“Wellness” as Incipient Illness: Dietary Supplements in a Biomedical Culture

By Colleen Derkatch

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In the spring of 2008, the Canadian government introduced to Parliament a bill that sought to increase Health Canada’s power to enforce already standing legislation regarding the safety of foods, cosmetics, and “therapeutic products,” a new legislative category encompassing drugs, medical devices, and human cells, tissues, and organs. The bill, known as Bill C-51, would have articulated clearer guidelines in Canada’s Food and Drugs Act for licensing, inspection, clinical testing (when relevant), and post-market monitoring, along with increased penalties for violations. C-51 represented not a change of course in Canadian health policy but an effort to add bite to previously “toothless” regulations that provide consumer protection (Picard). The bill appeared poised to pass the first reading in Parliament and eventually become law; however, to the surprise of many, it instead ignited a firestorm of debate in Canada about the rights of individuals, both as patients (i.e., recipients of medical interventions) and as consumers (i.e., choosers of interventions, as if from a menu of services).

The debate centered on the new category of “therapeutic products” (Bill C-51), which subsumed dietary supplements under the sub-category drugs. Dietary supplements include herbal remedies (e.g., echinacea, St. John’s Wort, black cohosh), high dose vitamins, and other plant and animal extracts, which are consumed, typically as capsules or pills, to support a person’s food intake.1 Over its sixty pages, Bill C-51 only refers directly to dietary supplements three times, never specifically on supplement regulation or enforcement, and yet thousands of Canadians quickly mobilized against the bill, fearing that it would drastically restrict their access to supplements. One online petition against the legislation quickly generated over 24,000 signatures (Klingbeil), while 53 groups formed in opposition on Facebook. The Facebook groups, some with memberships in the tens of thousands, all echoed one group’s framing of the bill as placing individuals’ “health at risk” by impinging on the overall “rights and freedoms of Canadians” (A. Burke). This legislation, the group argued, would result in the “erosion of democracy,” where “simply possessing herbs would become illegal.” Similarly, the website Stop C-51 warned that the bill would result in restrictions of Orwellian proportions, enabling the government to conduct “search[es] and seizures without warrants,” in which “no evidence will be required” for levying “up to $5 million [in] fines [against those] suspected of having unregistered natural health products.” Ultimately, the website claimed, the proposed law would “apply [a] crack house style of enforcement to the natural health industry,” under which even parents giving herbs such as echinacea to their children would face fines and possible jail time.2

What interests me in the case of Bill C-51 is how the outrage sparked by the bill seems so out of proportion to its comparatively innocuous mandate, which was to help enforce already existing regulations regarding the safety and efficacy of not just dietary supplements, but of all health-related products in Canada (Tiedemann). In this article, I focus on the discrepancy between Bill C-51 and the resulting public outcry, a discrepancy that I think evinces the pride-of-place accorded to dietary supplements by their users. I suggest that the protest emerged at least in part as the product of larger shifts in cultural understandings of bodies and health. To track these shifts, I aim here to answer a key question that lies underneath the debate about C-51: How have products such as echinacea and bee pollen accrued enough cultural capital to enable opponents of the bill to make leaps from the idea of taking supplements to maintain health all the way to the erosion of consumer freedom—and even of democracy itself?

The answer to this question, I propose, lies in the idea of wellness. I argue that wellness has become pathologized, to a significant extent, in contemporary Western culture, mapped conceptually onto a medically oriented illness model through processes that are fundamentally discursive in nature, centered on persuasion. Building on recent research on self-governance and the politics of health (Clarke et al.; Conrad; Henwood, Harris, and Spoel; Petersen; Rose), I suggest that those discursive processes have come to reshape how we think of our bodies and our health within a biomedical framework—even when we believe ourselves to be acting outside of that framework, as in the case of dietary supplements. The opposition to Bill C-51 can help to illuminate what is at stake, both publicly and politically, in rhetorics surrounding the production, regulation, and consumption of supplements and other wellness-oriented products.3

Dietary Supplements in the Wellness Model

As a regulatory category, dietary supplements include substances ranging from highly concentrated forms of everyday foods such as garlic and ginger, to pharmacologically active and potentially dangerous substances, such as ephedra and valerian root. Numerous alternative health providers dispense dietary supplements, but they are most readily accessed through natural food stores and, increasingly, pharmacies and grocery stores. Although supplements are usually sold as capsules or tablets, like pharmaceuticals, they otherwise seem antithetical: their packaging often features illustrations of leaves, flowers, or other symbols of nature, and earthy colors such as blue, green, and brown; they are often purchased in stores with wood floors and organic produce displays; and they are available without prescription, allowing consumers to decide for themselves what to take, how much, and how often. Supplements thus promise users a significant sense of agency (Nichter and Thompson 189), inviting them to reimagine themselves as active agents of wellness, in Kenneth Burke’s terms, rather than as passive scenes of illness (xvi-xvii; on these terms, see also Segal 74-90).

The idea of wellness is conceived broadly as health maintenance, contrasted with illness treatment. Both of these terms—wellness and health maintenance—circulate widely as keywords in popular media, in health and self-help books, and in the medical literature. Schuster et al. define wellness as “the generalized self-perception of health,” a perception that encompasses multiple domains—the physical, the psychological, the social, and the spiritual (351). Other definitions of wellness vary but all are linked by similar emphases on health over illness, function over dysfunction, agency over passivity, and general well-being over bodily state (see Stokols; Watt et al.). Nichter and Thompson’s recent ethnographic research shows that users of dietary supplements think of herbal and other remedies in exactly these terms, as operating outside the realm of conventional medicine, and, more importantly, outside of the illness-oriented model that supplement users see conventional medicine as representing.4 This perceived discontinuity between conventional medicine and supplements can also be found in discourse surrounding Bill C-51, as in this online posting in an anti-C-51 Facebook group: “Drugs will kill you. Herbs will heal you” (A. Burke).

Part of the discursive framing of supplements as natural and oriented to wellness stems from Canadian and US regulations governing how supplements may be described and promoted in the marketplace. Supplement producers are limited to making general, highly modalized claims regarding the purpose and effectiveness of their products, usually in reference to the structure or function of bodily systems, and are restricted in the claims that they can make regarding disease or its symptoms (Canada). For example, a supplement can “support regularity” or “help maintain cardiovascular health,” but it cannot “alleviate constipation” or “lower cholesterol” (Mitka 1555). Such structure-function claims limit how supplement producers may market their products but, at the same time, they also create an attractive discontinuity between supplements’ ostensible purpose, to maintain health, and that of pharmaceuticals, to treat illness. For example, if illness is the purview of biomedicine, then a product such as black cohosh, which “supports menopause,” may well seem outside of that model. As Nichter and Thompson argue, this apparent discontinuity between drugs and supplements—and, by extension, between illness and wellness—contributes significantly to the prevalence of supplements in North America.

The persuasive effects of such vague health claims turn out to be more complicated, however: as Nichter and Thompson’s study also found, supplement users often translate the products’ wellness claims into illness-oriented, biomedical terms. For example, while a label might claim that black cohosh “supports menopause,” users can easily make the cognitive leap from that generalized structure-function claim to the disease-symptom claim—that black cohosh will “reduce hot flashes.” Such intuitive label-translation is evident in Nichter and Thompson’s interview with Susan, who describes her herbal supplement for menopause as her “hot flash medication,” which she takes until she feels “symptom free” (205). Numerous commenters on the “Stop Bill C-51” petition similarly frame their use of supplements in terms of biomedical diagnosis and treatment, such as fish oil for attention-deficit hyperactivity disorder (Oke) and hemp oil for not only protecting against cancer but curing it (Kervin). As I suggest next, this tendency to frame wellness claims in terms of illness offers some evidence that the supplement-oriented culture of wellness is far more interwoven with a pharmaceutical-based, illness-oriented model than it first appears.

Wellness as a State of Risk

Although wellness is frequently framed as “health maintenance,” this idea appears to have expanded at least partly within the domain of illness, bringing those who choose wellness-oriented products such as dietary supplements into a realm defined not only by enhanced function but also by dysfunction. As a result, I argue in this section, the contemporary notion of wellness paradoxically includes practices of surveillance and intervention that resemble those of the illness model it is meant, partially, to displace. Further, while supplements appear to offer greater agency over one’s health (Nichter and Thompson), the notion of wellness may itself foster a new sort of dependence, except this time on supplements and related products (Nisly et al.). In the remainder of this essay, I investigate the slippage of an optimistic notion of wellness as a “generalized self-perception of health” (Schuster et al.) into something more pessimistic—what medical sociologist David Armstrong calls a “semi-pathological pre-illness at-risk state” (401; see also Clarke et al. 172). Against the backdrop of risk, dietary supplement discourse takes on an urgency not fully captured by a model of wellness as simply “health maintenance.”

One commenter on the “Stop Bill C-51” petition demonstrates this sense of urgency about supplement access in terms of both her civic and her health rights:

My health is at risk and in your hands. Who made you my “attorney”; I’m cognizant, intelligent and of sound mind. Let me choose my own healthy lifestyle. I don’t like chemicals and if you outlaw the natural remedies of nature, should I become ill, you are dictating I ingest a substance foreign to the body with God knows how many kinds of contradindications [sic] and side effects. Please, please do NOT DO THIS to the people of Canada! (Sampson)

This commenter evinces several overlapping understandings of wellness vis-à-vis dietary supplements, two of which I have already discussed—that supplements promote wellness and protect against illness (as part of a “healthy lifestyle”); and that supplements can treat illness (“should I become ill…”). There is another understanding of wellness in this passage that I am interested in here, that a “healthy lifestyle” necessarily requires intervention with external substances, on the order of pharmaceuticals, to offset illness risk. Other objections to Bill C-51 similarly figure wellness not simply as a bodily state to be enjoyed but one to be monitored vigilantly and defended actively through supplementation. One commenter on the “Stop Bill C-51” petition asks, for example, “don’t any of you want to live a life full of health and wellness? Your [sic] not only killings [sic] yourselves but your children too” (Cappelletti), while another argues that, without supplements, “More and more people will die from more disease and body shutdowns” (Johnny). For these commenters, the ability to take supplements to offset risk becomes a matter of life and death, echoing the beliefs about supplements held by participants in Nichter and Thompson’s study. Such beliefs, Nichter and Thompson argue, produce “strategies for managing risk [that] blur the distinction between a ‘risk role’ and a sick role” (186).

Writing on risk management in pharmaceutical rhetorics of bioterrorism, J. Blake Scott notes, in reference to Ulrich Beck, that “one of the ironies of world risk society is that even reflexive efforts to contain or control risk often end up increasing it and causing it to spin further out of control” (131; see also Petersen 193). Similarly, Peter Conrad notes that risk has become itself a marker of potential disease, producing higher levels of self-monitoring of bodily states that, while potentially beneficial in the case of early disease detection, has at the same time sponsored a “medical vision [that] now includes an increasingly large number of people who are regarded as potentially ill” (Medicalization 151; emphasis in the original). Faced with the belief that they are incipiently ill, then, contemporary health subjects may seek yet more fervently an ever-elusive, ever more qualified, notion of wellness. Lowenberg and Davis call this process potentially “enfeebling” (580), breeding in health seekers a dependence on supplements and other wellness-oriented interventions at the same time as they seek independence from a medical-pharmaceutical culture. This is not to say that supplement users necessarily feel enfeebled, or that supplements do not offer important benefits, physiological or otherwise. Rather, my point is simply that even in a wellness model, bodily states such as hot flashes continue to be framed as illness symptoms that require external intervention, as in the case of Susan above. That it is difficult to imagine framing such bodily states in terms beyond symptoms and intervention is exactly my concern.

In an important sense, then, a culture of wellness is partly a culture of surveillance, one in which, as Carl Elliott might argue, a person can never be well enough. For example, in a recent home handbook, The Wellness Prescription, Walter George Smith urges readers to practice daily “wellness monitoring.” They are advised, upon waking each morning, to survey their bodies methodically, checking their breathing to determine if it is without strain and free of tightness; to check their elimination, making sure that urination is comfortable and bowel movements normal; to monitor their mobility, to note if they feel energized and free of stiffness and pain; and so on. Anything out of the ordinary, he instructs, merits further investigation (“ailment recognition”) and treatment (“ailment amelioration”) with dietary supplements and various alternative health remedies. The level of self-monitoring advanced in Smith’s handbook implicates individuals in their own surveillance (Foucault 201-03; Nettleton), seeming as likely to compound concerns about one’s bodily state as to sponsor a sense of wellness. Ordinary sensations such as feeling tired or stiff in the morning may be ominous signs of a potential ailment; the body may become, in a sense, an object of suspicion.

Dietary Supplements as “Wellness Interventions”

Following on Nichter and Thompson’s study, I would like to suggest, in conclusion, that in making the semantic shift from a supplement’s wellness claim (e.g., “supports menopause”) to the corollary illness claim (“reduces hot flashes”), supplement consumers are interpellated as medical subjects even as they aim to act outside of an illness model. This process of shifting, unconsciously, between one sort of claim and another is almost enthymematic in nature, illustrating how one discourse (that of “wellness”) can become fused, almost invisibly, with a seemingly oppositional discourse (that of “illness”). In discourses surrounding dietary supplements, then, there appears to be some slippage in the notion of wellness from support and enhancement of the healthy body to targeted disease prevention and treatment in the at-risk body. The case of Bill C-51 is instructive because the protests against the legislation seem not only to be about individuals’ rights of access to products such as echinacea and bee pollen as agents of wellness but also as scenes of incipient illness. The mapping of wellness onto biomedicine, I suggest, has the potential to dramatically expand the ways in which we can be sick, subsequently reformulating us increasingly as candidates for medical intervention.

Endnotes



  1. In Canadian legislation, dietary supplements are more commonly referred to as “natural health products” or NHPs. I have used the term dietary supplement here to reflect global usage. return
  2. It is worth noting that the Stop C-51 website was later exposed as sponsored by supplement producer Truehope, a company with longstanding legal trouble with Health Canada (Blackwell). return
  3. Bill C-51 was ultimately dropped following the first reading, when the Parliamentary session came to a close, although portions of it have since been reintroduced to Parliament under several other bills. The C-51 Legislative Summary describes the potential impact of the public opposition on the bill itself (Tiedemann). return
  4. For example, many of Nichter and Thompson’s participants viewed dietary supplements as a means of engaging in “harm reduction” (185) by substituting or counteracting “toxic” pharmaceuticals with “natural” supplements (192). return

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