7.1 Introduction

Our starting point is not the individual, and we do not subscribe to the view that one should feed the hungry, give drink to the thirsty, or clothe the naked….Our objectives are entirely different: we must have a healthy people in order to prevail in the world.

—Joseph Goebbels, Minister of Propaganda, 1938 (USHMM 2020).

The Nazi imperative for a healthy nation—executed, in part, through the literal killing of Lebensunwertes Leben (“life unworthy of life”)—was derived from the practice of medicalization. As defined by Conrad (2007, 5), medicalization happens when “a problem is defined in medical terms, described using medical language, understood through the adoption of a medical framework, or ‘treated’ with a medical intervention.” This widely-accepted definition also contends that medicalization “describes a process by which nonmedical problems become defined and treated as medical problems, usually in terms of illness and disorders” (Conrad 2007, 4). The emphasis on process is reflective of both the machinations and breadth of medicalization, which extend beyond the hospital into social and political arenas. Most studies of medicalization trace its emergence to seventeenth century Enlightenment thinking, grounded in scientific and medical attempts to control nature (Lock 2004). The rise in medical authority in the nineteenth century resulted in more widespread medicalization, including that of the life processes (birth, adolescence, death), and the increased use of hospitalization (Lock 2004). The emergence of eugenics in the nineteenth century signaled a shift to a politicized medicalization that was embedded in social policies and legal doctrines designed to separate (and perhaps “cure”) individuals deemed medically “unfit” and therefore socially undesirable. The enactment of medicalized eugenic policies resulted in the forced sterilization of those deemed “unfit” (practiced in a number of countries throughout the twentieth century), and the mass murder of Jews, Roma, Sinti, ethnic Poles, and others by the Nazis.

Seen as “a process associated with modernity [that] reflects societal and medical practices designed to control and regulate diseases, illnesses, and injuries” (Bell and Figert 2015, 20), medicalization achieves its power through its authority to define a problem and therefore cure it (Conrad and Schneider1992). Medical power was achieved through what Michel Foucault calls “the clinical gaze,” which objectifies the patient and is “the eye that knows and decides, the eye that governs” (Foucault 1973, 89). Medicalization, then, is a means of asserting power through an identified problem that is observed and then fixed, cured, or isolated. Physicians are gatekeepers to this authority (Conrad 2007), but are not the sole practitioners: society itself is medicalized, “serving to monitor and administer the bodies of citizens in an effort to regulate and maintain social order as well as promoting good health and productivity” (Lupton 1997). Such regulation is achieved through the scientific classification of the gaze and its applied language that medicalizes bodies, and through dividing practices that turn individuals into binaries (healthly/unhealthy) and create spaces of division (e.g., asylums) (Foucault 1995).

Medicalization can be seen as a form of biopower, which is the “power to foster life or disallow it to the point of death […and that] has to qualify, measure, appraise, and hierarchize” life (Foucault 1990, 138, 144). In other words, medicalization has the power to manage health through its qualification of healthy (and therefore unhealthy), which then, through its own power, requires the regulation of bodies—which serves to perpetuate that power (Caleb 2019). In seeking to control lives, medicalization leads to “the individualization of social problems,” which situates the problem with individuals and not within a social context (Conrad 2007, 152). Medicalized social policies seek to regulate and cure these unruly individual bodies in order to improve society; examples include welfare reform policies that position the individual as the cause of alleged system abuse, or, in the case of the Nazi regime, the medicalization of Jews and others deemed unfit as a threat to Aryan health and supremacy.

This chapter will consider examples of medicalized social policies implemented by the Nazi government and parallel current medicalized social policies in three areas: so-called social deviance, unemployment and state assistance, and citizenship and immigration. For the Nazis, the medicalization of social policies supported their racial hygiene agenda: they used a medical framework of defining health and sickness to claim modes of difference that harmed the nation. Contemporary examples are not grounded in a racial hygiene agenda, but are informed by the same constructed modes of difference that are products of medicalized biases used to justify action against marginalized groups.

7.2 Medicalization and the Volkskörper

In mobilizing their followers, Nazi leaders evoked the concept of Volkskörper, frequently translated as “national body” and often understood as metaphorical (Neumann 2009), akin to the body politic (Musolff 2010). However, Volkskörper was more than a metaphor, just as Fremdkörper (foreign body) was more than a metaphor for Jews (Neumann 2009). This language was the product of medicalization that colonized language itself, so that Jews were not just Fremdkörper to the country. They were seen as a literal infection, a threat to the healthy nation. Both Hitler and Heinrich Himmler described Jews as diseases or disease-agents—Rassentüberkülose (race-tuberculosis) and Bazillus (bacillus), respectively—evoking the need for a medical and public health response to protect German bodies (Michman 2014). Jews, along with homosexuals,Footnote 1 political objectors, and criminals, were categorized as Volksschädling (parasite or vermin of the people), a threat that was both internal and external to the Volkskörper (Midlarsky 2005; Evans 2001). Similarly, people with so-called hereditary disabilities were seen as parasites, categorized as threats because of their perceived biological inferiority (Snyder and Mitchell 2006; Bengtsson 2018).

This medico-scientific language was an outgrowth of the Nazis’ racial hygiene program, which sought to divide individuals deemed to be fit (and therefore members of the Volkskörper) from those deemed unfit, described as Gemeinschaftsfremde (alien to the community). The ability to create such division rested on the medicalization of bodies, realized biopower that was actualized in social policies which perpetuated so-called biological difference. Importantly, physicians and scientists were central to both the alleged evidence for, and implementation of, racial hygiene policies, making such medicalization manifest. As noted by Proctor (1988, 29), “the Nazis medicalized politics as much as they politicized medicine; problems of racial, sexual, or social deviance were transformed into ‘surgical problems’ in need of surgical solutions.” These “surgical solutions” were both literal, in terms of sterilizations and medicalized murder, and social, through the development of policies that cut off those deemed eugenically unfit. Social policies were informed and strengthened by appeals to medical authority and medicalizations of social and physical bodies: such policies included those created to address so-called deviant behavior, to limit (or expand) access to government assistance, and to deny citizenship rights to individuals.

7.2.1 Regulating the Deviant (Social) Body

The very creation of the label “deviant” is an act of social control, signaling an unwillingness or inability to conform to the expectations and requirements of one’s society. Such categorization reveals the relationality of deviance, understood only through the moral and social norms defined by those in power at a given time. This label serves as a dividing process, indicating difference that is unacceptable to society and therefore an implied danger to the social order. In the nineteenth- and twentieth centuries, the rise of medicalization allowed for such social categorization to be scientifically classified. Thus, behaviors once deemed deviant because they did not adhere to social expectations were seen as medical conditions (such as homosexuality).Footnote 2 Moreover, the rise of eugenics and criminal anthropology mapped deviance onto the body, suggesting that criminal behavior was hereditary and identifiable based on one’s physiology and physiognomy.Footnote 3 These shifts to the medico-scientific approaches paradoxically increased and limited the scope of defining deviance: their authority allowed for politicians and physicians to expand definitions of deviance, while the so-called biological evidence restricted claims of deviance to those which were based on medico-scientific knowledge. Thus, in order to expand their racial hygiene agenda, Nazis medicalized social policies themselves, which resulted in greater control of those deemed to be engaging in deviant behavior.

Despite the new German Imperial Criminal Code of 1871 and the classification of homosexuality as a “mental illness” by Krafft-Ebing, the criminal persecution of homosexuals was not widespread in Germany—or even enforced in Prussia—in the early twentieth century. Yet, the appointment of Hitler to the chancellorship ended any disregard for the criminal code; his attack on homosexuality is seen as both an attempt to purify the Volkskörper and to later justify the murder of Ernst Röhm in 1934, who was openly gay and a potential rival in the Nazi regime (Giles 2001). While the latter speaks to Hitler’s political machinations, the former supports the broader medicalization that shaped Nazi thinking. In March 1933, Hitler announced the “Campaign for a Clear Reich,” which forced all gay and lesbian bars to shut, destroyed Magnus Hirschfeld’s Institute for Sexual Science, and abolished all gay presses (Spurlin 2020; Beachy 2010). The campaign indicated both a moral and medical cleansing of the Volkskörper, reflective of a pathologizing of homosexuality that was supported in the mid-1930s by German doctors, who claimed homosexuality threatened public health, even describing it as an epidemic (Proctor 1988).

This medicalization of homosexuality was amplified by Heinrich Himmler’s 1936 creation of the Reich Central Office for the Combating of Homosexuality and Abortion (Reichszentrale). The association of homosexuality with abortion speaks to the Nazis’ concern with reproduction, declining birth rates, and the nation’s body (Spurlin 2020; Giles 2001): the martial-medical metaphor of combatting so-called social deviance positions reproduction and the national good against non-reproduction and individual threats. Combatting suggests both fighting and curing, and the Reichszentrale’s focused efforts on policing homosexuality manifested Nazi beliefs of homosexuality as a disease (Beachy 2010). Such efforts were divided into curing the “disease” of homosexuality and stopping its spread, the latter of which included the elimination of any individuals with hereditary-based homosexuality, labeled as “incorrigibles,” by sending them to concentration camps (Beachy 2010). The prosecution of the gay community was a social policy designed to support the Nazis’ racial hygiene program by isolating the “disease of homosexuality” so as not to infect others and the national body.

Another group that the Nazis viewed as a infection risk to the Volkskörper was the broad category of “asocials,” individuals who engaged in behavior that was antithetical to the nation’s goals and health, including the “work-shy,” criminals, vagrants, beggars, prostitutes, unmarried mothers, alcoholics, and anyone else who was “unwilling to adapt to the life of the community” (Epstein 2015). According to Wolfgang Knorr, a physician working in the Racial Political Office, “asocials” were “conspicuous, not by occasional crime, but by their general inability to be useful in the life of the national community” (qtd. in Pine 2017, 172). As non-contributing members of the nation, they were an economic burden; as hereditary carriers of “asocial” behavior, they were a racial threat. In a rehabilitative attempt, an “asocial colony” was created in Bremen in 1936: Hashude, as it was called, was a virtual prison, with families being forced to live in houses that were guarded and inspected for cleanliness by Nazi officials. Children in Hashude were required to join the Hitler Youth and were taught about hygiene (Pine 2017; Shuter 2003). This colony created both the separation of those seen as diseased from healthy citizens and the imperative to be cleaner and therefore healthier in order to return to society—in other words, these individuals needed to be cured through commitment to the Volk. The closing of Hashude in 1940 coincided with a push beginning in 1938 to decrease spending on “asocials,” whom many in the Nazi party deemed as uncurable because of a hereditary stain. This argument justified the sterilization of some “asocials” under the Law for the Prevention of Hereditarily Disease Offspring (1933) and their deportation to work and concentration camps (Pine 2017).

7.2.2 Gemeinnutz Geht Vor Eigennutz: Medicalized Government Assistance

The central tenet of Nazi medicalization was the health of the national body, which included placing the needs of the community over any individual needs, realized through the slogan Gemeinnutz geht vor Eigennutz (“the common need over individual need”). As such, the introduction of economic incentives and the regulation of government assistance were used to help promote and grow a stronger, healthier nation. Through these policies, the government sought to support reproductive efforts of eugenically-fit parents while limiting economic and social resources for individuals deemed to be genetically unfit or not contributing to the health of the nation.

As such, reproduction was anything but personal: as noted by the NS-Frauenschaft (Nazi Women’s Group), “marriage is not merely a private matter, but one which directly affects the fate of a nation at its very roots” (qtd. in Stephenson 2013, 28). Marriage and procreation were acts that were medicalized through racial hygiene, which invaded the private space of a marriage and the bedroom. The enactment of the Law for the Protection of German Blood and German Honor on September 15, 1935 (part of the Nuremberg Laws) medicalized nationality and religion in order to distinguish so-called pure Aryan blood from Jewish blood by forbidding marriage or sexual relations between Germans and Jews; two months later, this law was extended to other groups deemed unfit, including Roma, Sinti, and Black people. Physician Ernst Rüdin evoked imagery of preventing sexually transmitted diseases and subsequent degeneration in his praise of the law for “preventing the further penetration of the German gene pool by Jewish blood” (qtd. in Lifton 2000, 28). This law was supplemented by the Law for the Protection of the Hereditary Health of the German People, enacted on October 18, 1935, which required individuals to seek public health certification of their eugenic fitness to marry. As Robert Proctor has noted (1988, 141, 142), “the Nuremberg Laws were generally considered public health measures […] Germany’s leading health officials saw the prevention of human genetic disease along, with the prevention of racial miscegenation, as part of a single program of responsible public health policy.” Thus, the Nuremberg Laws positioned medicine and health as central to their goals, and their execution in the middle of the marital bed.

The veneration of Aryan mothers in particular was vital to the eugenic discourse of the Nazis, as these reproductive women were seen as the source of future growth and therefore national expansion. Thus, motherhood was quantified and medicalized as central to nurturing the Volkskörper, with financial incentives and government support tied to the ability to reproduce eugenically-fit children. On June 1, 1933, the government introduced a marriage loan scheme under the Law to Reduce Unemployment, which granted each newly married couple a loan of 1,000 Reichsmarks with a low interest rate, provided the wife gave up her job; a quarter of the loan was forgiven for each child the couple bore (Stephenson 2013; Pine 2017).Footnote 4 The financial incentive tied to procreation and female domesticity quantified the value of reproductive and motherhood for both individuals and the State. Mothers and children were afforded additional state welfare benefits through the establishment of the Mother and Child Relief Agency in February 28, 1934. This agency provided necessities (clothing, bedlinen, and food) for mothers and their children, education on breastfeeding and childcare, and recuperation homes that allowed for mothers to recover from childbirth while being further educated in Nazi ideology (Pine 2017). The program medicalized motherhood by creating an imperative for healthy mothers, defined as loyal to racial hygiene and the Volkskörper, to raise their children in ways that supported the State (both in terms of their health and their education).Footnote 5

While the Nazi government provided benefits to eugenically-fit Germans, it denied or restricted these same benefits to those who were deemed to be parasites, seen as taking from the nation without providing any benefit. In 1933, the Nazi government brought all welfare services under the offices of the National Socialist People’s Welfare (NSV), eliminating private welfare organizations and distributing benefits only to individuals deemed “racially superior,” which was determined by their “value for the Volksgemeinschaft [people’s community]” (Reinhold Schleicher qtd. in Nolzen 2014, 93). “Asocials,” Jews, and other Volksschädling were excluded from a number of state-sponsored benefits, including the aforementioned marriage loan scheme, and saw reductions in their government assistance (Wachsmann 2008). Moreover, individuals with mental health illnesses and so-called hereditary disabilities were depicted in Nazi propaganda as being an economic burden and biological threat to the health of the nation, an argument used to justify the reduction in their benefits, their forced sterilizations under the Law for the Prevention of Hereditarily Diseased Offspring, and their eventual murders (Proctor 1988). These individuals were medicalized not only because of a believed biologically inferiority, but also because they were deemed to contribute nothing to society. The label unnütze Esser (“useless eaters”) became a justification for the policy of medicalized killing.

7.2.3 Medicalizing Citizenship

Nazi leaders believed the health of the Volkskörper was dependent upon individuals’ physical, mental, and social health and racial purity, which included commitment to the ideals of the Nazi party: those who could not or would not conform were marginalized, stripped of their rights, and eventually killed. The Nazis redefined citizenship in particular by changing citizenship from that of the state to that of the Reich (Reichsbürger) and defining membership to the Volk based on blood and heredity, making such citizens literal parts of the Volkskörper. This medicalization of citizenship was a hallmark of Nazi politics, evident as early as 1920 in their Twenty-Five Points program: “None but members of the nation [Volksgenosse] may be citizens of the state. None but those of German blood, whatever their creed, may be members of the nation. No Jew therefore may be a member of the nation” (German Workers’ Party [1920] 2013, 12). This declaration’s language identifies Jews as ethnically and racially different from Germans (given the use of the word Volk), setting the stage for rhetoric to become reality.

These racial claims were realized in the enactment of the Reich Citizenship Law on September 15, 1935, another of the Nuremberg Laws. Article 2, “Concept of Reich Citizenship,” states, “(1) A citizen of the Reich is only that subject who is of German or kindred blood and who, through his conduct, proves that he is both willing and able to faithfully serve the German people and Reich” (Reich Citizenship Law [1935] 2013, 209). Underpinning this law was a commitment to racial hygiene, an opportunity to purge the citizenry of individuals deemed racially inferior to Germans and who were seen as infecting the Volkskörper—in other words, “medicalized racial discrimination” (Kelly et al. 2018, 100). The primary target of this law was Jews (and later Roma, Sinti, and Black people), and historians have thoroughly traced their persecution from the Nuremberg Laws to the concentration camps (e.g., Pine 2017; Shuter 2003; Proctor 1988). In their commentary on the Nuremberg Laws, Nazi party lawyers Wilhelm Stuckart and Hans Globke argued, “every people is damaged in its vital capacities by absorption of alien blood into the Volkskörper. But one of its principal concerns should be to keep its blood pure” (qtd. in Neuman 2009, 172). Their implication of Jewish blood as poisoning the Volkskörper was used as justification for purging the Jews from the Reich—first legally and then physically.

In the act of legally denaturalizing Jews, the Nazi government also asserted that Jews’ natural state was one of inferiority to German biological superiority. Stuckart and Globke [1936] (2013, 213) rationalized that “Jews, who constitute an alien body among all European peoples, are especially characterized by racial foreignness. Jews, therefore, cannot be seen as being fit for service to the German Volk and Reich” (emphasis added). The stress on racial difference, on being unfit, and on being alien to the German social body all speak to a medicalization of Jews as a problem to be solved by medico-scientific legislation. Moreover, the subsequent classification system that determined “how Jewish” an individual was (and thus if they were given the rights of citizenship) represents eugenics-based scientific classification designed to further divide individuals through supposed medical authority and biopower. Such medico-legal language and action reduced Jews to an imposed biological status and denied rights to political action, movement, and eventually life.

While the Reich Citizenship Law guaranteed citizenship to individuals with German blood, it only did so if individuals were loyal and served the State. This additional requirement reflects the Nazi racial hygiene program that sought not only to cleanse the Volk of racially-inferior individuals, but also to cleanse itself of individuals that, while sharing its German blood, threatened the Volkskörper through their degenerative and unproductive behavior. In Stuckart and Globke’s commentary [1936] (2013, 2014), they explain that “misfits,” which included criminals and individuals who committed “offenses against the state,” could be excluded from Reich citizenship. While there is little evidence of Germans being stripped of their citizenship (excepting those that fled Nazi Germany), such language—tied to a biological understanding of citizenry—functions as biopower to maintain social order and control. Individuals would want to avoid actions that could result in the forfeiture of their citizenship because that also meant the loss of their biological status within the Volk and as part of the Volkskörper.

7.3 Medicalization Today

The pursuit of a healthy nation did not end with the Nazis, nor did the medicalization of social policies to pursue that end. While nations condemned the concentration camps and medical experimentation, they failed to make connections between their own policies of exclusion born from an over-reliance on medicine and the pseudoscience of eugenics. Forcible sterilization of individuals deemed unfit has continued across the globe through the twenty-first century, and legislative policies have sought to police bodies through public policy. While it is heavy-handed to state simply that these are continuations of Nazi policies, it is equally dangerous to ignore the fact that they are informed by the same privileging of medical authority and knowledge that allows for the social-biological regulation of people. The “sick-society” narrative that emerged in the late twentieth century was a condemnation of unruly individual bodies that failed to conform to social expectations and the need for social policies, informed by medical authority and frameworks, to cure these ailments and heal nations (Spence 2011; Schram 2000). The result was a continued medicalization of social problems that echo those discussed earlier in this chapter, i.e. controlling deviant bodies, determining government assistance eligibility, and controlling citizenship and immigration.

7.3.1 Medical Disqualification of Deviant Behavior

Medicalized social policies act as a social control that “seeks to limit, modify, regulate, isolate, or eliminate deviant behavior with medical means and in the name of health” (Conrad and Schneider 1992, 29). The continued medicalization of so-called deviant behavior (and therefore deviant bodies) is driven by some of the same forces that informed Nazi regulations of deviance—namely, the health of the nation, which includes protecting healthy individuals from the impact of deviance. While much of the pathologizing of so-called deviance is not imagined through the risk of disease transmission, there nevertheless remains a false medicalized view of contagion that is tied to behavior spread or to disease associated with such behavior.

Such fears are evident in the medicalization of homosexuality as tied to HIV/AIDS. While homosexuality was pathologized as a mental health illness for much of the twentieth century, the American Psychiatric Association’s 1973 removal of homosexuality from the DSM-II marked the beginning of its demedicalization (Conrad and Schneider 1992). However, the emergence and response to HIV/AIDS returned the medical spotlight on the gay community, and for some scholars, such as Philip Kayal (2008, 197), the “situation of gay AIDS is akin to previous ‘medicalization of homosexuality,’” which he connects to increased homophobia in the last decades of the twentieth century. While Conrad (2017) argues against this claim of remedicalization, stating that homosexuality itself was not repathologized during the height of the AIDS crisis, he does acknowledge an increased medical surveillance of gay communities. Such surveillance is, in fact, a form of medicalization, turning the clinical gaze onto individuals in an effort not only to diagnose but also to contain and control.

Medical surveillance “promoted the renewed stigmatization of homosexuality” (Conrad 2017, 107), perhaps most prominently in restrictions on blood donations, which tapped into fears of disease transmission. In 1983, the Centers for Disease Control and Prevention recommended that “members of groups at increased risk for AIDS should refrain from donating plasma and/or blood” (CDC 1983) due to an inability to screen for HIV, which only began in 1985. This recommendation resulted in a lifetime ban from donating blood for all men who had a male sexual partner since 1977, which was replaced only in 2015 with a requirement for all men who have sex with men (MWM) to abstain from same-sex intercourse for one year before donating; during the COVID-19 pandemic, this abstinence period was reduced to three months.Footnote 6 This ban does not account for safe sex practices, but assumes that being a sexually-active gay man is a marker for disease transmission, despite research to the contrary. HIV incidence in first-time donors was 2.62 cases per 100,000 person-years before the one-year deferral for MSM; after implementing the referral, the HIV incidence was 2.85 cases per 100,000 person-years, a difference that is not statistically significant (Grebe et al. 2020). This incidence rate is extremely low: as a comparison, HIV transmission via blood transfusion has a prevalence of 2.6 cased per 100,000 donations, whereas hepatitis B is 6.3 cases and hepatitis C is 19.0 cases per 100,000 donations (Steele et al. 2020). In December 2020, the American Red Cross, Vitalant, and OneBlood began investigating the viability of lifting this restriction, focusing on likelihood of infection rather than sexual orientation and therefore looking to actually demedicalize homosexuality (Advance Study 2021). Blood donation bans, however, echo the Reich citizenship requirement, particularly as “a method of recasting national identifications [in which] the positive associations of blood donations are symbolically transfused into the moral worth of the blood donor” (Bennett 2015, 7). Implied in such a blood donation ban is the inferiority of the disqualified individual, both medically and morally, and their isolation from the rest of society.

Medical disqualification from society also extends to prisoners, and some social policies look to police prisoners’ bodies via the pseudoscience of eugenics and a false notion of biological criminality. In the last decade, there have been increased reports of coerced sterilizations (or plea-bargain sterilization offers) of prisoners, who are often from marginalized groups. In one of the biggest cases in the United States, at least 148 pregnant prisoners (who were primarily Black or Latina) were sterilized in the California system after giving birth, and staff “target[ed] those deemed likely to return to prison in the future” (Johnson 2013). In justifying the sterilizations he and other doctors performed, Dr. James Heinrich monetized the procedure in terms of cost-savings to the state: “over a two-year period, that [$147,460 paid to doctors] isn’t a huge amount of money […] compared to what you save in welfare paying for these unwanted children—as they procreated more” (qtd. in Johnson 2013). His statement can be read in two ways: a cost associated with the inmates continuing to reproduce, or the cost of their children reproducing, suggesting a continued burden on the state. These remarks are not too distant from Oliver Wendell Holmes’s infamous support of eugenics in Buck and Bell (1927): “three generations of imbeciles are enough.” The assumed financial burden on the state is not limited to state support of the child, but also an implied belief in criminal heredity. In 2017, a judge in Tennessee offered reduced sentences to inmates if they chose to be sterilized; while the judge claimed that this was to reduce the number of children born addicted to drugs or ending up in foster care (Adams 2018), Glenn Cohen questions the underlying motive: “one worries that it actually reflects primitive conception of heritability of criminal behavior, which are roundly rejected by modern day genetics” (qtd. in Rosenblatt 2017). When placed within the context of eugenic sterilizations, such measures signal a medicalization of crime that seeks to regulate not just the criminal’s behavior but their body as well.

7.3.2 Government Assistance and the Medicalization of Benefits

The financial concerns regarding inmates and their children are echoed in politico-legal conversations about access to government assistance and the government’s responsibility to care for all its residents. Former United States Speaker of the House Newt Gingrich’s assertion that the US is a “sick society” and former British Prime Minister David Cameron’s claim of a “Broken Britain” indicate a perceived need to improve the state of their respective nations, linked to individuals receiving government assistance and the subsequent impact on the countries’ morals and economies. This language also medicalizes the problems of the nation, casting politicians in the roles of physicians to cure sickness or mend a broken limb. As Schram notes (2000, 60), “to medicalize welfare dependency is to create the conditions for moving welfare from an income redistribution scheme to a behavior modification regime.” This approach to behavior modification is reflected in changes to social policies and classification of individuals receiving benefits, thereby requiring individuals to improve (“get better”) in order for the nation to recover.

Former US President Ronald Reagan’s perpetuation of the “welfare queen” myth in the 1970 and 80s—an image of a Black single mother who relied on public benefits instead of working—reconceived the US welfare system as a product to be abused, casting its recipients in the role of substance abusers. This image led to a medicalization of welfare dependency, which was perpetuated by the medical surveillance of welfare use via the Welfare Indicators Act of 1994, which tasked the Department of Health and Human Services to track welfare dependency. Their research and reports are “framed as if welfare dependency were a public health problem. For instance, the fear of welfare dependency’s spreading from one generation to the next or throughout a neighborhood has led to government tracking of intergenerational welfare use and neighborhood effects” (Schram 2000, 63). This recasting of welfare dependency as a public health problem turned it into an illness that could be cured through the “therapeutic interventions” of welfare reform: “in the process, welfare itself is transformed from a repudiated program of benefit allocation to a socially accepted form of therapy” (Schram 2000, 59–60). One version of this therapy was the creation of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, whose title positions state assistance dependency as a problem of the individual and work opportunities as its cure. The Act’s first stated finding—“Marriage is the foundation of a successful society” (Personal Responsibility 1996, Section 101)—echoes the Nazis’ rhetoric of marriage prioritization to benefit society, though this act discourages reproduction more than it encourages it, targeting, in particular, single teenage mothers. Coupled with the emphasis on marriage is that of employment: the act limited the time individuals could receive benefits and required those individuals to secure employment within two years of receiving benefits (Personal Responsibility 1996, Section 402). This coupling of marriage with work is the therapeutic for welfare dependency: promote healthy reproduction and economic security independent of government support.

Similarly, the 2010 general election in the United Kingdom and the subsequent framing of the 2011 London riots were part of the Conservative party’s efforts to medicalize government benefit policies, positioning the recipients of these benefits as the cause of a “Broken Britain.” This twenty-first century narrative in the UK was derived from debates in the 1980s about the “work-shy,” the “underclass,” and growing “illegitimacy” within these groups (Slater 2012, 956, 960). Such narratives were framed by “concerns about lack of responsibility, family breakdown, the absence of communal bonds, incivilities and violent and anti-social behaviour [that] stem, in this view, from the erosion of moral standards caused by state welfare over a number of decades” (Hancock and Mooney 2012, 47). This social pathologizing was echoed in Cameron’s response to the London riots, in which he diagnosed Britain as being sick: “when I say parts of Britain are sick, the one word I would use to sum that up is irresponsibility. […] a complete lack of responsibility, a lack of proper parenting, a lack of proper upbringing, a lack of proper ethics, a lack of proper morals. That is what we need to change. […] it’s about making sure we have a welfare system that does not reward idleness” (qtd. in Hancock and Mooney 2012, 49). The focus on individual responsibility as the cause of this so-called social sickness is reminiscent of the medicalization of the US welfare system in the 1990s, though local councils took a more surgical approach to this sickness, removing families from social housing if a family member were convicted for riot-related crimes (Hancock and Mooney 2012). In response to the riots, physician Des Spence (2011, 426) claimed “work is health” and “doctors must embrace welfare reform and advocate work.” The comment is somewhat ironic, given the government’s elimination of the Pathways to Work program in Spring 2011, which had job centers partnering with the National Health Services to help individuals return to work. However, the medical prescription becomes one adopted by the government and is emblematic of Cameron’s cure for the sick society, manifested in the Welfare Reform Act of 2012 that focused on employing individuals to reduce the dependency on the government and thereby improve the (economic) health of the nation.

The medicalization of unemployment demonstrates the shift of responsibility from a social problem to that of an individual, likening unemployment to failing to care for one’s health—rather than recognizing social determinants that impact employment and health. In Sweden, the category of “occupationally disabled” functions to medicalize unemployed individuals not through biomedical conditions but rather through social and structural obstacles that prevent them from seeking employment, such as language barriers for immigrants (Holmqvist 2009). Rather than find fault with these social structures—as seen in a social model of disability—this label acts to place blame on individuals, labeling them as disabled and therefore “not fully fit for working in Swedish society” (Holmqvist 2009, 411). The Swedish system does employ doctors to confirm disabilities that would impact the ability to work, but employees of the Swedish Public Employment Service (SPES) have taken over the role of diagnosis, countering that “sometimes we know that clients are sick even if doctors do not think so” (qtd. in Holmqvist 2009, 413). The SPES requires a classification of “occupationally disabled” to receive unemployment benefits, which SPES sees as recognition of unemployment being a problem of the individual and not the system (Holmqvist 2009), and which perpetuates a medicalized view of unemployment.

7.3.3 Policing Medicalized Borders and Regulating Immigration

The image of immigrants as carriers of disease is centuries old, based on a mix of xenophobia and racism. The unknown foreign body—physical, cultural, and economic—was a source of medicalized anxiety in the late nineteenth- and twentieth centuries, tied to eugenic assumptions of biological inferiority and immorality. Immigration policies developed during this time were also products of increased authority from public health, which helped perpetuate false claims of immigrants spreading diseases (Kraut 1995). This “medicalized nativism” (Kraut 1995, 3) is not unique to a single country, but is particularly evident in historical and contemporary US immigration policies, which continue to medicalize immigrants as diseased Others.

US immigration policy is grounded in a preference for desirable, and the rejection of undesirable, individuals, which is medicalized in the language and implementation of these policies. The first of these, the Page Law of 1875, prohibited Asian prostitutes and functionally most Asian women from coming to the US and was derived from claims by medical and public health officials of incurable syphilis transmitted by Chinese prostitutes and the “distinct germs” carried by Chinese immigrants that were deadly to whites (Luibhéid 2002, 35, 37). Racialized immigrants were cast as a medical problem by both the medical community and the federal government, which became the backbone of subsequent immigration policies and public perceptions of immigrants as disease carriers. The Immigration Act of 1891, the bedrock of current immigration policies, refused entry to individuals with “loathsome or contagious disease” and tasked steamboat companies with policing this policy through inspection and disinfection of their passengers (Markel and Stern 2002, 761). This policy led to the United States Public Health Services conducting inspections of immigrants at ports of entry, a practice still continued today. As Howard Markel and Alexandra Minna Stern note (2002, 777), “the realistic menace of imported germs—which scorn all boundaries and can incubate just as elusively and easily in an American tourist heading back from a vacation in the Bahamas as in a Russian visa applicant seeking to join her relatives in Chicago—was eclipsed by the recalcitrant connection between foreigners and disease.” In other words, the examination of immigrants specifically is tied to a medicalized view of immigration itself that is not based on science but rather racialized bias.Footnote 7

Such thinking has continued in the US into the twenty-first century under the Trump administration. From its beginnings, the Trump administration was very clear in its desire to limit or even stop immigration from countries it deemed inferior to the US and linked crime to disease in their argument to close borders, implying that actual disease was never the real issue (da Silva 2018). In particular, the administration focused on illegal immigration and migration from Central America, which President Trump claimed would “infest” the US, evoking both medicalized nativism and the Nazi rhetoric of “parasite” to claim migrants threaten national security and the nation’s economy (Zimmer 2019). Former Immigration and Customs Enforcement agent David Ward claimed, “they are coming in with diseases such as smallpox, leprosy, and TB that are going to infect our people in the United States” (qtd. in Belluz 2018). The rhetoric perpetuates dividing practices of separating a “primitive” them who bring seemingly historical diseases (smallpox was eradicated in 1980) to the healthy us of the US. Stephen Miller, Trump’s chief advisor, repeatedly tried to close the southern US border (Dickerson and Shear 2020), diagnosing it as a site of disease transmission due to the immigration of racialized bodies. Claims of diseased bodies threatening US borders plays upon public fears of both disease transmission and of racialized difference—a fear that is used to justify such medicalized immigration policies, built not to protect residents’ health but to regulate unruly bodies deemed unfit by a racialized biopower.

7.4 Conclusion

At the end of The Medicalization of Society, Conrad (2007, 164) poses the following questions: “How will medicalization affect the organization of society, and how will we deal with the consequences?” I would respond to the first question by suggesting we have seen some of the effect on social organization, most clearly in how the Nazis used the medicalization of social control to advance their eugenic agenda. We are seeing the effects of this continued process in the regulation of immigration and in restrictions on government assistance programs, which threaten the most vulnerable through a guise of protecting the health of a nation. Though by no means an exhaustive account of the medicalization of social policies, the examples in this chapter serve to demonstrate the expansive (bio)power of such practices that seek to regulate individual lives in pursuit of solving a perceived problem. Haines (2003, 26) has pointed out that “medicalization depoliticizes moral problems by reconceptualizing them in medical and scientific terms that are considered to be ‘above’ morality, i.e., in the realm of ‘facts’ and scientific certainty.” This depoliticization, particularly at the policy level, contributes to the social stigma of individuals who are medicalized through such policies, creating a dangerous situation in which the public does not question this process because of the perceived authority of medicine. Medicalization, then, can contribute to stigma and othering, which can create situations in which groups do not help individuals defined as problems because of their trust in medical authority (in a best-case scenario) or because such authority confirms, through “scientific fact,” their beliefs about the inferiority of those different from them (in a worse-case scenario).

Peter Conrad’s second question still remains: what do we do with the consequences of medicalization? Such a question poses two threads that need answering: a response to what we do with knowledge of medicalization and a response about the perceived inevitability of medicalization. To the former, we must dedicate ourselves to understanding that historical events are not static or isolated: they inform current practices and shape the biopower that controls our lives today. To the latter, we should challenge the inevitability of medicalization, particularly with regard to social policies. As demonstrated in this chapter, such medicalization contributes to harmful dividing practices. While we need to be careful not to outright reject medicine as a discipline (or medical knowledge as scientific), we need to recognize the dangers of unchecked medical authority and question the motivations and the implications that lead to medicalization of social policies and the diagnosis of a “sick society.”