This piece is a part of our ongoing series, entitled “Rethinking the Revolutionary Canon.”
By Blake Smith
Capitalist democracy has a problem with public health. The premises of political and economic liberalism, which organize society around the self-directed and self-interested action of individuals in accordance with generally-binding laws, are incompatible with those of modern “medical consciousness.” The latter understands society as a space in which contagion flows from one body to another, or rather sees society as a single, ailing organism. Unlike the famous body politic depicted on the frontispiece of Hobbes’ Leviathan, in which a multitude of individuals composes a sovereign super-individual, the social body seen by “medical consciousness,” like those of the people it contains, is porous, vulnerable and teeming with pathogens.
That this mode of perceiving society has inevitable illiberal and authoritarian consequences should have been obvious since the French Revolution, the first moment in modern politics in which political actors tried to resist the growing power of medical expertise. The French Revolution can be understood as a movement against what revolutionaries called ‘privilege’, the system of exceptions, hierarchies and special rights that constituted France’s Old Regime economy and society. In the economic sphere, revolutionaries completed the work of laissez-faire economists like the Gournay Circle and the Physiocrats to eliminate internal trade barriers, guilds and other supposed obstacles to the spontaneous, natural movement of goods, people and ideas. In the social and legal sphere, they abolished distinctions of rank and title, remaking society as a horizontal plane in which equal citizens freely circulate. But the principles of economic and political liberalism, apparently triumphant, were headed for defeat when they encountered the “medical consciousness” of public health.
Michel Foucault thus diagnosed the relationship between Western societies and public health in one of his first major works, The Birth of the Clinic (1963). He argued that the relationship between the late eighteenth-century French state and the medical profession reveals an essential contradiction between the concepts of liberalism, through which we continue to imagine our political and economic life, and those of the “medical consciousness” that began its political trajectory in the last decades of the French Old Regime. The medical consciousness, he argued, creates a division between a privileged minority who claim to understand the flows of contagion—an epistemic elite of medical experts—and the masses whose health they monitor and manage. Rather than individuals pursuing private happiness within an order of universal laws and rights, what appears here is a herd kept in good condition by shepherds, a secular pastorate that rules in the name of science. In a dark irony, the victory of this privileged caste was assured in the moment that has been long misunderstood as the birth of modern democracy, the liberation of the masses from their rulers: the French Revolution.
Birth of the Clinic foreshadows Foucault’s future thinking about public health as an essentially illiberal phenomenon tied to the rise of what he would call “bio-power,” in such texts as History of Sexuality (1976) and the lecture series Society Must be Defended (1976) and Security, Territory, Population (1977-78). Beyond the question—so obviously important in the present crisis—of public health and its apparent conflict with political and economic liberalism, Birth of the Clinic poses a provocative claim for the relevance of history to our contemporary problems. Foucault warns us that we have not escaped the fundamental contradiction between public health and liberal democracy that first appeared at the end of the eighteenth-century.
Medical consciousness is the product not of liberal democracy, but of the Old Regime that the former was meant to abolish. Birth of the Clinic begins by tracing the French monarchy’s aspirations, in its last decades, to create a network for relaying information about medical phenomena (such as the spread of epidemic diseases) from the provinces to the capital, while sending knowledge about new medical advances back to the provinces via the same channels. Imposed on the old archipelago of hospitals (mostly run by the Church or along lines of organization imitating ecclesiastical forms), this network would allow a handful of experts, endowed with political power and scientific knowledge, to have a “medical consciousness” about all of France, while transforming their subjects’ own “medical consciousness,” making them aware what hygienic measures they ought to follow.
This project was the basis of modern public health, Foucault argues. It was also in contradiction with the political and economic vision of the French Revolution. It depended on institutions of confinement and control (hospitals) and privileged corporate bodies (the medical establishment and university departments of medicine). Instead of letting people, goods and information circulate freely, it organized them into channels flowing to and from a governmental center of power. Revolutionaries in the years immediately after 1789, in contrast, dreamed of “an ideal state in which the human being would no longer know hard labor or the hospital that leads to death.” They railed against the universities where medical knowledge seemed to be imprisoned. The institutions through which the French monarchy had produced, disseminated and codified medical knowledge, and through which it had applied that knowledge to treat the sick, appeared as so many Bastilles, fortresses of state power and elite privilege. To establish the reign of liberty and equality, both the “esoterism” of institutionalized knowledge and the “rigidity” of politicized expertise would have to disappear.
But the triumph of freedom was a catastrophe for public health since disease, like individuals and information, was now moving freely. In 1792-3, as the wars of the French Revolution began, France faced a public health crisis. The state had seized hospital funds (as it had with the capital and land of the Catholic Church) and the military had enrolled much of the qualified medical personnel, leaving the civilian population bereft of medical aid. The latter turned, in desperation, to “quacks” peddling dubious advice. Foucault’s account focuses not on the number of people thus exposed to contagious diseases or harmed by medical malpractice, but on the panicked discourse of French elites. The doctor and legislator Gilles-Charles Porcher de Lissonay, for example, warned colleagues that France risked being inundated “with ignorant murderers” and “dangerous charlatans” whose ignorance would be at least as lethal as the ills they sought to remedy.
By the middle of the 1790s, with such fears mounting, and with Thermidor marking an end of the Revolution’s radical phase, the “dangerous experiment of total liberty” in public health was over. The French state returned the medical profession to its place as a privileged body of experts, who were granted the power to define what counted as legitimate medical practice and who counted as a legitimate medical practitioner. Thus organized, the medical profession was to become a vast machine for gathering data from across the country to maintain a keen awareness of possible outbreaks of disease, while distributing back to the nation information about the hygienic practices that would keep its members in good health.
Although the Revolution had been waged in the name of abolishing privilege, here it appeared necessary for medical experts to preserve their epistemic and political privileges in order to “protect both the social order and individual lives.” The experience of contagious disease in the early 1790s seemed to have convinced the revolutionaries to make a critical exception to their own principles. As Foucault summarized, it appeared, “a free state that wishes to maintain its citizens free from error and from the ills that it entails cannot authorize the free practice of medicine.”
For Foucault, French revolutionaries’ inability to apply liberal principles to the issue of public health revealed the fundamental contradictions between the intellectual presuppositions of liberalism on the one hand, and those of the emerging “medical consciousness” on the other. In later works, he would extend this argument—still largely implicit in Birth of the Clinic—to emphasize the ways in which not only the modern state, but a range of institutions, practices and disciplines such as pedagogy and psychiatry “govern” human beings as members of a herd or “population.” Where political and economic liberalism see individuals pursuing a great variety of self-oriented projects, and seek to establish rational, general norms within which such projects can be pursued to individuals’ mutual benefit, this “governmentality” sees individuals as components of a collectivity whose health, well-being, etc. must be maintained through constant, and constantly changing, interventions guided by scientific knowledge. Governmentality aims at “biopower,” that is, power over the biological life and flourishing of the governed, and is fundamentally at odds with liberal conceptions of power as general norms for the preservation of individual rights.
This set of concepts—population, governmentality, biopower—is crucial to Foucault’s later work, and has been widely adopted in the American social sciences. But it has rarely been understood to have arisen out of Foucault’s reflections on the history of the French Revolution, and his sense that the Revolution, as the point of origin for modern liberal democracy under which we still live, is an ideal point to rediscover the fundamental contradictions of contemporary political life.
It goes without saying—although as Foucault joked in a lecture at Berkeley, it goes even better with saying—that the interpretation of Birth of the Clinic developed above, this attempt to take up Foucault’s perspective on the French Revolution as a means of apprehending the problems of public health in a liberal democracy, is a response to the Covid-19 crisis. A discussion of historiography might seem a circuitous, or indeed torturous, route to saying something about the self-evident disaster that has touched all of us: a sort of Rube Goldberg device of discourse.
There is this danger. Certainly, many historians (whose names go better without saying) are now writing to the public about Covid-19 in displays of erudition or “historical perspective” that point us to what no one can avoid seeing. Historians do not know better than anyone else what will happen next, and are rather less equipped than many sorts of people to tell us what is happening now. For those who have abandoned (wisely) the hope of discovering objective ‘laws’ of history, our interventions in public debates amount mostly to invitations to nuance and thoughtfulness, to pleas for widened outlooks. Foucault however does otherwise. In the preface to Birth of the Clinic, he presents history not as a resource to be exploited for lessons or perspective, but as a darkness that envelops us and into which we must venture still more deeply if we are to find the light.
The preface explains, in rather opaque and immodest terms, Foucault’s methodology, insisting upon its unprecedented originality. Foucault claims his study of the transformations in French medical discourse and practice in the eighteenth and early nineteenth centuries constitute a new “historical and critical” approach that he describes as “structural.” Before himself, Foucault reports, scholars had either tried to reconstruct the intentions of historical actors (asking what someone had really meant by a statement) or combined various statements by different actors in an impressionistic fashion to produce a vague sense of the ‘spirit of the age’. He, in contrast, attempts to uncover the “conditions” (conceptual, political, economic etc.) that make a certain set of ideas, doings, debates, styles etc., possible “from the outset.” 
Whether Foucault, in searching for the conditions of possibility behind the rise of modern medicine in France, does in fact escape what he regards as the fallacies of looking for hidden intentions and drawing up categories on nebulous “aesthetic” grounds need not detain us. What is important is that, for Foucault, such an approach is not only what distinguishes him from other scholars, it is our era’s only hope for thinking about the most desperate problems of the present.
“Primary philosophy,” Foucault asserts, is impossible in our time. That is to say, it is not possible for us to ask, as the philosophers of classical Greece did, what truth, justice, the good, and so on are. Since the Enlightenment, Western thinkers have been increasingly aware of two essential features of human thought that make the questions of the Greeks appear dangerously naive. These two illuminations force us to ask what truth, justice, the good etc. are for us, for such beings as we are, bound to particular, limited ways of knowing.
First, thanks above all to the work of Immanuel Kant, we understand that the “fact that there is such a thing as knowledge” (the fact that it is possible for us to know anything at all) depends on our thought being organized “from the outset” by certain conditions of possibility. We are able to think and to know because our minds have already organized the flux of sensory experience into something thinkable through such categories as time, space, quantity etc. Foucault’s project of looking at the particular conditions necessary for the emergence of modern medical knowledge derives from the original Kantian project of discovering the most general and universal categories that are necessary for human knowledge as such, under any conditions whatsoever.
However, Kant’s supposedly “critical” project, Foucault suggests, appears hardly less naive than the questions of the ancient Greeks, once we consider the second inheritance of the Enlightenment: historicism. The latter, which we can define as the consciousness of the fact that all knowledge is produced in specific historical contexts and articulated in particular, local discourses, emerged over the course of the seventeenth and eighteenth centuries and reached a peak of intensity with “Nietzsche the philologist,” after whom, Foucault implies, it is no longer possible to seek to reveal once and for all the general conditions that make human knowledge possible. Now that we have a sense of ourselves as historical agents, operating within the limits of our culture and producing knowledge bound to its fundamental assumptions and orientations, it appears that if we continue the Kantian search for the general, transhistorical “conditions” that make all human knowledge possible, we will be merely “going forward in our blindness,” presenting our contingent, historically-bound ‘discoveries’ as definitive truths of human nature.
Understood in this sense, Foucault is not actually continuing the Kantian project by asking what were the conditions for modern medical consciousness. He is not contributing to an enormous collective endeavor by which scholars working from many directions might reveal, bit by bit, the various sorts of conditions that have made possible all the different forms of knowledge, filling in the gaps and finally grasping how these conditions have evolved and how they relate to each other. This sort of meta-knowledge is just what Foucault, following Nietzsche, denies is possible for us. Given the insights of Nietzsche and Kant—or rather, given the historical conditions of which these philosophers are perhaps merely the expression—we are “doomed historically to history.” That is, we are “doomed” to historical self-consciousness, to ask questions about how truth, justice, the good etc. appear in the present, from our limited horizon, and to offer answers that we know in advance cannot aspire to universality or impartiality.
The Enlightenment has doomed us to a kind of “darkness,” a sense that we are trapped in history and language as in a cave. This is an irony that should be understood as the twin of that other irony by which the French Revolution, rather than beginning the era of freedom and equality, handed us over as a herd to the pastorate of experts. Foucault’s diagnosis—not only of the relationship between public health and liberal democracy since the eighteenth-century, but of the eighteenth-century itself and its whole suite of political and intellectual legacies—is grim.
Arguing this, Foucault both is and is not participating in an intellectual movement that explores the negative aspects of the eighteenth-century, seen as the threshold of the modernity we still inhabit—its racism, nationalism, and environmental devastation. Within this enormous corpus of critique, one can trace, for example, how the Enlightenment and Revolution made possible the mass killings of World War Two, from the searing polemic of Max Horkheimer and Theodor Adorno’s Dialectic of Enlightenment (1947) to David Bell’s sober and scholarly The First Total War (2007) Toward the end of his life, Foucault would call to question what he saw as an overly negative judgement against the eighteenth-century, as well as our apparent need to return again and again to it as a way of thinking about our own condition (“What is Enlightenment?”, 1984). What should be noted in Birth of the Clinic is that Foucault pursues a critique of Enlightenment and Revolution not in order to judge or undo them, but rather to demonstrate that we have done little more in the last two centuries than obscure the desperate contradictions that the eighteenth-century opened for politics and thought.
The legacy of the Enlightenment, it appears from Birth of the Clinic, is darkness, but a darkness in which something beckons. Through the study of history we can hope, not to answer the “primary” questions of philosophy, or even to outline once and for all time the conditions of knowledge, but to “disentangle” the discourses that structure our contemporary thinking and practices, tracing them back from the knotted “density” of the present to the starker clarity of their origins. Here, at their beginning, we find contradictions between public health and liberalism at their greatest intensity and urgency, before people had yet learned to disguise them with convenient fictions of ideology or to live with them as inevitable ‘facts’ about the way things simply are. This task of undoing the knot, which is of course one of imagination as much as of empiricism, makes it possible to confront anew the dilemmas of modernity.
The study of history cannot tell us where we are going, or what we ought to do. It can, however, remind us that the world we have made for ourselves, with its particular forms of power and knowledge, its scientific experts and universal rights, is riven with contradictions but also (therefore) “open” to transformation. Foucault suggests that if we are to create a world in which “medical consciousness” can be compatible with the rights and collective sovereignty to which we aspire, we will indeed need to transform public health and liberal democracy, to bring them in relation around some new third term. It would not be enough, his work warns, for the COVID-19 crisis to spark another revolution in the name of the rights and sovereignty that have already failed to contain the authoritarian, illiberal dimensions of public health. Returning to the eighteenth century as the origin of our contemporary dilemmas should prepare us, not to reenact the traumas of their foundation, but to move at last beyond them.
Blake Smith is a Harper Schmidt Fellow at the University of Chicago. His research focuses on exchange between Europe and South Asia. His essays appear in venues such as Tablet and Aeon. He is also a literary translator, as well as an editor at Age of Revolutions.
 Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, translated A.M. Sheridan Smith (New York: Vintage Books, 1994 ), 26.
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