The Healthy Asthmatic
Authors: Kenner Alison 
Published: October 2020

Tiffany is running down a suburban street with headphones and a hoodie on. Her breath is clearly audible, rhythmic, steady, and in pace with her footsteps. The Tiffany’s Story video testimonial on the Be Smart. Be Well. website then cuts to Tiffany sitting at home describing her earlier experiences with asthma: “The hospital became like my second home... I couldn’t breathe on my own.” Dr. Wolf, who has been treating Tiffany since she was diagnosed with asthma at age 8, joins in, “At that time she had really severe asthma. It was very difficult to manage and remained very difficult to manage for many years” (Be Smart. Be Well). As a child, Tiffany could never run, with steady breath, as she did at the beginning of the video, titled The Right Meds Keep Her in the Ring (Be Smart. Be Well). But after figuring out a treatment regime that worked, Tiffany became a healthy teenager; the video features her in contexts where she is jogging, smiling radiantly with her mother, and holding up victory belts from her boxing matches. From a child unable to breathe on her own, to a teenager with dreams of going to the Olympics, Tiffany’s asthma story underscores some of the defining narratives of contemporary asthma care. Her experience moves from uncontrolled asthma that limited her activities to a well-managed condition where she is able to pursue her aspirations without interference. Her Olympic dreams fit perfectly, reproduce even, the iconic image of the asthmatic athlete. It’s an image that has been in circulation since the early years of the contemporary asthma epidemic, a moment in the 1990s when federal health agencies and advocacy organizations worked to give the growing population of child asthmatics hope and encouragement to overcome their asthma. Yet the figure of the athletic asthmatic, and other accomplished icons with well-controlled asthma, also promotes an idealized image of health: “you can be greater than you are,” when you take your medication. The messages, of course, are well intentioned, designed to educate and show kids that asthma does not equate with disability. Yet these messages frequently work on logic where drugs control symptoms to enable you to do better in life. In some corners of asthma care, concern with symptoms is subsumed by narratives of activity and accomplishment. This article sketches shifts in the meaning of health and disease in the context of asthma treatment, moving from a time when treatments were not disease-specific and illness was seen as debilitating, to the contemporary moment where pharmaceutical companies market disease and promote health through direct-to-consumer advertising (DTCA). It’s a move situated within a broader, biomedicalized context where health isn’t just achieved, it’s augmented. Tiffany’s story is typical of someone with severe or even moderate asthma: uncontrolled symptoms, use of emergency care, unresponsive to medications, and an inability to live life as fully as desired. Symptoms and the threat of symptoms prevent people from undertaking routine activities (such as exercise, visiting friends, or attending work or school) and going into spaces that might trigger an attack. Asthma, in other words, can prevent people from living a “normal” life. But it can also be more than a chronic inconvenience that shapes behaviors; in the U.S., asthma still kills more than 3,000 people each year (Moorman et al. 20). Medical practitioners, researchers, and patients persistently search for insight into asthma’s causes and possible cures (Whitmarsh). Both cause and cure still allude, but preventative measures have improved dramatically in the last thirty years, through both pharmaceutical advancements and better public health approaches. Whereas a century ago, or even 30 years ago, severe asthmatics would have lead quite restricted lives—confined to their homes and unable to be active—today’s asthmatics are not limited by their condition to the degree they were decades before. We see this in asthma research that shows improved morbidity, decreased hospitalizations, and better quality of life (Moorman et al. 1-67). We also see this in DTCA, asthma advocacy campaigns, and even public health messages that actively combat the historic image of the weak, invalid asthmatic with stories of famous athletes, entertainers, or politicians who overcame asthma to achieve great things. It moves the discourse from an overly negative image—as one asthmatic interlocutor conveyed, “there was a stereotype in the 80s, in the movies, where the nerdy wimpy kid always had asthma, and the inhaler was associated with that”—to an extraordinarily positive image of high achieving asthmatics. Inhalers, formerly a sign of weakness, are now common in competitive sport contexts (Arie 344). The contrast between these representations—the 1980s nerdy wimp and the 21st century athlete—is stark. The latter image participates in the shift towards augmented health, where active bodies have become the new idealized norm. The shifting representations of asthmatics, even over the last twenty years, makes sense in the context of biomedicalization (Clarke et al. 172), where treatment regimes moved from a focus on “attaining control over the body” under medicalization, to “enabling the transformation of bodies to include desired new properties and identities” (Clarke et al. 183). The right treatment will allow you to do things that your body wouldn’t let you do otherwise. The question is: should treatment be sold on this premise? What would have been considered a return to health a hundred years ago wouldn’t be considered doing enough to manage your asthma today. A hundred years ago, the absence of symptoms would have been a success; today, the focus is on the degree to which one feels limited and how much you can accomplish in the span of 24-hours. Missed school and work days are a key measure in asthma epidemiology and care; these public health measures not only signal uncontrolled asthma, but do so by counting absence in the context of labor. The discursive shift can also be seen in the change from the urge to “breathe easy” (language from the Centers for Disease Control) to suggestions in pharmaceutical ads that you can “breathe better.” What new selves are being created by emergent health rhetorics, as Metzel asks (6), rhetorics which seem to be consumerist and neoliberal as much as they are biomedical? Role Reversal  Historically, those with severe asthma led their lives carefully, or in reclusion. French novelist Marcel Proust, in addition to his literary accomplishments, spent much of his life confined to his home. Despite searching through medical texts and experimenting with various treatments, Proust’s asthma “dominated” his daily life, in the words of Mark Jackson (6). Writing of asthma’s history, Jackson continues, Proust constitutes the archetypal asthmatic, whose breathlessness and discomfort echo across space and time. Proust’s intimate descriptions of his symptoms—‘an asthmatic never knows if he will be able to breathe’ he wrote to the novelist Andre Gide in 1919—bear striking similarities both to Greek and medieval accounts of asthma many centuries earlier and to recent surveys suggesting that, at the turn of the millennium, many asthmatics continue to suffer from severe attacks that prevent them from speaking or make them fear for their lives. (8) In Proust’s time, advertisements for asthma and other respiratory treatments focused on providing symptom relief; some even purported to cure respiratory woes. These advertisements were rarely asthma specific, in part, because manufacturers sought the widest possible customer base, but also because it was difficult to distinguish one respiratory illness from another (Jackson 201). Asthmatics like Proust tried a range of remedies, including asthma cigarettes, the Carbolic Smoke Ball, and various forms of early inhalers. Most of these early asthma remedies instructed customers to use their product when in need of relief. Some ads stated that more regular use could stave off symptoms as well remedy them in the moment, but prevention wasn’t the primary message. The principle focus was addressing symptoms at hand. Just about a hundred years later, at the beginning of the U.S. asthma epidemic, symptoms were still center stage. National attention turned towards the asthmatic condition as the public health effects of severe asthma became visible—asthma-related deaths and hospitalizations had increased, along with rising prevalence rates. Asthma—formerly kept hidden in homes and in low-income communities—emerged as a major public health issue (Mitman 245). Advocacy campaigns were created on the heels of the epidemic’s emergence; they aimed to make asthma visible and show kids that their condition didn’t have to get in the way of life. Elite athletes became central figures in these campaigns. The Asthma All-Stars program, which featured Olympic medalists Jackie Joyner-Kersee and Amy Van Dyken, as well as Pittsburgh Steeler Jerome Bettis, worked to educate the public through acknowledgement of the condition as well as treatment advocacy. The National Library of Medicine’s exhibit on asthma, “Breath of Life” (1999), exemplifies this period with a showcase of famous asthmatics. In the exhibit, more than half the profiles of contemporary asthmatics feature Olympic or all-star athletes; entertainers, politicians, and scientists round out the exhibit. The legacy of the asthmatic athlete persists today; it’s still common to see sports figures speaking at fundraisers or spearheading events. These images are important, particularly for patient populations who truly feel limited and unable to do things because of their asthma. Athletes who speak about their condition are always clear: well-controlled asthma comes from adherence to treatment. The importance of these images also stems from the use of the image of the All-Star asthmatic to counter the historical stereotype of the weak, invalid asthmatic, who, like Proust, could not even leave the house. The man who recalled the stereotyped asthmatic from the 1980s, stated “I think I mapped myself onto that [stereotype], like, this is a disability, right, the media tells me this is a disability cause it’s always the kids who can’t do anything who are puffing their puffers.” In step with emergent 21st century health rhetoric, and increasing asthma prevalence, the image of the asthmatic was revised, falling in line with newly normalized health ideals (Clarke et al. 181; Metzel 2; Sinding 262).  Active Asthmatics If 19th and early 20th century inhaler advertisements declared their products could relieve if not cure respiratory symptoms, at the beginning of the 21st century asthma treatment went beyond simply relieving symptoms; advertisements and medical discourse emphasized preventative symptom control, improved lung function, and better breathing. With the development of long-term controller medications, many asthmatics could reliably prevent symptoms a majority of the time. When combination inhalers hit the market in the early 2000s, the mood of advertisements could be summed up by a line from a GlaxoSmithKline commercial, “Coping is not the same as controlling” (GlaxoSmithKline). Prevention rather than symptom relief was the order of the new century. And yet just in the last ten years, pharmaceutical messages have shifted yet again, moving from an emphasis on controlling symptoms to living a better life: don’t let asthma slow you down, or stop you from living the life you want to live. It’s a message predicated on a particular view of what a normal life should look like, one characterized as augmented health. A 2012 Advair commercial reflects the tone of augmented health, “Asthma can hold you back, but it doesn’t always have to. Advair is clinically proven to significantly increase symptom free days, to help you do more of the things you like to do, more of the things you have to do, and more of what you want to do” (Advair). Strategically placed throughout the commercial, a voice chimes in “GO!” as the hero of the commercial, a middle aged asthmatic man, bikes down a wooded trail; moves through a busy hallway where he greets one person after the next, all of whom hand him file folders or blue prints; dances at a nightclub; and walks down bleachers to join a group of friends at a ballgame. The commercial ends with the man arriving home well after dark, comfortably settling into bed, and then energetically waking up to do it all over again the next day.  Marked by words like increase, more, and go, the Advair commercial depicts a life full of activity. Not only that, the commercial leverages contexts that are commonly problematic for asthmatics: being outside and in foliage rich areas; biking and dancing, or other physical activities that could leave one breathless; and sleeping comfortably—nighttime attacks are common among asthmatics. The message is clear: look at all the things asthmatics can do when their condition is well controlled—with Advair, of course. It’s a message that builds on an earlier trend in asthma advocacy, during the 1990s, when well-known asthmatic athletes were used to bring visibility to asthma. If asthma control in the 1990s emphasized that asthmatics didn’t need to be held back, 21st century ads suggest that one could do more. By augmenting your health, asthma control can transform your life by allowing you to do more.Today, DTCA for asthma drugs are just as likely to emphasize improved lung function as they are symptom control, and, as advertised in the Advair commercial, improved lung function enables one to do more. A man featured in a 2012 Symbicort commercial explains, “Symbicort helps significantly improve my lung function, starting within five minutes… With Symbicort, today I’m breathing better” (Symbicort). The man’s renewed capacity to go on fishing trips with loved ones is the example in this commercial. Control, relief, and cure are nowhere to be found in these DTC advertisements; symptoms have been dropped from the frame. Rather than work off illness, or the older stereotype of the weak, homebound asthmatic, the new wave of DTCA champions augmented health: a higher quality of life, where patient-consumers can “do” whatever they like. What would have been considered a return to normal a hundred years ago, in Proust’s time, wouldn’t be considered doing enough to manage your asthma today. A hundred years ago, getting out of the house would have been enough; today, it’s a question of how much can you accomplish in the span of 24-hours. The portrayal of health in these DTCA calls to mind Lauren Berlant’s description of OTC cold medicine, which claim to make you feel better, but are really more concerned with making sure people can stay productive (28).  Conclusion Had Proust lived a century later, he may have, like Tiffany, led a less restricted life. Or as Dr. Wolf put it, “A normal life. Busy and as active as she’d like to be. But she needs to take medication to do it” (Be Well. Be Smart). Symptom-free doesn’t seem to be enough anymore. Contemporary images of asthmatics—as an all-star athlete, an aspiring boxer, and a hyper-busy city dweller—are shaped by an imagined healthy norm. Advocacy campaigns originally intended to combat long-standing negative representations partake in the promotion of augmented health. Increasingly, health is no longer defined by the absence of symptoms, but by how active you are and how much you do. Busy and productive is a gold standard of the idealized norm, a norm that circulates—to a greater or lesser extent—in direct-to-consumer advertising, asthma advocacy campaigns, and public health messages (Sinding 262). Without doubt, the pharmaceutical industry plays a tremendous role in shaping contemporary health norms. Yet, as Joseph Dumit describes it, "the pharmaceutical industry is a massive elephant. Like the blind men of the famous parable, we each catch a hold of a tiny piece of it -- leg, tail, trunk -- and think we have a handle on it" (18). A powerful force with influence on many aspects of contemporary life, the pharmaceutical industry could be understood through the lens of biomedicalization: Biomedicalization imposes new mandates and performances that become incorporated into one’s sense of self. The subjectivities that arise out of these performances of what it is to be healthy (e.g., proactive, prevention-conscious, neo-rational) suggest how biomedical technoscience indicates a type of governmentality that can enact itself at the level of subjective identities and social relations. (Clarke et al. 182) Disease marketing—prevalent in the 1990s—is no longer needed or effective; health marketing has taken over and pharmaceutical companies are not at the table alone (Elliott 97). Instead of working through disease difference, health marketing attempts to level ground through images and standards that everyone can work towards, asthmatics included. Of course, pharmaceutical marketing simultaneously renders invisible socioeconomic conditions that contribute to asthma incidence, and marginalized populations that struggle to access medication and medical care in the first place. Augmented health works to flatten difference across social, economic, political, and ecological scales, as if these inequalities didn’t matter for disease management. Scholars writing about emergent modes of health—how health is imagined, constructed, studied, and sold—have documented how new health regimes work off potential risk categories, race, class, and gendered ideologies, or hoped-for modes of living. Some are literally “against health” (the title of Metzel and Kirkland’s edited volume). But to be against health, as Metzel writes is not to be against needed treatment (9). To examine the ways in which DTCA or advocacy campaigns promote specific, idealized images of health—images where people are athletic, outgoing, and busy—and question whether these drugs go above and beyond the restoration of health, should not be equated with a statement about whether medication is necessary. Epidemiological evidence and clinical studies are clear that contemporary treatments help reduce the burden of asthma in various ways: through reduced hospitalizations, lower death rates, and better-controlled asthma. Drugs keep many asthmatics relatively symptom-free. The point, rather, is that health is complex, structured by various institutions, actors, politics, and materials. One of the valences of the new health regime is augmented health, seen in the context of this paper at work in DTCA and possibly emerging in other corners of the asthma care arena as well.   To date, most writing on augmentation has focused on how advancements in science and technology extend the capacity of human bodies—from prosthetics and fertility drugs, to steroids and life support (Hogle 696). Less has been written on the ways in which chronic conditions like diabetes, heart disease, and asthma—conditions where life hinges on medications, but are common enough that they are deemed unexceptional—produce a rhetoric of augmentation; where the new healthy is augmented living. It’s not the drugs for life rhetoric that works off new risk categories, as Dumit has shown (201); asthmatics are symptomatic, always at risk anyways, and often already on drugs for life. Drugs for chronic conditions like asthma may simply control symptoms, but they’re increasingly sold on the promise of enhancing life capacities as well. As Elliott has observed, it’s part of a move from disease marketing to health marketing (97). The discursive shift in asthma care, and perhaps other chronic disease contexts as well, doesn’t register as enhancement or augmentation because it mirrors the new health norm that is part of the broader context of biomedicalization. As the frame of health shifts, questions about bodies, ethics, and enhancement technologies might need to shift as well. Linda Hogle’s question is apt here: “what is necessary to sustain health? At which point does repair become something more than restorative, and for which (and whose) purposes are interventions defined as 'therapeutic'” (697). Since health norms have become augmented in the last ten years, this question becomes all the more difficult to answer. Within these new health regimes, potential has not only become open-ended, it also seems to be a therapeutic goal. References Arie, Sophie. “What Can We Learn from Asthma in Elite Athletes?” British Medical Journal 344 (2012). Be Smart. Be Well. “The Right Meds Keep Her in the Ring.” Be Smart. Be Well. 14 Aug. 2013. 1 Dec. 2013 ‹http://www.besmartbewell.com/childhood-asthma/tiffany.htm›. 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