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The past two years of pandemic governance in Britain – as elsewhere – have been shaped by concepts of “risk”: whether the relative risks of vaccination, the modelled risks of exposure and spread, or the way that “balances” of risks and rights, of the individual and collective, have interpellated the everyday.
Although frameworks of “risk” have experienced a hitherto-unknown prominence in public debate and national government since March 2020, concepts of risk – and related practices of calculation and management – have long and complex histories, in commerce, science, and political life. Crucially, from their very beginnings, ideas of risk have frequently been entangled with changes in, and contestations over, understandings of “evidence” in Europe and North America.
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As the next sections of this entry explore further, the cultural resonance of “risk” in imperial (and former imperial) states intensified greatly after the Second World War, with most visible and wide-reaching effects in the field of medicine.[1]
However, as Mary Douglas points out, European conceptions of risk have a much longer lineage.[2] They first emerged in relation to gambling and mathematical theory in the seventeenth century, with the term “risk” initially having neutral connotations. Risk, Douglas explains, originally referred simply to ‘the probability of an event occurring, combined with the magnitude of the losses or gains that would be entailed’, before accumulating connotations of danger or hazard.[3]
But, as Ian Hacking has suggested, the emergence of such probabilistic thinking and calculation in European philosophical thought was itself reliant upon shifting ideas of “evidence”.[4] Specifically, in Hacking’s terms, a necessary precondition for probability was the development of an explicit concept of ‘inductive evidence’: the evidence of things pointing beyond themselves (and to the existence of something else), as distinct from ideas of demonstration, testimony or verisimilitude.[5] It was, on this reading, only by the mid-seventeenth century that modern conceptions of inductive evidence emerged, and “signs” (one thing indicative of another) became interpreted through statistical frequencies and mathematical likelihood.[6]
With such understandings in place, “modern” concepts of risk, as calculable likelihoods of future outcomes, could slowly emerge. Fuelled by colonial expansion, European wars, state centralisation, and the development of new economic systems, insurance industries (maritime, fire and life) first developed around the seventeenth and eighteenth centuries, as did new forms of Government finance that required risk calculations around annuities.[7]
This was not, however, the only transformation in “evidence” with which concepts and practices of risk were connected. Calculations of risk and probability also require forms of evidence upon which to be based: most notably, defined large-scale numerical datasets. The growth of “risk” thinking within fields of agriculture, insurance, demography, science, medicine and governance has, in other words, also been entangled with both the development of mathematical techniques, and new forms of data collection: bureaucratic record-keeping (for instance, births and deaths, censuses, insurance records), statistical tables (such as eighteenth-century life tables), and social surveys.[8]
The social, political and cultural conditions underpinning the emergence – and broader acceptance – of these forms of evidence in imperial centres are too diverse to discuss in depth here. From tentative beginnings in the eighteenth-century, however, statistical sciences and social surveying grew substantially over the nineteenth and early twentieth centuries, fostered by social and governmental responses to industrialisation, developing forms of (imperial) capitalism, and – particularly into the twentieth century – the imperatives of colonial government.[9]
Statistical and qualitative social surveys were, moreover, integral parts of the slow formation and function of welfare states in imperial centres, especially from the 1940s onwards.[10] Indeed, as – from a certain perspective – welfare states can be considered as the collectivisation of capitalism’s social risks, such institutions mark another intersection of risk and evidence.[11] Alongside insurance agencies and commercial bodies, professional societies, and think tanks, that is, academic institutions and welfare state infrastructure have created knowledge about “mass society” and risk, knowledge which itself becomes enrolled into contests over the roles those very institutions are to play.[12]
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This was certainly the case in medicine after the Second World War.
The exact origins of “risk-factor thinking” in twentieth-century biomedicine have recently been questioned.[13] Traditional explanations centred on US insurance companies and the world-renowned Framingham heart disease study and have been queried, and nuanced by more multifactorial explanations drawing together longer histories of risk concepts and languages, particularly in surgery.[14] Nonetheless, in terms of spreading particular understandings of health risks in the post-war period, the growth of insurance industries, the development of state (and international health) institutions and welfare structures, and the spread of epidemiological knowledges in public health and clinical medicine were undeniably important nodal points.[15] Foundational epidemiological research, moreover, was supported by imperial state agencies as well as pharmaceutical companies in search of new markets.[16]
As analysts of these frameworks have shown, post-war conceptions of risk and risk-factors fundamentally transformed understandings of illness. Disease moved from being marked by particular forms of evidence and temporality – felt symptoms, detectable microbial agents, or observable signs of physical pathology in the present – to being increasingly defined by another set of data and orientation to time: deviations from statistical norms, drawn from large-scale study samples, in which future disturbances in function or structure are considered more likely.[17]
Thus, since the 1960s, it has been possible for an individual to be diagnosed with (and treated for) diabetes or hypertension – among many other conditions – without symptoms or physical pathology, but instead based purely on population-level statistical evidence that a particular physiological deviation (such as blood-sugar level) is more likely to result in a range of severe outcomes.[18] Indeed, in recent decades, thresholds for treatment have been steadily reduced, and new “pre-disease” states (such as prediabetes) have been defined by considerations of individuals being “at risk”. Moreover, as David Armstrong notes, within the temporal and social cosmologies of risk almost any event, relationship, physical or social feature can be transformed into a “risk factor” – objectified and quantified as evidence that an individual faces an increased or decreased likelihood of some “outcome”. One disease can even be a risk for another.[19]
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In fact, a prominent line of historical, anthropological and sociological analysis, especially with regards to medicine in Europe and North America, is that frameworks of risk have increasingly individualised the causes of illness, and privatised responsibility for risk reduction and “risky” existences since the 1940s.
Across epidemiology and clinical medicine, for instance, historians have suggested that medical and political interests in structural inequalities and poverty as causes of disease gave way to a focus on individual behaviour and lifestyle.[20] Though beginning in the 1950s and 1960s, Mary Douglas and others have also pointed to the renewed politics of individualism embodied in 1980s’ and 1990s’ neoliberalism as shaping contemporary cultures of risk and blame in Britain and its former white settler colonies.[21] And the efforts of governments across these territories to privatise state assets and impose retrenchment and austerity during the 1980s, 1990s and post-2008 financial crisis, would speak to this privatisation of previously collective risks.[22]
Indeed, within this historical framework, the very conceptual slipperiness of “risk” that made it attractive across political regimes has also enabled the structures that put certain people at greater risks than others to be consistently concealed.[23] In some instances, ‘risked populations’ have been blamed for individual choices or “culture”; in others, the power dynamics and governmental interests of epidemiological knowledge have simply created evidence gaps around the health risks faced by people Othered by racialisation sexuality, gender identity, or countries of origin.[24] Thus, the racialised, gendered, and class-ed insurance risks of the nineteenth century finds echoes in pandemic risk discourse of today – only with less “evidence” to draw upon.[25]
Yet, there have been persistent counter-narratives about discrimination and social structuring of risk among critical public health practitioners over the past 80 years. Especially since the 1970s, individualised responsibility for risk management has met resistance. In the UK, for instance, proponents of social medicine have used the evidence produced from institutions of the welfare state to highlight persistent class and racialised inequalities in health.[26] That is, they have used differential exposures to risk as evidence for continued structural and social marginalisation, and economic and political violence.
Of course, welfare states themselves have historically been institutions that functioned on exclusion and disciplinary power, and they have emerged from – and helped to constitute – racialised, gendered and class-ed identities and visions of moral desert.[27] In the UK, Britain’s national collectivisation of risk was built on racialised imperial labour and contested notions of citizenship.[28] Migrants from empire were actively recruited to sustain Britain’s welfare infrastructure but, despite legal status as British subjects, their access to its services were highly mediated by a series of legislative changes and administrative procedures, alongside racial prejudice and xenophobia among Britain’s politicians, electorate and street-level bureaucrats.[29]
With regards to “risk” inequalities, the data gaps noted in some healthcare systems were addressed to some extent by both the colonial entanglements of medical research and collective activism of socially marginalised and racialised minority groups themselves.[30] However, this evidence, often gathered through state-funded systems, has also been used to frame individuals and racialised minority communities – alongside poor white families, and especially working women – as “risky” figures in need of greater regulation, and violent forms of intervention.[31]
Such historical complexities highlight the ways in which risk discourses have persistently bound the individual “at risk” within collective, social categories. Throughout the twentieth century, considerations of who was “predisposed”, and later “at risk”, of chronic conditions like diabetes has resulted in certain diseases been central to how they become racialised, gendered and class-ed in different ways, in different settings.[32] A similar focus on differential risk and therapeutic effectiveness – along with biomedicine’s entanglement with racialised capitalism – have also been involved in the racialisation of treatment.[33]
This enmeshing of individual and collective – and the reconstruction of subject positions and identities around notions of risk – has perhaps been most notable within genetics. Particularly since the 1980s, specific genetic markers have been added to “risk” discourse and practice, supplanting and complementing old “family histories”, and generating new sets of preventive measures and identities.[34]
In many areas of clinical practice under the NHS, genes have tended to complement, rather than dislodge, other markers in calculating risk and risk profiles. However, where genetic and molecularised approaches have manifested most strongly – both geographically, and in particular conditions – they have contributed to broader remakings of identity. “Previvorship”, for instance, is one of the latest manifestations of risk discourse in relation to cancer. But notions of “risky genes” have also been central parts of rewriting ethnic identities, just as genetic research (for instance, around heart disease risks) has been involved in rewriting racialised histories – and indeed, ideas of race itself – for whole populations.[35]
Without the group referent, that is, individual risk calculation makes no sense. But the evidence generated, and from which individual risk is to be assessed, has also historically remade the meaning of the group.
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In many respects, then, “risk” is a very modern concept. It is not only bound up in “modern” orientations to probability and uncertainty, to the future as to some extent predictable or controllable provided the right sort of evidence is available. But the concept of risk – alongside its practices of calculation and management, and the structures of evidence generation – have also been bound to industrialisation, colonisation, governance, and power disparities central to forms of “modernity” manifesting European imperial centres and settler societies.
Tracing these connections is a task outside the possibilities of one short entry. A fact to which, one day, this Index will hopefully attest.
FOOTNOTES
[1] Ulrich Beck, tr. Mark Ritter, Risk Society: Towards a New Modernity, (SAGE, 1992 [1986]); Mary Douglas, Risk and Blame: Essays in Cultural Theory, (London: Routledge, 1994 [1992]). Anglophonic use of the term “risk” skyrocketed after the 1970s in particular.
[2] Mary Douglas, ‘Risk as a forensic resource’, Daedalus, 119:4 (1990), 1-16.
[3] Ibid, p. 2.
[4] Ian Hacking, The Emergence of Probability: A Philosophical Study of Early Ideas about Probability Induction and Statistical Inference, (Cambridge University Press, 2006 [1975]).
[5] Ibid, pp. 31-5.
[6] Ibid, pp. 39-48.
[7] William Rothstein, Public Health and the Risk Factor: A History of an Uneven Medical Revolution, (University of Rochester Press, 2003); Moshe A. Milevsky, King William’s Tontine: Why the Retirement Annuity of the Future Should Resemble Its Past, (Cambridge: Cambridge University Press, 2015).
[8] Rothstein, Public Health and the Risk Factor; Ian Hacking, The Taming of Chance, (Cambridge University Press, 1990).
[9] Theodore Porter, Trust in Numbers: The Pursuit of Objectivity in Science and Public Life, (Princeton University Press, 2020 [1995]); Martin Bulmer, Kevin Bales and Kathryn Kish Sklar (eds.), The Social Survey in Historical Perspective, 1880-1940, (Cambridge University Press, 1991); Barbara Bush, ‘Colonial research and the social sciences at the end of empire: the West Indian Social Survey, 1944-57’, Journal of Imperial and Commonwealth History, 41:3 (2013), 451-74
[10] In the British context: Jon Agar, The Government Machine: A Revolutionary History of the Computer, (MIT Press, 2003); Daisy Payling, ‘“The people who write to us are the people who don’t like us”: class, gender, and citizenship in the survey of sickness’, Journal of British Studies, 59 (2020), 315-42. For welfare state formation in comparative and historical perspective: Jane Lewis, ‘Gender and the development of welfare regimes’, Journal of European Social Policy, 2:2 (1992), 159-73; Martin Gorsky, The political economy of health care in the nineteenth and twentieth centuries’, in Mark Jackson (ed), The Oxford Handbook of the History of Medicine, (Oxford University Press, 2011), 429-47.
[11] For instance: Gareth Millward, Sick Note: A History of the Welfare State in Britain, (Oxford University Press, 2022).
[12] On the feedback loop of welfare state evidence: Rhodri Hayward, ‘The pursuit of serenity: psychological knowledge and the making of the British welfare state’, in Sally Alexander and Barbara Taylor (eds.), History and Psyche: Culture, Psychoanalysis and the Past, (Basingstoke, 2012), 283-304.
[13] David Shumway Jones and Gerald M. Oppenheimer, ‘If the Framingham Heart Study did not invent the risk factor, who did?’, Perspectives in Biology and Medicine, 60:2 (2017), 131-50.
[14] As exemplars of the more “traditional” interpretations: Rothstein, Public Health and the Risk Factor; Gerald M. Oppenheimer, ‘Profiling risk: the emergence of coronary heart disease epidemiology in the United States (1947-70)’, International Journal of Epidemiology, 35:3, (2006), 720-730; Élodie Giroux, ‘The Framingham Study and the constitution of a restrictive concept of risk factor’, Social History of Medicine, 26:1 (2013), 94-112. On risk in surgery over a longer period: Patricia Jasen, ‘Breast cancer and the languages of risk, 1750-1950’, Social History of Medicine, 15:1 (2002), 17-43; Claire Brock, ‘Risk, responsibility and surgery in the 1890s and early 1900s’, Medical History, 57:3 (2013), 317-337.
[15] Robert A. Aronowitz, Making Sense of Illness: Science, Society, and Disease, (Cambridge University Press, 1998), pp. 111-44; Virginia Berridge, Marketing Health: Smoking and the Discourse of Public Health in Britain, 1945-2000, (Oxford University Press, 2007); Dorothy Porter, Health Citizenship: Essays in Social Medicine and Biomedical Politics, (Berkeley: University of California Press, 2011); Carsten Timmermann, ‘Appropriating risk factors: the reception of an American approach to chronic disease in the two German states, c.1950-1990’, Social History of Medicine 25:1 (2012), 157-74.
[16] Jeremy A. Greene, Prescribing by Numbers: Drugs and the Definition of Disease, (Baltimore: Johns Hopkins University Press, 2007); Martin D. Moore, ‘Harnessing the power of difference: colonialism and British chronic disease research, 1940-1975’, Social History of Medicine, 29:2 (2016), 384-404.
[17]David Armstrong, ‘The rise of surveillance medicine’, Sociology of Health & Illness, 17:3 (1995), 393-404. Forming part of what Giddens calls modernity’s “colonisation of the future”: Anthony Giddens, Modernity and Self Identity: Self and Society in the Late Modern Age, (Polity Press, 1991).
[18] C. Timmermann, ‘A matter of degree: the normalization of hypertension, c.1940-2000’, in W. Ernst, (ed), Histories of the Normal and the Abnormal: Social and Cultural Histories of Norms and Normativity, (London: Routledge, 2006), 245-61; Greene, Prescribing By Numbers.
[19] Armstrong, ‘The rise of surveillance medicine’.
[20] D. Porter, ‘From social structure to social behaviour in Britain after the Second World War’, Contemporary British History, 16:3, (2002), 58-80; Berridge, Marketing Health; Porter, Health Citizenship.
[21] Douglas, ‘Risk as a forensic resource’; Alan Peterson and Deborah Lupton, The New Public Health: Health and Self in an Age of Risk, (SAGE, 1997).
[22] On histories of neoliberalism: David Harvey, A Brief History of Neoliberalism, (Oxford University Press, 2005). Privatisation did not necessarily mean individualisation, however, as “the family” remained an important collective unit for neoliberal economists: Melinda Cooper, Family Values: Between Neoliberalism and the New Social Conservatism, (Princeton University Press, 2017). And as contemporary academics noted in the UK case, “privatisation” could mean many different things: Andrew Gamble, ‘Privatization, Thatcherism, and the British state’, Journal of Law and Society, 16:1 (1989), 1-20. David Marsh, ‘Privatization under Mrs Thatcher: a review of the literature’, Public Administration, 69 (1991), 459-80.
[23] Aronowitz, Making Sense of Illness. On historical deployment of risk, even in socialist states: Timmermann, ‘Appropriating risk factors’.
[24] Ryan J. Petteway, ‘LATENT//Missing: On missing values, narrative power, and data politics in discourses of COVID-19’, Health Education and Behaviour, 47:5 (2020), 671-6.
[25] Ibid. On historical insurance exclusions: Rothstein, Public Health and the Risk Factor, pp. 54-5; Beatrix Hoffman, ‘Scientific racism, insurance, and opposition to the welfare state: Frederick J. Hoffman’s Transatlantic journey’, The Journey of the Gilded Age and Progressive Era, 2:2 (2003), 150-90.
[26] See the special issue on ‘Inequalities in Health’, edited by Virginia Berridge: Contemporary British History, 16:3 (2002). Also: George Weisz, Chronic Disease in the Twentieth Century: A History, (Johns Hopkins University Press, 2014); P. Clarke, ‘What else can you expect from class-ridden Britain? The Whitehall studies and health inequalities, 1968 to c.2010’, Contemporary British History, 35:2 (2021), 235-57. And in more contemporary manifestations: Michael Marmot et.al., Fair Society, Healthy Lives. The Marmot Review: Strategic Review of Health Inequalities in England post-2010.
[27]Roberta Bivins, ‘Picturing race in the British National Health Service, 1948-1988’, Twentieth Century British History, 28:1 (2017), 83-109; Cotton Seiler, ‘The origins of white care’, Social Text 142, 38:1 (2020), 17-38; Des Fitzgerald, Amy Hinterberger, John Narayan and Ros Williams, ‘Brexit as hereditary redux: imperialism, biomedicine and the NHS in Britain’, Sociological Review, 68:6 (2020), 1161-78.
[28] Ron Ramdin, The Making of the Black Working Class in Britain, (Verso, 1987 [2017]), pp. 309-19; Christopher Kyriakides and Satnam Virdee, ‘Migrant labour, racism and the British National Health Service’, Ethnicity and Health, 8:4 (2003), 282-305; Joanna Bornat, Parvati Raghuram and Leroi Henry, ‘“Without racism there would be no geriatrics”: South Asian overseas-trained doctors and the development of geriatric medicine in the United Kingdom, 1950-2000’, in Laurence Monnais and David Wright (eds.), Doctors Beyond Borders: Transnational Migration of Physicians in the Twentieth Century, (University of Toronto Press, 2016), 185-207; Julian Simpson, Migrant Architects of the NHS: South Asian Doctors and the Reinvention of British General Practice, (Manchester, 2018); Gurminder K. Bhambra and John Holmwood, ‘Colonialism, post-colonialism and the liberal welfare state’, New Political Economy, 23:5 (2018), 574-87.
[29] Kathleen Paul, Whitewashing Britain: Race and Citizenship in the Post-War Era, (Cornell University Press, 1997); S. Virdee, Racism, Class and the Racialized Outsider, (Basingstoke: Palgrave Macmillan 2014); Olivier Esteves, The ‘Desegregation’ of English Schools: Bussing, Race and Urban Space, 1960s-80s, (Manchester: Manchester University Press, 2018). See chapter 3 in: Millward, Sick Note. For race, gender and class in welfare regimes in comparative perspective: Fiona Williams ‘Race/ethnicity, gender and class in welfare states: a framework for comparative analysis’, Social Politics, 2:2 (1995), 127-59.
[30] Roberta Bivins, Contagious Communities: Medicine, Migration and the NHS in post-war Britain, (Oxford University Press, 2015); Moore, Harnessing the power of difference’.
[31] Beverley Bryan, Stella Dadzie and Suzanne Scafe, The Heart of the Race: Black Women’s Lives in Britain, (London: Virago, 1985). Though this violence was itself also mediated and resisted, both by those subject to it and through broader political instruments: Gail Lewis, ‘Race’, Gender, Social Welfare: Encounters in a Postcolonial Society, (Cambridge: Polity Press, 2000); Roberta Bivins, Contagious Communities: Medicine, Migration and the NHS in post-war Britain, (Oxford University Press, 2015).
[32] David Arnold, ‘Diabetes in the tropics: race, place, and class in India, 1880-1965’, Social History of Medicine, 22:2 (2009), 245-61; Harshad Keval, ‘Risky cultures to risky genes: the racialised discursive construction of south Asian genetic diabetes risk’, New Genetics and Society, 34:3 (2015), 274-93; Shane O’Donnell, ‘Changing social and scientific discourses on type 2 diabetes between 1800 and 1950: a socio-historical analysis’, Sociology of Health and Illness, 37:7 (2015), pp. 1108-11; Arleen Tuchman, Diabetes: A History of Race and Disease, (Yale University Press, 2020).
[33] Anne Pollock, Mediating Race: Heart Disease and Durable Preoccupations with Difference, (Duke University Press, 2012); Jonathan Kahn, Race in a Bottle: The Story of BiDil and Racialized Medicine in a Post-Genomic Age, Columbia University Press, 2015).
[34] Marie I. Boutté, ‘Waiting for the family legacy: the experience of being at risk for Macado-Joseph disease’, Social Science and Medicine, 30:8 (1990), 839-47; Illana Löwy, Preventive Strikes: Women, Precancer, and Prophylactic Surgery, (Johns Hopkins University Press, 2010).
[35] Ian Whitmarsh, ‘Hyperdiagnostics: postcolonial utopics of race-based biomedicine’, Medical Anthropology, 28:3 (2009), 285-315;Jessica Mozersky, Risky Genes: Genetics, Breast Cancer, and Jewish Identity, (Routledge, 2012); Keval, ‘Risky cultures to risky genes’. For a broader, cultural theoretical analysis:Lara Choksey, Narrative in the Age of the Genome: Genetic Worlds, (Bloomsbury Academic, 2021).
