Bio-governmentality: regimes of subjectification, embodiment and biosociality in the Explicit Health Guarantees (EHG). Approximation to expert repertoires1.

Dr. Jorge Castillo-Sepúlveda2

University of Santiago de Chile

Abstract. With the term bio-governmentality, we make reference to the modes of subjectivation and

embodiment that are associated with techniques and procedures involved in the government of the

biological, and particularly of the relationship between health and disease. This work deals with emerging

aspects in a research project that begins a case study on the last important health reform in Chile, initiated

the year 2005: the Regime of Explicit Health Guarantees (EHG). Such reform, provides a context for

analyzing a series of transformations in the traditional conceptions of the State and the citizens: (a) for its

articulation, EHG constitutes a complex system of relationships among government, private and civil

entities, which redefines its traditional boundaries; (b) it has been established new regimes of association

between biomedical scientific evidence and decision-making at all levels, political, economic and clinical,

influencing the performance of governmental processes and thus also in events of a biological nature; (c)

new modes of incidence in the processes of prioritization and decision-making are inscribed. These

transformations affect the ways in which citizenship is understood itself to the public network, and the ways

in which the experience of illness is configured social and materially. Addressing a pragmatic discourse

analysis of experts associated with the prioritization of health problems in Chile, we expose initial results

that refer to multiple regimes of truth in the composition of certainty in the prioritization of interventions that

are part of the program. Following to Foucault, the prioritization establishes regimes of obligation on the

biological, territorializes the body in a liminal scale, and behaves as a mesh composed of heterogeneous

entities that redefine the values and priorities in a contingent mode, opening various scenarios for the

readjustment of the politics on the life.

Keywords: Biopolitics, Governmentality, Regime of Explicit Health Guarantees (EGH), Subjectivation,

Evidence-Based Medicine.

1 This work is part of the project Fondecyt No. 11140590, funded by CONICYT Chile. The author thanks to the research team, formed by Jorge Tapia, Tamara Díaz, Marjorie Espejo, Miguel Catalán and José Toro, in the composition of the analysis that are exposed. 2 Email: Jorge Castillo Sepúlveda. Web: www.bio-gov.info

… [it] was not the triumph of the prideful individual subject (…) as the triumph of the quest for certainty over the quest for wisdom.

Richard Rorty, Philosophy and the Mirror of Nature.

Biogovernmentality. Medicine has been seen by authors as Michel Foucault (1976, 2002), Nikolas Rose (2001, 2007)

and Paul Rabinow (2005) as one of prime devices of modern societies for the understanding of the ways

in which the government articulates with subjectivity and everyday life. From aspects such as health and

disease, it has become a series of knowledge, institutions and strategies that manage temporalities,

spatialities and adequate livelihoods. For Foucault (1976) and Rose (2007), in recent decades, medicine

has achieved to affect in several spaces of political and social expressions of live, to the point that it is

difficult to think of an area in which it has no influence (Foucault, 1976). For them, medicine has important

implications in terms of governmentality, that is, in terms of the link between the various public and private

devices in the creation and understanding of the self, and of this in terms of managing the own freedom

(Foucault, 2006; Rose, 2012). We believe that in the case of Chile this is evident in the recent Health

Reform, a device that redefines the traditional relations between State, private sector and citizens, and that

is bound to promote specific modes of subjectivity in regulatory and economic context of neoliberal order.

This would be linked to the establishment of certain ways of conceiving the healthy and the sick in this

system, which is articulated with specific strategies and techniques developed into certain ways to enact

and understand science.

In this work, we expose the basis and advances of the first year of the project Fondecyt 11140590,

entitles “Contributions of Science and Technology Studies to the understanding of diseases addressed by

evidence-based medicine: subjectivation, embodiment and biosocial regimes in EHG”. Such project

proposes to address a series of material and social relations at the basis of new governmental practices

inscribed at the Regime of Explicit Health Guarantees (EHG)3, key component of the Health Reform started

in 2005. EHG Regime “is a program that prioritizes 80 health problems, which have explicit guarantees laid

down by law, which must be fulfilled for all Chileans” (Fondo Nacional de Salud [FONASA], 2013, p. 5).

This reform articulates modes and configurations of knowledge practices and material elements which

enable new links between traditional institutions associated with government and health, economy and

citizenship.

With the notion of bio-governmentality -or biomedical governmentality- we refer to three processes

exposed at the base of EHG: (a) for its articulation, GES has due to constitute a complex system of

relationships among government, private and civil entities, that diffuses and redefines its traditional

boundaries; (B) it has been established new regimes of association between biomedical scientific evidence

and decision-making at all levels, political, economical and clinical, influencing the understanding and

3 In Spanish: “Regimen de Garantías Explícitas en Salud” or GES. Law Nº 19.966, from September 3, 2004. The program was known as AUGE at their beginning.

performance of government processes and thus also in events of a biological nature; and (c) these

processes affect the ways in which the citizenship is understood itself in relation to the public mesh, and in

the ways in which the experience of illness is configured social and materially.

In this scheme, the biomedical research is the new canon to understand the processes involved in the

health-illness, medical research and clinical practice, establishing parameters that are used as a resource

for the enactment of government operations. Through these, the subject operates not just as an object of

government, but also "he can make his own life a practice of subjectification" (Castro 2011, p. 34), having

influence on the conception of the self -subjective and bodily- and its deployment in the institutional

networks.

In this regard, biogovernmentality draws attention to the progressive composition of a governmental

technology that articulates knowledge, institutions and material strategies that manage and produce

temporalities, specialties and canyons on the life, formulated from the description and agency that behaves

the same life, and which have influence on the understanding of the self in terms of the management of the

own freedom (Foucault, 2006; Rose, 2012; Revel, 2009). The term refers to the formulation of certain

devices of government in which biomedical knowledge of life becomes essential.

In the research, develops an approach that considers approaches specifically from the emerging theory of

Actor-Red. For the current phase of development, particularly the notion of enactment, proposed by

Annemarie Mol (2005, 2004).

In this research, we consider approaches addressed by Actor-Network Theory (Latour, 2001, 2005;

Mol, 1999). For the current phase, particularly the notion of enactment, proposed by Annemarie Mol (2005,

2004). With this, we made reference to the contingency of the objects and the generative quality of the

practices, i.e. how in the action composed by various actors (humans and non-humans), something is

constituted as real for a given scenario. It is in such practices that objects get multiple ontologies, in the

sense that each scenario sets various enactments, by overlapping, contrasting or splitting up. For this

perspective, entities are constituted in networks of complex relationships of actants, such as patients,

nurses, parents, fans, records, monitors, among others. That is to say, the enacted object does not exist

without the network of actors and actants that holds and are them (Hadders, 2009). From this perspective,

the same entities are the result of a composition of stories both social and material, an articulation of

enactments (Mol, 2005, 1999; Akrich & Latour, 1992; Hadders, 2009).

In this work, we expose some emergent elements linked with the definition of biogovernmentality

in EHG, from the analysis of the discourse of experts who participate in the design of priorization of health

problems for the law. This priorization entail not only epistemological, but also biopolitical processes linked

with the composition of the abstraction of life and its relation with how it could be subjectivied.

Evidence-based biogovernment. Much of the transformations associated with the modes of representation and configuration of

states of the body has been associated with the modification of the criteria through which to produce and

value knowledge, generating new forms by which establish and assess the biological truth (Rose, 2001,

2007).

One of the most significant transformations in this sense refers to the emergence of the so-called

"Evidence-based medicine" (Timmermans & Kolker, 2004; Knaapen, Cazeneuve, Cambrosio, Castel &

Fervers, 2010). Although the term may mean different things, in the medical discourse mainly denotes the

use of clinical practice guidelines to disseminate knowledge and diagnoses that have been tested

(Timmermans & Berg, 2003; Sackett & Rosenberg, 2005; Claridge & Fabian, 2005). To the base of this

transformation, various authors point a threefold process that involves the redefinition of the clinical

practice, its epistemological commitments (Sackett & Rosenberg, 2005; Claridge & Fabian, 2005), and the

aforementioned relationship between what is healthy and sick. The first refers to the gradual realignment

of the relationships between biology and medicine, and with this a new configuration of the clinical and

laboratory practices, all of what have been called biomedicine (Cambrosio, Keating & Bourret, 2006).

Secondly, the emergence of new criteria to define the adequacy of diagnosis and treatment based

on the systematic use of procedures of collective production of evidence and the introduction of conventions

within the framework of reflective practices, involving the registration of measurement and evaluation

techniques that define the objectivity of a clinical trial: a regulatory objectivity (Moreira, May & Bond, 2009;

Cambrosio, Keating, Schilich & Weisz, 2009; Bourret, 2006, 2005).

And third, that the tension health-pathology is reconfigured according to the established in a series

of propositions registered in these clinical guidelines, which install systems for comprehension and

technologies that recreate -enact-, contexts of normality or abnormality and what is meant by corporality

(Tirado, Gálvez & Castillo, 2012).

EHG (implemented in 2005) is constituted by, and at the same time crystallizes, several of these

processes. It emerges as one of the main axis that articulates a plan for a health reform initiated in 2000,

established by the rhetoric based on: (a) the treatment of the longevity of population; (b) the consideration

of the health as benefits provided by public and private health services, according to the availability of

specific treatments and technologies; (c) focus on the person responsible for the consumption of such

benefits.

Four guarantees are established, concerning to access (several criteria associated with the

configuration of a health problem enabled to receive benefits), quality (registered and evaluated providers

for this purpose), financial protection (maximum established to be paid by the benefits) and opportunity

(regulation of the temporalities or deadlines for the exercise of the benefits by providers) (Superintendencia

de Salud, 2015). Such benefits are associated with a set of prioritized programs, diseases or health

conditions, which are established from a series of health care and financial analysis, which integrate

"epidemiological studies to identify a list of priorities in health interventions and to consider the situation of

health of the population, the effectiveness of interventions, its contribution to the extension or to the quality

of life and, when possible, their cost-effectiveness relation" (Ferrer, 2004, p. 3).

The EHG manages temporalities, practices and techniques for people who comply with a series of

symptoms or indicators that can be verified according to the criteria laid down by the clinical guidelines

(Ferrer, 2004; Cunill, Fernandez & Vargas, 2011). For this, private markets are powered from direct

financing granted by their participation in the EHG regime.

Blurred boundaries. The prior considerations are associated to three possible consequences in the field of governance

that affect the formation of collective identities.

In the first place, EHG redefines the relationship between the State and the subject: the public is

configured as a guarantor in health for any person who is suffering a combination of symptoms, i.e.

expression of certain provisions enable biological registration in a predefined protocol; in this regard, the

State already not only ensures the proper exercise of the supply and demand for health, but also the

guarantee for a specific number of individualized pathologies. This would imply the formation of a regime

of commitments in which the State guarantees and the subject engaged in EHG translates its experience

in these terms.

Secondly, EHG reconfigures the boundaries between the public and private sectors: it provides

guarantees of an economic nature for citizenship, financing all or a part of the medical procedures (Infante

& Paraje, 2010). In this sense, the State no longer only monitors the health care market (through the

Superintendence), but also constitutes one of its own, at the same time that power it in relation to the

allocation of certain rights to the citizen: "Explicit Health Guarantees are defined as those rights in health

relating to access, quality, timeliness and financial protection by the State" (Bastías & Valdivia, 2007, p.

53).

Latter, and perhaps most importantly, EHG establishes canons of attention, a certain regime of

activities and materials that must participate in any relationship of care, regardless of the source of services,

whether provided by public hospitals, clinics or private specialized centers: configures a path that not only

is explicit, but also demanded by the various actors (Méndez & Vanegas, 2010). Both the explicit guarantee

of quality, such as the explicit guarantee of opportunity (Bastías as saying & Valdivia, 2007), imply the

accreditation and assurance of certain procedures and basic conditions which must participate in any

instance of diagnoses and treatment. It doesn’t involve only the enactment of a collectivity of actions, actors,

and materials, but also the control of the intrinsic variability of human and biological phenomena: a

standardization of the disease (Timmermans & Berg, 2003) and, therefore, a specific performance

management of citizen subjectivation (Ramos Zincke, 2012).

Limits between public and private, disease and interventions, are in some sense blurred, and are

reassembled in a new configuration of biopower based-on-evidence. As a contemporary form of authority

(Rose, 2012) the evidence on the life can only be considered as series of regulatory plays (Cambrosio,

Keating & Bourret, 2006), i.e. from the formulation of knowledge with some regulation value. In this

scenario, biopolitics becomes the regularization of the knowledge and regularization of the power over life.

At the same time, the individual and responsibility that takes on its own care is reconfigured as a

legal, technological and economical process.

For Ferrer (2013), the development of health policies in Chile since the 1970s is associated with

the installation of a "concept of health as individual responsibility [that] has clear manifestations in the

reflection and practice of public health as biopolitics," (p. 3), implying "the response of the neoliberalism to

chronic diseases" (p. 4). Such expression would be inscribed in the EHG, as a manifestation of such

processes of reform. In a sense, this regime establishes a focus on the consumer behavior of the citizen,

now linking it to benefit systems (diagnostics, treatments, drugs) associated with the composition of health.

From the subject of rights, there would be now a practical variation that would formulate the subject of

consumption as a basis for the implementation of the guarantees. In fact, the same guarantees are not

"guaranteed" by the State as its economic support, but are a component of a complex network of

redistributions of charges and taxes by part of the private insurance companies that now have the possibility

to exercise functions traditionally associated with the government: the collection of a prime which is

redistributed in certain networks to provide the features associated with the processes of prioritization

(Superintendencia de Salud, 2015).

Notwithstanding the foregoing, the idea of individual responsibility on health, focuses only on a

component of this framing, and involves a moral discourse about health and action (Latour, 2001). Such

vision assigns the individual, as a total entity, the possibilities to manage not only its own decisions, but

also the resources by which manage its own conditions of life. However, EHG constitutes a layout

somewhat more complex: the responsibility lies not only in who is subjectived as responsible, but it is

distributed in a schema of relations both social and material, as heterogeneous as for the same idea of

liberal control or autonomy in the system can be problematized. It is not the subject who choose, but the

same must be articulated to a complex epistemological, technological, economic and legal framing that

legitimate certain actions over others, certain experiences in the place of other, associated with modes of

understanding of the self.

Priorization of health problems entail a mesh of epistemological elements which enable the

institutional and economical processes linked with the localities of clinical attention for selected biological

dimensions. In this priorization, all the above aspects participate in the enactment of specific qualities and

relations related to how biomedicine abstract the process of life. This scenario establishes an important

dependency of techno-scientific formations for the constitution of the regimes of truth which have an

influence in the configuration of local normativities about health and disease. In this process, not only

epistemological, but also biopolitical dimensions emerge as a product of complex associations between

social, economical and material entities.

Below, we give an account of emerging elements in the analysis of such socio-technical networks

for priorization of health problems, considering as material for analysis the discourse of experts and

professionals associated with the design and implementation of EHG in Santiago de Chile. We think that

such analysis serves as approach to some qualities of contemporary biogovernmentality in Chile.

The multiple composition of truth in EHG. Foucault (2014) has defined a regime of truth as " which obligates individuals to a series of acts of

truth (…) what defines, determines the shape of these acts and sets for the conditions of enactment and

specific effects ( …) is what determines the obligations of individuals about the procedures of manifestation

of the true" (p. 115). At the same time, he said that such regimes, with their procedures, operators,

witnesses, and objects, are not reduced to the dichotomy of the scientific and mundane, but "involves taking

into account the multiplicity of the regimes of truth [and] the fact that any regime of truth, whether scientific

or not, entails specific ways of linking ( …) the manifestation of the true and the subject who carries it out"

(p. 123).

To address how biogovernmentality -the linkages between biomedical knowledge, regularizations

of such knowledge and its effects in the spectrum of the subjectivation-, we have begun the analysis of the

speeches of experts in the design of health policies, mainly linked to ministerial and university fields. For

purposes of the investigation, the confidentiality of their stories and institutional secondments are respected.

For the analysis, we implement the strategy of pragmatic discourse analysis (Íñiguez, 2006) and of

interpretative repertoires (Whetherell & Potter, 1996), mainly using the notions of conversational

implicature, conversational presupposition and conversational speech acts (Grice, 1970; Austin, 1967;

Searle, 1965). In such analyzes, the notion of enactment (Mol, 2005) has been important to establish how

described actions participate in the creation of various ontologies, part of the same composition of the

prioritization and management in health. The analysis of the repertoires has not been finalized, however

have emerged the following considerations.

Beyond the truth: the biological enforcement. In the first place, it becomes necessary to point out that the objectification of health conditions is

multiple. In this regard, what counts as health refers to figurations and processes of argumentation that

articulate heterogeneous actors, which acquire meaning according to criteria quite dissimilar.

For example, in the following quote, it is constituted a regime (in which operate criteria, operators,

and objects) based on the evidence, one economic and one practical4:

Por lo tanto, podías como hacerlos como no hacerlos, ¿No cierto?, °en ese entendido°,

eh: >PERO sin embargo los requisitos qué dice<, y en la lógica de la priorización, ¿No

cierto?, que: tengan- las patologías que tengan harta carga de enfermeda:d, que se haya

demostrado que tiene intervenciones que son efectivas, ¿No cierto?, ↓y eso lo demuestras

a través de la medicina basada en la evidencia↑, que… las intervenciones sean costo

efectivas, que sean prioridad para los pacientes, eh y que sean implementables en la red.

Entonces, >si tú te imaginabas eso te decías<, “bueno necesito una serie de estudios,

4 Transcription has been developed using the conventions generated by Gail Jefferson Code (Antaki & Díaz, 2003). For the purpose of this presentation and to sustain the codification of the prosody, we maintain the original transcription in Spanish.

para llevar esto a cabo, y es un estudio de carga de enfermedad actualizado”, ¿No cierto?,

tener un guías de práctica clínica bien hechas, para poder ver cuáles son las

intervenciones que han demostrado efectividad, tener estudios de costo efectividad, eh y

tener como:, un estudio que vea como: como la capacidad de ofe(h)rta de la red, ¿No

cierto?, y de y final- también un estudio que hablara de la preferencia de los pacientes.

(Fernanda, personal interview, April 9, 2015, par. 100).

The evidence does not reflect a stable canon for the priorization. It is one among other components,

political, economic, and, above all, contingent, in which are defined the relationship between health and

disease, and also what comprise both. In these expert scenarios, such relationships (what is healthy and

ill) are considered primarily as interventions:

Claro, pero como era muy caro, ↓igual sabíamos que >Hacienda no lo iba a pasar< [, mi

jefe dijo “No, hay que priorizar”↑, y ahí, eso más bien fue una reunión, en una primera

instancia, ↓como para sacar lo↑, en la cual estaba él, el jefe de división de ese minuto con

la doctora Tohá, y yo. Yo traté de no:m porque para mí no era lo: (>jajaj<) lo ma:s… ↑no

estaba bien hecho eso↓, pero un poco decía “no esto no por”, >cualquier fundamento<, no

me acuerdo hoy día pero ↓“no mira esto no porque (0,3) está la embarra con esto,

entonces si lo metemos va”↑, y así, criterios que no… a juicio del minuto, ↓de la jefatura

del minuto↑. Y ahí se limpió eso, lo mismo con las intervenciones de las once nuevas, ya

estaba elegida la patología pero, no hay que olvidar que dentro de la patología hay una

serie de intervenciones que tú puede:s… y: la cosa es que:. Entonces >eso pasó a una

segunda etapa< en que se les mostró a las autoridades, y las autoridades también como

que dieron su visión, ↓pero como una visión mucho más macro↑. (Fernanda, personal

interview, April 9, 2015, par. 184)

No patologías si no que intervenciones al interior de la patología. (Fernanda, personal

interview, April 9, 2015, par. 190)

Various regimes of truth act in the same process about health: a technical rationality, the same

evidence, economic calculations, "macro visions" associated with institutional discourses of future. The

objectification of health does not refer to a specific dynamic, but is composed as a field of epistemological

feuds, practices and policies, which gets a specific product, an intervention.

In the following two extracts is expressed how an embedded intervention as a guarantee from

prioritization based-on-evidence process, is transformed into others by a meeting with various regimes of

truth:

E(h)h: es como el mensaje:, no podían ser setentainueve, <eso> ¿Ya? ↑Porque hay un

tema político detrás↓. ↓Entonces bueno pasó eso, nosotros nos molestamos, >pero ya

bueno<↑, y DESPUÉS, a mí me llama el ministro, y me dice eh: “te quiero informar que”,

↓estaba el subsecretario creo también↑, “que el glaucoma”, la doctora creo >estaba

enferma<, y como te decía el glaucoma era su bandera de lucha, eh: y me dice, “El, el

glaucoma no:, no puede entrar, no hay presupuesto”, y yo le dije, ↓pero traté de un poco,

con la doctora ¿No?↑, “pero es que mini:stro, usted sabe”, y me- así me dijo, “yo no te

estoy pregu(h)ntando”, °me dijo°, “yo te estoy diciendo porque o si no el presidente no nos

va a dar presupuesto, eh: para:, no nos van a dar la plata para el AUGE”, (1) y- y- y mira

lo que me dijo, me dijo, que ATROZ ah, bueno… (Fernanda, personal interview, April 9,

2015, par. 194)

¡Ah, no pero antes creo que lo del glaucoma!, sí. Había una patología, (2) claro nos dijo,

nos dijo la jefa (…) ↓que tenía una nueva visión↑, ↓pero sin embargo ya estaba muy el

proceso ya casi finalizando entonces por lo tanto no no hizo mucho↑, (…)Entonces ellas

nos informó (0,3) a nosotros que (0,3) no, no:, por temas de presupuestos, ↓no me acuerdo

qué patología era, pero era no iba a poder entrar↑, y una patología se iba a tener que

dividir en dos, <que es lo de:…> >¿Lo como se llama?<, Eh: insuficiencia mitral y:: aórtica,

bueno. .hh y eso en el fondo se tuvo que dividir como en en subcategorías. .hh Y bueno y

pasó [e:so… (Fernanda, personal interview, April 9, 2015, par. 190)

Therefore, what is integrated or not, is part of epistemological conflicted processes, in which the

legitimate is expressed as the translation of all these elements.

Throughout this process, the epistemic acquires a fundamental value: it is not a question of

managing bodies, but to produce effects of truth, certainties on certain biological regularities or how to

intervene them, according to a series of technical and and political resources which operate in a contingent

modality, through various epistemological canyons, but also ethical:

Ahora, (1) el tema de priorización no sólo necesariamente responde a un criterio de

eficiencia de >asignación de los recursos< eh: sino que podría responder a otros valores

sociales °también° entonces tú podrías decir: mira yo por ejemplo estoy dispuesto a

financiar una tecnología que sea cara, que dé pocos beneficios en salud, pero estoy

dispuesto porque es en dos pacientes en Chile y son niños y tienen una enfermedad ultra

rara, entonces eso tú lo valoras de una manera especial y entonces no le aplicas la misma

regla. (Íñigo, personal interview, August 17, 2015, par. 83)

Beyond the truth, in the process of prioritization and definition of performance and health as a

benefit, is what Foucault (2014) has pointed out as enforcement:

… the complement of force and the obligation, of coercion that makes one is effectively

obliged to (…) [raise something] as true even though you know that it is false, or that it is

not sure whether something is true, or that it is not possible to demonstrate that it is true or

false. (p. 117)

The expert design does not constitute a subjectivant panopticon (total vision), which establishes

once and for always a device for the production of a disciplined body, but, in terms of Latour (2008) by a

oligopticon (what sees little): a set of contingent relations, an establishment where are enacted modes of

health, benefits, interventions… a government that manages technical resources with an effect of visibility.

Evidence-based medicine is not a truth, but a way for producing it. However, continuously enter

new agents that can redefine the same prioritization or processes for obligation; for example, the same

bioeconomic interests (Rose, 2007) associated with the pharmaceutical industries:

Justamente, eh sino que son cualquier intervención que tenga el potencial de generar

salud. Ahora en la práctica hacemos más medicamentos y:, y tecnologías digamos: de las

que uno tiene en la mente intuitivamente porque hay más demanda porque se haga, (1) o

sea, el medicamento está la industria farmacéutica detrás que quiere >vender sus

medicamentos< entonces pa' la industria farmacéutica en muchos países esto es un: una

necesidad el tener estos >estos< estudios, entonces la industria paga por esos estudios

>así como paga< por los ensayos clínicos randomizados para poder eh: registrar sus

productos: paga por las evaluaciones económicas en esos países, para poder mostrarle y

demostrarle a los gobiernos de que es eficiente el uso de recursos comprando estas

nuevas tecnologías, estos nuevos medicamentos. (Íñigo, personal interview, August 17,

2015, par. 79)

Therefore, the regimes of obligation in prioritization processes are subject to multiple objects that

constitute, in contingent mode, heterogeneous truths about life, its affections and processes.

Governing the territory: spacialization of the body. Notwithstanding the foregoing, the regimes of obligation are geared to a relatively common process

associated to the consideration of the body such as a space, and its process of territorialization. Life is

enacted in a multiple mode, and the same bodies disappear as effects of specific interventions product of

regimes of obligation, heterogeneous: evidence-based, product of cost-effectiveness analysis, in relation

to indicators of longevity associated with interventions, the production of bioeconomical and political

obligations.

Rose (2001, 2007) has pointed out how during last decades the medicine has been mobilized to

its definition and practice predominantly variables and resources settled in genetic dimensions that have

led its to experience a total “molecularization". This would not be much of a change in the framing of the

medical explanations, as a reorganization of the approach of the conception of life itself, of the institutions

that are implemented for its analysis, the tools and spaces of operations, and the emergence of new forms

of capitalization (Rose, 2001). Such are differentiated and at the same time are integrated to anatomopolitic

strategies, or on the body.

However, appreciating the modes of operation of EHG emerges a diverse and specific condition,

that instead of standing on the scale of the genes, or in the dimension of the body and its functions, it is

situated in a liminal space between the two, in a range:

Garantizado, cachaí? O sea, no cabe la menos duda que lo va a recibir, entonces claro

pero pasa, si es que yo vi y llegué y le comenté a la doctora, “¿Sabe qué, doctora, sabe

que con la (Andrea) me puse a llorar y mostraban una señora mayor de 65 años ↑que una

cadera era GES y la otra no era GES” (…) ¿Le puedes encontrar lógica a eso? (…) Pero

ahí no es el problema ni la guía ni el criterio de por qué se metió la endoprótesis total de

cadera o no, no es el criterio ese (…) ↑porque lamentablemente a las personas todavía no

se les ve de manera integral >y siguen siendo un pedazo de pierna, un pedazo de cadera,

un pedazo de rodilla, un pedazo de corazón, según lo que te afectó<= (Pamela, personal

interview, August 3, 2015, par. 235)

The pre-eminence of biomedical criteria sets a different kind of objectification of the subject and

understanding of the self: it is not about to circumscribe a human in function of its objective constraints,

internal or external, but of the formation of interventions based on knowledge about biological instances

that are regularized. The biological, its temporary or sexual stretch, is insured, but not the subject.

Synthesis. It has been exposed in a general way, the basis of a research project that, around the concept of

biogovernmentality, discusses how the modes of biomedical knowledge are constituted as part of the arts

of government, considering as a case for study the Regime of Explicit Health Guarantees in Chile.

In this regard, the approach to the analysis of the discourse of expert designers gives an account

of at least three processes:

a) Beyond operate a single biomedical evidence-based canon, the prioritization of interventions and

the formulation of recommendations is associated to multiple regimes of truth that are articulated

and that promote various intensities by which emerge heterogeneous actions. The canons on the

regulation of life are many, and, therefore, the modes of understanding and defining the same life,

multiple.

b) In a different way to anatomopolical biopower, or a molecular biopolitics, EHG creates a new scale

for intervention and management of the life: an interval between the somatic and genetic. These

actions are rooted in technoscientific enactments of what is insured, according to the criteria of a

temporary (for example, period of life, age ranges) and spatial (for example, sex, area in a body)

nature.

c) About prioritization itself, rather than a single evidence-based canon, it behaves as a mesh, formed

and feasible to be redefined by heterogeneous entities: an indicator, a study, the irruption of political

discourse, the own political participation, the power of pharmaceutical research, a behavior

confined by a technician, all of them can change the value of a process of prioritization.

Various regimes for truth or obligation are involved in the composition of this mesh. Human and

non-human are associated in the spaces that will be operated from the formation of a national

network of benefits.

Such aspects transform not only the processes by which becomes real a specific health problem

and its intervention, but also give account of political scenarios in which the health problems may or may

not be represented or registered in the systems for guarantees. Although these processes have been

described by authors such as Rose (2007), Novas & Rose (2000), & Rabeharisoa Callon (2007), Bourret

(2006), explaining how the engagement with biomedical technoscientific networks affect the production of

the somatic identities or biologically active citizenship, it is suggested that the EHG establishes certain

specificities.

i) First, the engagement to the political and knowledge systems are not performed through total

individualizations, i.e. in terms of citizenship, but either as part of the engagement with more specific

actions: interventions over components or intervals of the body. That is to say, of liminal nature.

ii) In these diagrams the production of evidence is fundamental and the expertise is considered not

only as a question of the management of the knowledge about the disease. It implies a commitment

not only with the problem of health, but also with the mechanisms of enforcement or obligation: it

implies, therefore, a process of subjectivation, a way to be understood and to understand

mechanisms to be part of a political and epistemological bio-collective.

iii) Finally, the notion of guarantee sets forth a different way of understanding the responsibility in these

processes. Beyond an accountability of an individual figuration, it becomes the articulation to certain

regimes by which biological experiences can be translated into interventions or recommendations:

according to multiple canons, according to the alliance to various entities and through completely

different modes of understanding the self in these processes.

We believe that such outlines of approaches can be associated as complementary lines to the

recent work associated with different processes of biopolitics, such as work on the pharmacological

practices (Camargo & Ried, 2015) –as a process different to anatomolopolitics, and associated to

molecularization exposed by Rose (2007).

It is pending in this work, the development of other components emerging in the research process,

specifically associated with the consideration of EHG as a biopolitical vector, i.e. as a schema that redefines

and configures the temporalities and organizations of the biology of population.

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