers to the arrangements that compensate for the inequality introduced into society by the capitalistic market economy. This perspective has highlighted work and welfare as the central aspects of social rights. Health and illness are considered conditions that influence citizens’ access to and position in the labour market, and the discussion on health focuses on arrangements needed to compensate for citizens’ temporary or permanent lack of income due to poor health or impairment and to reintroduce them into the labour market. Due to this emphasis, health becomes one issue among many within the field of the social, without a specific character. Consequently, health citizenship is subsumed into social citizenship.

Second, the few studies that single out health from other aspects of social citizenship and explicitly focus on health citizenship typically foreground healthcare services instead of health in a broader sense (Harjula 2015; 2016; Johnson Redden 2002). Unlike political rights such as eligibility to vote, health is not a legally enforceable entity; it is indefinite and influenced by many contingent natural and social factors (see Greco 2004). The state cannot provide an absolute guarantee to health as a right, but can only offer services that promote, safeguard, and restore it. This requires resources, which are necessarily limited, unlike health needs which tend to expand. This dynamic accentuates the question of access to health services: who is entitled to (what type of) healthcare, and who is excluded from (which) services? When approached from this perspective, health citizenship becomes defined as ‘healthcare citizenship’ (cf. Moran 1991, 35).

A good example of this tendency is Minna Harjula’s (2015, see also 2016) study of health citizenship in Finland in the twentieth century, which is framed as a question of access to health services. She distinguishes between three aspects of access: the supply of services (availability), their pricing (affordability), and expectations relating to their use, including the necessary social, cultural, and epistemic competences (acceptability). Harjula (2015) follows these aspects throughout the development of national healthcare and welfare services from the early nation-building period before Finnish independence in 1917 to current dismantling of the welfare state and retrenchment policy. Her foci are class, gender, and regional variations in the supply and pricing of services as well as the principles used to refer people for treatment in different historical periods. Harjula (2015) covers the aspects of availability and affordability well. She also highlights the interconnectedness of civil, political, and social citizenship: for the poor and infirm, becoming the recipient of welfare services often had repercussions in the two other spheres, such as loss of property or restrictions in the right to vote.

However, due to Harjula’s focus on service provision, her study foregrounds healthcare and bypasses key areas of health citizenship. The discussion of acceptability falls especially short, since understanding the development of the social, cultural, and epistemic preconditions for service use requires one to look beyond the service system to broader health-relevant contexts such as health advice, education, or promotion, and social care outside of the medical system. These realms create preconditions not only for service use but, more generally, for the performance of full health citizenship. Consequently, key aspects of health citizenship cannot be grasped by looking only at access to healthcare, which makes Harjula’s concept of healthcare citizenship too narrow for our purposes.

Finally, those few studies that do aim for a broader approach to health citizenship (one not defined through access to services) emphasize a liberal reading of health citizenship that focuses on individual rights. In her authoritative studies, Dorothy Porter (1999, 2011) introduced the concept of ‘the social contract of health’ to characterize the relationship of the state and citizens vis-à-vis health. The concept refers to the implicit understanding among members of a society about how society should be organised, how benefits are distributed, and how shared responsibilities with reference to health and illness are defined for all citizens. Although the concept is flexible enough in principle to cover different iterations of health citizenship, the key ‘citizenship moments’ Porter’s studies highlight are enunciations of rights-based principles. Thus, it was ‘French revolutionaries [who] declared health an obligation of the social contract between the democratic state and its citizens and invented the idea of health citizenship’ (Porter 2011, 1; see also Porter 1999, 57). Further, in 1848, ‘French and German revolutionaries, Jules Guérin […] and Rudolf Virchow […], interpreted health citizenship as constituted through democratic freedom, universal education and amelioration of social and economic inequality’ (Porter 2011, 3; see also Porter 1999, 106–167). In her discussion of nineteenth century industrialisation and urbanisation and the policies created to mitigate their associated sanitary problems and epidemic diseases, Porter (1999, 63) framed health ‘as a civil right to equality under the law to protection from assault from disease’, while welfare provision and the notion of social citizenship dominate the account on the twentieth century (Porter 1999, 163). Although Porter does not explicitly define health citizenship, these emphases point to a liberal conceptualisation. It derives from Porter’s (1999, 5) general focus on ‘the implications of health citizenship as a “right of man” within democratic states’.

A similar liberal tendency can be identified in a volume edited by Huisman and Oosterhuis (2014). As summarised by Porter (2016, 350), they divide the history of citizenship into ‘three analytical and chronological categories: liberal citizenship, which underpinned the development of public health movements up to the First World War; social citizenship, originating in mid-nineteenth-century revolutionary movements and which subsequently paralleled the rise of welfare states up to the mid-twentieth century; and the post–World War II emergence of neoliberal citizenship in a risk society’ (see Huisman and Oosterhuis 2014, 16–40).¹ This division reproduces the typical periodization of the liberal, rights-based conceptualisations of citizenship.

The problem in such liberal conceptualisations is that health citizenship is approached from a contemporary perspective tied to the emergence of the welfare state and social rights. This leaves out important iterations of health citizenship that are not articulated primarily through rights. In fact, examples of such iterations are present in both Porter’s and Huisman and Oosterhuis’s books. Porter (1999) tends to focus on developments in which a rights-based position is articulated or is in conflict with a more ‘social’ viewpoint (restriction of individual rights in the name of the common good). These are typically battles that the affluent wage against the state’s attempts to restrict their liberties (see e.g. the example of smallpox vaccination resistance on pp. 128-130). However, throughout Porter (1999) also addresses situations in which less affluent members of the society – those who are considered unfit, problematic, or dangerous – are subjected to measures of correction. While the measures articulate a relationship between the state and its members and thus belong to the domain of health citizenship, these groups are not subjects of rights – at least, not until the rise of the welfare state – but rather objects of charity, instruction, or coercion (see e.g. reactions to cholera in Britain on pp. 91-92). Similarly, the individual essays in Huisman and Oosterhuis’s (2014) volume exhibit more conceptual plurality regarding health citizenship than indicated in their introduction (see e.g. Oosterhuis 2014).² These observations point to the limitations of the liberal, rights-based conception of health citizenship and call for an expanded and more flexible concept, in order to give credit to the various iterations of citizenship in the long history of the social contract of health. In light of this literature, our article has three aims: to highlight the specificity of health within the field of social rights, to reformulate the concept of health citizenship so that it includes but is not restricted to questions regarding access to healthcare, and to broaden the scope of the concept beyond liberal rights-based formulations of health citizenship.

Biological citizenship

Biological citizenship (Rose and Novas 2005; Rose 2007, 131–154; Rose 2010; cf. Petryna 2002; for overviews, see Plows and Boddington 2006; Raman and Tutton 2010; Wehling 2011) denotes another corpus of work addressing the amalgamation of health and citizenship. However, it is rather detached from the literature on social rights and the welfare state and health(care) citizenship discussed above. In their seminal paper, Rose and Novas (2005, 439) claim that ‘a new kind of citizenship is taking shape in the age of biomedicine, biotechnology and genomics’, adopting Adriana Petryna’s (2002) concept to name this new biological mode of citizenship. Biological citizenship is conceived as ‘a more general version of […] “genetic citizenship”’ (Rose 2007, 136; on genetic citizenship, see Heath, Rapp, and Taussig 2004), with three key aspects discussed. The first aspect is the role of biomedical knowledge and advanced biotechnologies in the shaping of subjectivities and ‘making up’ (see Hacking 2002, 99–114) of biological citizens. This includes both a heightened emphasis on corporeality as basis for identity, or ‘somatic individuality’ (Novas and Rose 2000), and the imperative of active stewardship of personal biological characteristics and health. The second aspect is the emergence of novel types of patient associations, disease advocacy networks, and self-help groups that are based on biological knowledge and engender new forms of subjectivity and collective action, or ‘biosociality’ (see Rabinow 1996, 91–111). The third key aspect is the way the new technological possibilities ‘transform the potentialities embodied in life itself into a source of value creation’ (Rose and Novas 2005, 455), encapsulated by the notion of ‘biovalue’, another ‘bio-’concept that emerged simultaneously with biological citizenship (see Waldby 2002; Novas 2006).

Subsequent research on biological citizenship has proceeded along these lines, with studies extending from cutting-edge bioscience and biotechnology to other contemporary biomedical realms. In such studies, biological citizenship has often been replaced with related concepts such as ‘health citizenship’ (Petersen et al. 2010), ‘therapeutic citizenship’ (Nguyen 2005), or ‘pharmaceutical citizenship’ (Ecks 2005). These terms are regularly evoked in studies focusing on current neoliberal policies, in which individuals are expected to take ownership of their health and well-being and to engage in active self-monitoring and self-management to maximize their vital potential. Often, but not always (e.g. Setälä and Väliverronen 2014; Dingel et al. 2017), these studies address not only medical subjectivity, but also its entanglement with social networks of solidarity or issues of inequality (e.g. Pienaar 2016; Spoel, Harris, and Henwood 2014). This connects them to studies that have explored patient activism and disease advocacy related to actual or expected options for new medical interventions (e.g. Callon and Rabeharisoa 2008; Fitzgerald 2008; Gibbon and Novas 2008; Hughes 2009), highlighting the expansion of rights and opportunities to participate and make choices over personal biology as the core of biological citizenship.

Rose (2007, 137) did suggest that ‘genetics contributes only […] one axis of the ways in which the biological makeup of each and all can become an issue for political contestation, and for recognition and exclusion, and for demands for rights and the imposition of obligations’ and addressed ways in which biology had previously been inserted into citizenship projects. However, discussions have recently centred on more contemporary transformations along the lines opened by the formulations in the earlier studies.³ Moreover, the initial framing of the history of biological citizenship unduly emphasised its racial and eugenic aspects (Rose and Novas 2005, 443–445; Rose 2007, 137–139; cf. Rose 2010), thus projecting backwards in time the then topical focus on genetic and hereditary influences which dominated the early discussion on biological citizenship. From this perspective, the history of biological citizenship tends to be restricted to its ‘eugenic past’, which we find too narrow a view that eclipses essential historical configurations of citizenship by vitality.

Therefore, there is room for a more comprehensive account of citizenship by vitality. Such an account considers the influence of contemporary life sciences, biomedicine, and biotechnology as only the latest twist in a much longer history. It includes the entire domain of public health, population policy, and politics of healthcare, as well as the variety of relationships between political actors and individual citizens therein. It also engages with the whole range of literature covering this domain and these relationships. Next, we offer a sketch of this domain and suggest some ways to approach it in terms of citizenship by vitality.

Citizenship by vitality

The concept of health citizenship emerged with the political and social development by which universal citizenship – declared by the French Revolution in 1789 – was actualised in the Western countries that adopted the political form of the nationstate in the nineteenth and twentieth centuries (see Isin 2002, 191–202). Universalisation and expansion of the scope of citizenship (on the latter, see Turner 1993) in the context of nationstates had a significant biopolitical aspect. Politicisation of human biology and biologization of citizenship were essential characteristics of the nation-building, state formation, and social reforms enacted by industrialised countries in the late nineteenth and early twentieth centuries. National biopolitics concretely manifested in a variety of projects promoting the health and welfare of society and its members, ranging from fighting infectious diseases; measures of social, mental, and racial hygiene and eugenics; to welfarist public health reforms and social care. These projects created a very influential context of reasoning and action in which health and citizenship aligned, and they brought national vitality and health into the focus of politics. The vitality of individuals was increasingly seen as an important aspect of national citizenship, and citizenship by vitality became the basis of health citizenship.

We can discern two historical configurations in the development of health citizenship within Western nationstates. The first accentuates citizenship as membership in the organic unity of the nation or the people (Volk, folket). The second defines it through individual rights, or rather, entitlements. The historical dividing line is roughly the Second World War, although the configurations should not be understood as two successive periods but rather as overlapping layers (the former paradigm continued to coexist alongside the latter).

Health citizenship as membership

In the nineteenth century, political thinking in the Nordic countries, including Finland, defined citizenship as belonging to one’s nation. In Finnish, this connection is firm: the word referring to citizen, kansalainen, has the same root as the word denoting a people or nation, kansa, and lacks the connection to city-dwellers that the other Nordic languages share with major European languages (e.g. citizen, citoyen, burger, medborgare) (Kettunen 2000; Stenius 2019). In the late nineteenth and early twentieth centuries, this idea became embedded in an understanding of the state and the nation as an organic whole, the interests of which subsumed those of the citizens. In this period, this notion of the state or nation as an organism was reinforced throughout Western countries and was important to public health measures and general population policy that defined health citizenship. The state approached people as a population that was characterised by vital processes such as fertility, morbidity, and mortality, which were to be calculated, intervened in, and manipulated for the common benefit (see Foucault 2009, 67–79). Concretely, this meant nurturing citizens’ capacities to work, procreate, and fight in war. Population health was also an economic issue, since excess morbidity and mortality generate costs from lost labour and increased care needs. In Finland, health was also an issue of nation-building: indicators such as low infant mortality were regarded by the national elite as essential for putting the emerging nation on a par with other European ‘civilised countries’ (Harjula 2015, 37, 2016).

From the perspective of membership, health citizenship was shaped by two sets of rationales and practices (Helén and Jauho 2003; Helén 2016, 302–304). One consisted of attempts to educate every member of society to citizenship and integrate each into the national whole through healthcare measures. Health education and public hygiene were integral aspects of social reforms and nation building in Western industrialised nations in the late nineteenth and early twentieth centuries. In the Nordic countries, education on personal hygiene formed a cornerstone of national public health campaigns (Jauho 2007; Olsson 1999; Palmblad and Eriksson 1995). It was promoted by physicians, public health authorities, and civic associations and often defined as a specifically feminine domain of social activity (see Sulkunen 1987; Ollila 1995). Health education aimed to mobilize all members of society into safeguarding their own health and vitality. The education campaigns consisted not only of teaching the technical aspects of healthcare and self-treatment, but also covered such civil virtues as diligence, regularity, thrift, and cleanliness. Good physical and mental health were presented as preconditions for being a productive and useful citizen, and embracing healthcare was presented as a civic duty. However, the promotion of personal hygiene did not encourage the broad masses of health citizens to take an interest and participate in politics – this was mostly reserved for male upper-class citizens – but was intended to make them concerned about the preservation and augmentation of their own vital capacities for the benefit of the nation (Helén and Jauho 2003). Health was not articulated as a right, but as a mutual obligation between the state and the citizens: while the individual was expected to safeguard their own personal health, the state maintained public order and hygiene and provided medical aid for the infirm.

The other set of measures defining health citizenship as membership in an organic national whole consisted of rationales and practices that medically assessed and sorted individuals and groups of people according to their vital capacities and put them onto different citizenship trajectories depending on these classifications (Helén and Jauho 2003; Helén 2016, 303). Harjula (2015, 68–112, 2016) describes how access to health services was differentiated by social class and occupation in early twentieth-century Finland. People with means could enjoy private medical care and hospital treatment, and large companies provided services such as factory doctors and sickness funds for their employees. For the poor, state hospitals and mental institutions reserved free beds, and state or municipally funded doctors were obliged to provide medical care free of charge. Access to these services was regulated by the poor relief, and it ‘was not a social right or realisation of full citizenship. […] Recipients of poor relief were excluded from universal suffrage both in national and local elections until the 1940s and their civil rights were also restricted’ (Harjula 2016, 580; see also Satka 1995, 25).

Instead of social class and occupation, we want to highlight the vital potential and capacities of individuals as the basis of classification of population groups with regard to health. Differentiation by vitality was a crucial aspect in the various projects of social, mental, and racial hygiene. Vitality was used as a yardstick to create a hierarchy for citizenship on biological and medical terms. Those deemed unfit or misfit – the disabled, the dangerous, the unproductive, the incorrigible – were subjected to surveillance, treatment, or coercive measures by various experts and public authorities. For example, prevention of epidemics, tuberculosis, and venereal diseases was used to justify – depending on the specific condition – the compulsory notification, registration, vaccination, or isolation of individuals deemed dangerous (Harjula 2015, 56–62; Häkkinen 1995; for Nordic countries, see Blom 2007). Legislation on sterilisation to ward off ‘hereditary degeneration’, introduced in Finland in 1935, was another example of such policy (Hietala 2005; Mattila 1999; 2018). In addition, the poor were judged based on their vitality, as sickness was the most common cause for needing poor relief. Social benefits were reserved for ‘deserving’ citizens who could be expected to support themselves in the future, leaving out people who were ‘chronically ill, over 40 years of age, or too severely impaired or defined as mentally defective’ (Harjula 2016, 582).

Even though authoritarian states adopted extreme measures to annihilate the unfit elements of the population (Proctor 1988; Weindling 1989), categorising individuals based on their vital potential and capacities did not primarily mean exclusion. The early twentieth-century biopolitical rationale of differentiation did not imply a binary opposition that defined individuals as either with or without entitlement to citizenship in the nation-state. Rather, it formed a continuum by which an individual could be defined as more or less a citizen. Related to this was a tendency not to exclude those members of the nation considered to be deficient, but to either subject them to surveillance or incarceration or provide them with therapy or care (Helén 1997; Helén and Jauho 2003).

Right to health: entitlement and vitality

The nation states developed into welfare states, especially in Northern Europe, during the latter half of the twentieth century. With this gradual change, citizenship by vitality was no longer defined solely in terms of membership in and subordination to the nation-state. Within the new welfare regimes, citizenship became aligned with health and vitality through rights as well, with the implication that the state was obliged to protect citizens’ health and to provide them with healthcare. The claim for a right to health originated from the French Revolution, where it was attached to the citizens’ responsibility to treasure and foster their vitality. During the century and a half that followed, the concept of a right to health became a powerful idea, and it was appealed to in various pleas for better healthcare. However, the idea and the claim did not really become operative in practice until the rise of the welfare state (Porter 1999).

Founding documents of international organisations signified a new approach to health citizenship. The Constitution of the World Health Organization defined ‘the highest possible attainment of health’ as ‘a fundamental right of every human being’ and gave governments the ‘responsibility for the health of their peoples’, to be ‘fulfilled […] by the provision of adequate health and social measures’ (WHO 1946, preamble). Similarly, the Universal Declaration of Human Rights proclaimed by the United Nations in 1948 granted everyone ‘the economic, social and cultural rights indispensable for his [sic] dignity and the free development of his personality’ (United Nations 1948, Article 22). They included ‘the right to a standard of living adequate for the health and well-being of himself [sic] and his family’, including, among other provisions, ‘medical care and necessary social services’ (United Nations 1948, Article 25).

In its current meaning, the right to health refers to citizens’ entitlement to medical care and other public services that safeguard their personal health. In practice, this is provided by universal health insurance and a public medical system that offers equal services to all citizens in Finland. Unlike most civic and political rights, the right to health is – like other social rights – not definite nor substantial, but conditioned by the structure and level of public services, making it contingent and contested. In Finland, welfare entitlements were not articulated primarily as individual social rights, but were seen as ‘legitimized by the need to secure the material well-being of all segments of the population equally’ (Kotkas 2017, 16; see also Kotkas 2019). Thus, it was universal availability and access to all population groups rather than an explicit rights discourse that drove the building of Finnish healthcare service systems and social security schemes.⁴

According to a prominent definition (Kuusi 1961), the ultimate goal of social policy was the promotion of citizens’ well-being, which was best achieved by ensuring the continuous rise of their standard of living. Economic activity and consumption opportunities fed each other in a ‘virtuous circle’ (see Kettunen 1997), and the task of social policy – and health policy as its subsection – was to keep every citizen in the workforce and assure them means for consumption. Social and economic growth were thus portrayed to go hand in hand; public spending on health services was money well placed, since it fuelled people’s industriousness. In this way, healthcare expenditures were a necessary step to ensure the inclusion of all citizens in the social body. Vitality in the form of good health was considered instrumental for full participation in society.

The first steps towards more universal health services had already been taken during and after the Second World War, when a number of statutory tax-funded municipal services (midwives, municipal doctors, public health nurses, and school doctors and dentists) and a programme of building medical institutions on a regional basis (general hospitals, tuberculosis sanatoria, and mental institutions) were introduced (Harjula 2015, 138–167). Many of these reforms targeted mothers and children and were motivated by population policy. In this sense, they still belonged to the earlier constellation of health citizenship defined through membership in the national whole. However, they also induced and improved equality in the availability and access to medical and related social services. A good example of this duality is the maternity allowance, introduced in 1937 and expanded in principle to all mothers in 1949 (Harjula 2015, 188–196). It was offered to all mothers, but on the condition that they attended a maternity clinic. Rooted in population policy, it was a universal right that came with health-related obligations.

Beginning in the 1960s, the focus of public health reforms shifted from maternity care and child welfare to care for adults and from hospital to outpatient services. The infant mortality rate in Finland was among the lowest in Europe, but the rate of adult mortality from chronic diseases such as coronary heart disease was the highest. Despite investment in a large hospital sector, the national health situation among adults was still poor. According to Kuusi (1961, 256–257, 268-273), the problem was that citizens sought medical assistance too late and mostly with severe conditions, due to the scarcity and relatively high cost of outpatient services compared to hospital care. His suggested remedy for the situation was to institute regular health check-ups and accessible, low-cost or free outpatient services for the adult population. These targets were realised by a comprehensive health insurance scheme introduced in 1962 and the Primary Health Care Act (Kansanterveyslaki) that followed ten years later. The reforms were guided by a strong belief that an increase in outpatient services and better benefits would lead to higher service utilisation and earlier treatment, and consequently to fewer severe illnesses and better health, especially for disadvantaged population groups and areas.

Redistribution projects aimed at equality in service provision were one source of health citizenship entitlements. Other drivers for their development were recognition claims to accommodate into public health services and benefits for members of marginalised population groups, who had previously been under guardianship or considered in need of protection. From the late 1960s onwards, the social situation and rights of ethnic minorities, such as the Roma and Sami people (Pulma 2006, 179–188, 201-203; Lehtola 2016), individuals with various disabilities (Leppälä 2014b), as well as various ‘deviant’ groups such as the homeless, were the subjects of intense debate and reform in Finland. The issues were advocated by both members of marginalised groups themselves and radical left-wing professionals and activists organised in the so-called November Movement (Marraskuun liike) (see Parhi and Myllykangas 2019).

We argue that the importance of ‘the biological’ has not decreased with the rise of rights as the reference point of health citizenship. Rehabilitation services and workers’ compensation are a good example of a domain of the welfare state in which differentiation of individual citizens based on their vitality takes place in a framework of health-related rights. In Finland, every person who experiences an accidental injury or a severe or chronic debilitating illness is entitled to economic compensation and rehabilitation and support services paid for by public health insurance. These entitlements need to be applied for personally. For the application, a specialised physician (or in many cases several medical experts) examines the person, makes a diagnosis, and evaluates the degree of her or his impairment. The application and the medical reports then proceed to public health authorities – in most cases to the Social Insurance Institution of Finland (KELA), and sometimes also to a municipal healthcare authority. They conduct an expert assessment of the case and make a decision on the person’s eligibility and the scope of public services and compensation to be awarded. For occupational or traffic injuries, the assessments and decisions are made by medical experts in the private insurance companies that handle compulsory occupational injury and vehicle insurances. The applicant has the right to appeal the decision either at KELA, where the social security cases are is re-assessed in a special board, or at a civil court for occupational and traffic insuries. This example concretely demonstrates that the right to health is double-edged. In the case of physical or mental impairment, the Finnish welfare state considers all citizens as equally entitled to care and compensation, but simultaneously, this entitlement is dependent on expert and administrative assessments on the person’s vital capabilities, expressed as social factors like age, employability, or even place of residence. Thus, citizens’ rights align with health in a manner that potentially induces differences and hierarchies between citizens. Parallel to the policy and practices of the first half of the twentieth century, such differentiation is biopolitical. In earlier times, a medical assessment of vital deficiency could lead to a person being subjected to administrative or expert interventions or even incarceration. Today, medical experts and public officials who assess a person’s physical or mental impairment function as gatekeepers who may approve or deny eligibility for the care or compensation to which a person, as a citizen, is in principle entitled.

Active health citizenship: from entitlement to choice

Since the 1990s, the right to health has become a subject of contestation in new settings in affluent Western societies. First, patient rights movements and disease advocacy groups have become more vocal and varied in their demands for recognition by experts and public authorities of specific symptoms, impairments, or medical needs and of their eligibility for public support and services (e.g. Gibbon and Novas 2008). Second, many governments began to emphasize individual choice in healthcare services as the main health policy rationale, congruent with the ethos of the ‘New Public Health’ (Petersen and Lupton 1996) and neoliberal market orientation in public service provision (O’Malley 1996). With these tendencies, the right to health has been reconfigured from a universal entitlement of citizenship and an administrative and policy principle to actual demands of individual ‘active’ citizens who press for recognition of their particular vital features and medical needs and claim their right to choose the medical treatments they prefer.

A further dimension of ‘active citizenship’ (Kotkas 2010; Kourachanis 2020, 43–66) in the domain of health is the so-called New Public Health’s emphasis on the responsibility of individual citizens over their own health and personal management of health risks through lifestyle choices and self-monitoring (Ayo 2012; Nettleton 1997; Lupton 1993; Mayes 2015; Petersen and Lupton 1996). In Finland, the responsibilisation of individuals over health and illness is most proclaimed in the context of popular health promotion by public authorities and civic organisations. Such promotion reaches back to the late 1960s, when Finnish health authorities started to fight the rising number of chronic diseases – cardiovascular disease in particular – by launching national health promotion activities (Kananen 2018; Jauho 2021). The focus of these campaigns was on various aspects of individual lifestyle, such as eating fatty foods, exercising too little, or smoking cigarettes that were configured in large epidemiological studies as risk factors for cardiovascular disease (Aronowitz 1998, 111–144; Giroux 2013; Rothstein 2003).

The objective of this ‘lifestyle politics’ (Larsen 2011, 202) is to reduce health risks and make them manageable. With a more individualised notion of public health and health risk management, personal healthcare has become morally loaded. This is manifested both as a heightened sense of personal responsibility over one’s own health and as more vocal blaming of those who are perceived as having failed to fulfil their obligations. Exercising regularly, stopping smoking, controlling one’s eating, maintaining a normal weight, etc. are presented as virtues of the active citizen, in contrast to citizens who may become an economic ‘burden’ to public healthcare and society due to their unhealthy lifestyles and negligence of personal healthcare (e.g. LeBesco 2010; Lupton 1993). This is not new to health citizenship, since the obligation to mind personal health was a key element of late nineteenth-century public hygiene, as described previously. At that time, health promotions underlined membership to the nation and presented personal healthcare as a citizen’s duty toward the nation and the state. This message was supported by coercive measures, if necessary. Today, the emphasis is on individual liberties and choices, and health promotion has adopted a persuasive approach that appeals to personal well-being and utilises consumerist technologies of regulation, such as controlling advertising and developing food labelling (Berridge 2007; Berridge and Loughlin 2005; Porter 2011, 204–220). All this is based on an assumption that active citizens are capable of making informed choices over their own lifestyle and health.

Within the neoliberal policy framings that emphasised austerity in public spending and ‘activation’ of citizens since the 1990s, health citizenship was reconfigured so that the vitality of the nation was eclipsed by personal vitality in different modes. First, new patient activism and disease advocacy demand recognition of particular medical needs and corresponding rights to benefits by appealing to specific vital features or diminished capacities of individuals with certain diseases, symptoms or impairments. Second, policies to expand the scope of choice in healthcare and medical treatment imply a view of the individual citizen as a kind of health consumer who seeks to maintain and enhance his or her own vitality and well-being through medical choices. Finally, lifestyle medicine and health promotion focused on personal responsibility over risky lifestyles codify health citizenship on the level of vitality by creating a set of self-control practices that citizens are expected to follow. These three modes introduce new divisions within health citizenship. They create a continuum that differentiates active citizens who personally care for their health and vitality from passive ones, who manage to do so to a lesser degree or not at all. Members of vulnerable and disadvantaged groups often lack the capabilities and resources to advance their position as patients, to make informed choices on the medical marketplace, or to lead a lifestyle codified as healthy. Therefore, they are in danger of being excluded from their citizenship entitlements.

Discussion and conclusion

In this paper, we have suggested an approach to rethink the conceptual and historical alignment of health and citizenship in modern Western societies. Our argument is that health citizenship is rooted in ideas about the vitality and biological existence of populations and individuals. Health and illness form a paramount point in which membership and belonging, rights and entitlements in the nation-state, and authoritative ‘truths’ and expertise on the biological capacities and characteristics of individuals and groups of people – or vitality – intersect.

Our historical overview identified two dimensions of health citizenship. The dimension of membership was predominant in national biopolitics up until the first half of the twentieth century. In this dimension, a person’s belonging to the organic unity of the nation-state and its population and their subjection to national interests connected citizenship with issues of health and illness and brought individuals’ vital characteristics into focus. After the Second World War, individual citizens’ entitlement to healthcare became increasingly prominent as the core element of health citizenship. With examples from Finland, we described how health citizenship historically reached its most exemplary modes in public health insurance and health service provision in North European welfare states between the 1950s and 1980s. Within those states, health citizenship adopted a dual character: on one hand, individual citizens were subjected and bound to the nation-state and society through their vitality; on the other hand, they were entitled to and could demand personal protection, care, and even improvement of their vital capacities from public authorities. We then followed this outline with a sketch of the latest developments in health citizenship, induced by the neoliberal turn in health and welfare policies that emphasizes active citizenship. We identified patient activism, medical choice, and lifestyle medicine as three new modes of health citizenship, each of which relies on citizens’ activity and responsibility and mobilises their personal biology.

Throughout this paper, we foregrounded the ways in which the vitality of individuals and populations, and knowledge and expertise on vitality, have been used in definitions of health citizenship and the struggles surrounding it. We identified two contrasting tendencies within health citizenship projects: an integrative or universalising rationale and a dividing or ‘conditioning’ rationale, both based on assessment of individuals’ vital capacities and characteristics. These two tendencies were historically most clearly visible in the first dimension of health citizenship, which emphasises membership. However, they are also present in the entitlement dimension, as we showed through the example of workers’ compensation, and in contemporary modes of active health citizenship.

Crucially, both the integrative and dividing rationales and their associated health citizenship practices work upon the vital capacities of individuals and populations. Thus, we argue that even in societies where universal democratic citizenship prevails, the biological characteristics of individuals and population groups are essential to health citizenship, with ‘biology’ being socially and politically produced and morally valorised. In studies of health citizenship, this makes it important to include the ways in which biological facts are generated and valued in various practices. Studying how the vitality – that is, the characteristics and capabilities considered elementary to life – of a population, groups of people, and individuals has been invested in various ‘citizenship games’ illuminates key aspects of the development of health citizenship and highlights its biopolitical character.

Our redefinitions here are congruent with studies that approach health citizenship in terms of Marshallian social rights and social citizenship (e.g. Harjula 2015; Johnson Redden 2002). However, we argue that the concept of health citizenship is too restricted if it addresses health and illness as just a dimension of social citizenship. We consider it crucial to determine what is specific and distinctive to health when juxtaposing health citizenship and social citizenship. In light of biopolitics, health citizenship does not denote merely the consolidation of a social right or a policy idea of personal entitlement to social security that extends (social) citizenship with the dimension of health. Instead, when the alignment of health and citizenship is seen as embedded in the politicisation of people’s vitality, the concept invites one to consider the basic biological elements of social citizenship, and of modern citizenship more broadly.

Moreover, our analysis foregrounds how health citizenship cannot be reduced to access to healthcare alone, although service provision and service claims are, of course, important aspects of health citizenship. Both dimensions of health citizenship in our outline – membership and entitlement – highlight the central role assessing individuals’ vital capabilities in terms of both their autonomy and competence to act as productive members of society and ways to educate, support, or treat different groups based on this assessment. These assessments point to dimensions of health citizenship that go beyond service provision, such as individuals’ and groups’ capacities to safeguard their own vitality through health care and the practices of health education and health promotion that aim to support these capacities.

Last, we have strived for a more balanced account of the development of health citizenship which gives equal credit in its genealogy to the liberal right to health and to the more authoritarian ‘duty to be well’ (cf. Greco 1993). This is intended as corrective to approaches which take the liberal notion of individual right to health and entitlement to health care as the core of health citizenship. Our concept brings out the historically significant and still relevant authoritarian aspects in the relations between a polity and its members vis-à-vis health that the liberal perspective misses.

Our perspective on health citizenship throws into relief the biopolitical character of citizenship within the nation-state. This is to say that health citizenship should be conceived of as an important biologized mode of ‘being political’ (see Isin 2002; Foucault 1980, 141–145). The concept illuminates how far into human existence politicisation reaches in modern Western societies. Not only are citizens’ membership in a political community, or their rights to protection and care included in the domain of political rule. As we have shown, health citizenship means that individuals’ vital features, capabilities, and potential are used as criteria to assess their membership in a nation or society, to define the quality of their citizenship, and to allow or restrict their access to citizenship entitlements. Hence, politics reaches the specific vitality of the person – today even on the molecular level (Rose 2007). In parallel to biological citizenship (Rose and Novas 2005), our proposal of vitality as the distinctive element of health citizenship thus highlights the politicisation of biology and the biologization of politics. However, while biological citizenship is mostly used to address the social, political, economic, and ethical repercussions of vanguard biomedical technologies and the biomedicalisation of human lives (Raman and Tutton 2010), our conceptual revision gives the amalgamation of health and citizenship a longer historical trajectory. We also refute the idea that the biologization of citizenship is a recent invention exclusively connected to the rise of advanced biotechnology and suggest that we need to consider other domains of medicine as well in order to understand the forms and permutations of health vis-à-vis citizenship. Thus, health citizenship provides a wider and historically more nuanced framework for studying the alignment of biology and citizenship. The examples in this paper illustrate the potential of our concept. Still needed are further studies of citizenship based on vitality in different contexts, time periods, and geographical locations that are historically informed, situated, and comparative.

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Additional information

Notes on contributors

Mikko Jauho

Mikko Jauho is University Researcher at the Centre for Consumer Society Researh at the Faculty of Social Sciences, University of Helsinki. His research focuses on the biopolitics of public health, health risk, and health consumption. Currently he is working on a book on the emergence of lifestyle health.

Ilpo Helén

Ilpo Helén is Professor of Sociology at University of Eastern Finland and Adjunct Professor (Docent) in sociology at University of Helsinki. His studies focus on biopolitics of healthcare and on politics and economy of new biomedicine, especially medical genomics, biobanking and personalized medicine. His recent publications include, for example, Marja Alastalo and Ilpo Helén (2022) A code for care and control. PIN as an operator of interoperability in the Nordic welfare state (History of the Human Sciences 35, No 1, 242-265), and Heta Tarkkala, Ilpo Helén and Karoliina Snell (2019) From health to wealth: The future of personalized medicine in the making (Futures 109, 142-152).

Notes

1 Porter (2016) talks about a categorisation of health citizenship, but Huisman and Oosterhuis (2014) actually address citizenship in more general terms and then use this general categorisation to organize the various articles in the book. Thus, strictly speaking, they do not present a periodization of health citizenship.

2 Huisman and Oosterhuis’s (2014, 9) definition of the concept of citizenship is more nuanced than their periodization. Besides rights and obligations, they stress ‘public commitment’ and the role of ‘the social space of free association’ that is civil society, combining liberal and republican elements of citizenship.

3 We are not alone in our criticism of biological citizenship as too narrowly focused on the progress and expectations of high-tech medicine and related new patient activism and ‘biosociality’. Scholars who study immigration management and border control have shown how advanced biotechnology provides public authorities with new possibilities of surveillance, exclusion, and denial of human and citizen rights on a biological basis, which have been missed by the dominant emphasis of biological citizenship (Aas 2011; Ajana 2012; Helén 2014; Heinemann and Lemke 2014; Lakhani and Timmermans 2014; for a similar criticism in another domain, see Charles 2013). However, unlike our position, also these criticisms start from advanced biotechnology.

4 According to Pauli Kettunen (2019, 98), ‘[i]n the Nordic countries, […] the notion of social citizenship developed through policies and collective actions, in which people were defined, and defined themselves, as parties of asymmetrical social relationships to be levelled. Through these policies and collective actions, the weaker parties were not just protected but also empowered to articulate their interests within their social relationships and towards the state, in the framework of a national society. Such an interest-oriented social citizenship was different from the social citizenship defined by individual social rights.’